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Ikeda M, Tamada T, Takebayashi R, Okuno G, Yagura I, Nakamori S, Matsumura T, Yoshioka T, Kaneko S, Kanda N. Development of Fulminant Type 1 Diabetes Mellitus in the Course of Treatment with Atezolizumab for Hepatocellular Carcinoma: A Case Report. Intern Med 2022. [PMID: 36288990 DOI: 10.2169/internalmedicine.0860-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/07/2023] Open
Abstract
A 71-year-old woman with recurring stage IV hepatocellular carcinoma (HCC) was admitted to our hospital while being treated with atezolizumab and bevacizumab and complained of fatigue, vomiting, and appetite loss. The following were noted on admission: serum glucose level, 633 mg/dL; metabolic acidemia (HCO3- of 19.5 mmol/L); remarkably low serum and urinary C-peptide levels (0.16 ng/mL and ≤1.5 μg/day, respectively); and urinary ketone body level, 4,197 μmol/L. She was diagnosed with atezolizumab-induced fulminant type 1 diabetes mellitus (T1DM), and insulin therapy improved the symptoms. To our knowledge, this a novel report of atezolizumab-induced fulminant T1DM in an HCC patient.
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Affiliation(s)
- Munehiro Ikeda
- Department of Gastroenterology and Hepatology, Takatsuki Red Cross Hospital, Japan
| | - Takashi Tamada
- Department of Gastroenterology and Hepatology, Takatsuki Red Cross Hospital, Japan
| | - Risa Takebayashi
- Department of Gastroenterology and Hepatology, Takatsuki Red Cross Hospital, Japan
| | - Gaku Okuno
- Department of Gastroenterology and Hepatology, Takatsuki Red Cross Hospital, Japan
| | - Iori Yagura
- Department of Gastroenterology and Hepatology, Takatsuki Red Cross Hospital, Japan
| | - Shohei Nakamori
- Department of Gastroenterology and Hepatology, Takatsuki Red Cross Hospital, Japan
| | - Taishiro Matsumura
- Department of Gastroenterology and Hepatology, Takatsuki Red Cross Hospital, Japan
| | - Takuto Yoshioka
- Department of Gastroenterology and Hepatology, Takatsuki Red Cross Hospital, Japan
| | - Shizuka Kaneko
- Department of Diabetes/ Endocrinology/ Metabolism, Takatsuki Red Cross Hospital, Japan
| | - Naoki Kanda
- Department of Gastroenterology and Hepatology, Takatsuki Red Cross Hospital, Japan
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2
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Kapke J, Shaheen Z, Kilari D, Knudson P, Wong S. Immune Checkpoint Inhibitor-Associated Type 1 Diabetes Mellitus: Case Series, Review of the Literature, and Optimal Management. Case Rep Oncol 2017; 10:897-909. [PMID: 29279690 PMCID: PMC5731100 DOI: 10.1159/000480634] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Accepted: 08/24/2017] [Indexed: 12/21/2022] Open
Abstract
With the introduction of immune checkpoint inhibitors into clinical practice, various autoimmune toxicities have been described. Antibodies targeting the receptor:ligand pairing of programmed death receptor-1 (PD-1) and its cognate ligand programmed death-ligand 1 (PD-L1) in rare reports have been associated with autoimmune diabetes mellitus. We report 2 cases of rapid-onset, insulin-dependent, type 1 diabetes mellitus in the setting of administration of nivolumab, a fully human monoclonal antibody to PD-1, and atezolizumab, a humanized monoclonal antibody to PD-L1. This appears to be the first report of autoimmune diabetes mellitus associated with atezolizumab. In addition, we provide a brief review of similar cases reported in the literature and a discussion of potential mechanisms for this phenomenon and propose a diagnostic and treatment algorithm.
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Affiliation(s)
- Jonathan Kapke
- Division of Hematology and Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Zachary Shaheen
- Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Deepak Kilari
- Division of Hematology and Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Paul Knudson
- Division of Endocrinology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Stuart Wong
- Division of Hematology and Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
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3
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Phillips B, Giannoukakis N, Trucco M. Dendritic cell-based therapy in Type 1 diabetes mellitus. Expert Rev Clin Immunol 2010; 5:325-39. [PMID: 20477010 DOI: 10.1586/eci.09.8] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Dendritic cell (DC) immunotherapy is a clinical reality. Despite two decades of considerable data demonstrating the feasibility of using DCs to prolong transplant allograft survival and to prevent autoimmunity, only now are these cells entering clinical trials in humans. Type 1 diabetes is the first autoimmune disorder to be targeted for treatment in humans using autologous-engineered DCs. This review will highlight the role of DCs in autoimmunity and the manner in which they have been engineered to treat these disorders in rodent models, either via the induction of immune hyporesponsiveness, which may be cell- and/or antigen-specific, or indirectly by upregulation of other immune cell networks.
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Affiliation(s)
- Brett Phillips
- University of Pittsburgh School of Medicine, Department of Pediatrics, Division of Immunogenetics, Children's Hospital of Pittsburgh, Rangos Research Center, 530 45th Street, Pittsburgh, PA 15201, USA.
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4
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Atsumi T, Sato M, Kamimura D, Moroi A, Iwakura Y, Betz UAK, Yoshimura A, Nishihara M, Hirano T, Murakami M. IFN-gamma expression in CD8+ T cells regulated by IL-6 signal is involved in superantigen-mediated CD4+ T cell death. Int Immunol 2008; 21:73-80. [PMID: 19050105 DOI: 10.1093/intimm/dxn125] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Infection with pathogens containing superantigens (Sags) can result in massive excessive CD4+ T cell activation and death in such conditions as toxic shock, food poisoning and autoimmune diseases. We here showed how enhancement of IL-6 signaling suppresses Sag-mediated activated CD4+ T cell death. Sag-induced CD4+ T cell death increased in IL-6 knockout (KO) mice, whereas it decreased in mice characterized by enhanced IL-6-gp130-STAT3 signaling. The serum concentration of IFN-gamma was inversely correlated with the magnitude of IL-6 signaling, and IFN-gamma deficiency inhibited Sag-induced activated CD4+ T cell death, suggesting that IL-6 suppresses CD4+ T cell death via IFN-gamma expression. Interestingly, depletion of activated CD8+ T cells inhibited Sag-mediated increases in IFN-gamma expression in IL-6 KO mice as well as the augmented CD4+ T cell death. The results demonstrate that IL-6-gp130-STAT3 signaling in activated CD8+ T cells contributes to Sag-induced CD4+ T cell death via IFN-gamma expression, highlighting this signaling axis in CD8+ T cells as a potential therapeutic target for Sag-related syndromes.
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Affiliation(s)
- Toru Atsumi
- Laboratory of Developmental Immunology and the Core Research for Evolutional Science and Technology Program of the Japan Science and Technology Agency, Graduate School of Frontier Biosciences and Graduate School of Medicine, Osaka University, Osaka, Japan
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5
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Trucco M, Giannoukakis N. Immunoregulatory dendritic cells to prevent and reverse new-onset Type 1 diabetes mellitus. Expert Opin Biol Ther 2007; 7:951-63. [PMID: 17665986 DOI: 10.1517/14712598.7.7.951] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Herein, the authors provide an overview of where dendritic cells lie in the immunopathology of autoimmune Type 1 diabetes mellitus and how dendritic cell-based therapy may be usefully translated to treat and reverse the disease. The immunopathology of Type 1 diabetes mellitus offers a number of windows at which immunotherapy can be applied to delay, stop and even reverse the autoimmune processes, especially in light of the recent antibody-based accomplishment of improvement in residual beta-cell mass function. As in almost all cell-specific inflammatory processes, dendritic cells are central regulators of diabetes onset and progression. This realisation, along with accumulating data confirming a role for dendritic cells in maintaining and inducing tolerance in multiple therapeutic settings, has prompted a line of investigation to identify the most effective embodiments of dendritic cells for diabetes immunotherapy.
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Affiliation(s)
- Massimo Trucco
- Children's Hospital of Pittsburgh, Diabetes Institute, Pittsburgh, PA 15213, USA
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6
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Bottino R, Lemarchand P, Trucco M, Giannoukakis N. Gene- and cell-based therapeutics for type I diabetes mellitus. Gene Ther 2003; 10:875-89. [PMID: 12732873 DOI: 10.1038/sj.gt.3302015] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Type 1 diabetes mellitus, an autoimmune disorder is an attractive candidate for gene and cell-based therapy. From the use of gene-engineered immune cells to induce hyporesponsiveness to autoantigens to islet and beta cell surrogate transplants expressing immunoregulatory genes to provide a local pocket of immune privilege, these strategies have demonstrated proof of concept to the point where translational studies can be initiated. Nonetheless, along with the proof of concept, a number of important issues have been raised by the choice of vector and expression system as well as the point of intervention; prophylactic or therapeutic. An assessment of the current state of the science and potential leads to the conclusion that some strategies are ready for safety trials while others require varying degrees of technical and conceptual refinement.
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Affiliation(s)
- R Bottino
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA
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7
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Bertera S, Alexander A, Giannoukakis N, Robbins PD, Trucco M. Immunology of type 1 diabetes. Intervention and prevention strategies. Endocrinol Metab Clin North Am 1999; 28:841-64, x. [PMID: 10609123 DOI: 10.1016/s0889-8529(05)70105-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Type 1 diabetes is the outcome of a progressive and selective destruction of insulin-producing cells in the pancreatic islets of Langerhans. The precise cause and mechanism(s) that trigger the insulin-producing cell destruction are still unclear, although it is well accepted that an autoimmune process plays a central role in diabetes development among genetically susceptible children. Additionally, certain viral infections, especially those caused by Coxsackievirus B, have been associated with the onset of type 1 diabetes. Possible gene therapy-based prevention and intervention strategies are discussed, based on the most accepted models of type 1 diabetes pathogenesis.
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Affiliation(s)
- S Bertera
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pennsylvania, USA
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8
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Murphy VJ, Harrison LC, Rudert WA, Luppi P, Trucco M, Fierabracci A, Biro PA, Bottazzo GF. Retroviral superantigens and type 1 diabetes mellitus. Cell 1998; 95:9-11; discussion 16. [PMID: 9778241 DOI: 10.1016/s0092-8674(00)81775-4] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- V J Murphy
- Autoimmunity and Transplantation Division, The Walter and Eliza Hall Institute of Medical Research, Royal Melbourne Hospital, Parkville, Australia
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9
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Luppi P, Rudert WA, Zanone MM, Stassi G, Trucco G, Finegold D, Boyle GJ, Del Nido P, McGowan FX, Trucco M. Idiopathic dilated cardiomyopathy: a superantigen-driven autoimmune disease. Circulation 1998; 98:777-85. [PMID: 9727548 DOI: 10.1161/01.cir.98.8.777] [Citation(s) in RCA: 43] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Many cases of idiopathic dilated cardiomyopathy (IDC) result from an inflammatory myocarditis. The specific immunological mechanisms are not yet defined. Various autoimmune diseases are associated with superantigen-triggered immune responses, resulting in massive T-cell activation and tissue damage. We studied 3 cases in a search for evidence that such a phenomenon is also implicated in IDC. METHODS AND RESULTS Myocardial, lymph node, and thymic tissue samples were obtained from IDC patients who were undergoing heart transplantation. Infiltrating immune-cell phenotypes and gene expression of T-cell receptor (TCR) alpha- and beta-chain variable (Valpha and Vbeta) regions were analyzed by immunostaining and polymerase chain reaction. Similar technical approaches were used to assay the tissues for the presence of coxsackievirus B (CVB). In all the specimens analyzed, an overexpression of the TCR Vbeta3, Vbeta7, and Vbeta13.1 gene families was detected among the infiltrating T cells. These tissues were also found to be CVB3-positive. In vitro exposure of peripheral blood mononuclear cells to lysates of cells infected with CVB3 was capable of stimulating expansion of the same TCR Vbeta families. The TCR Valpha repertoire was never found to be skewed. CONCLUSIONS A superantigen-mediated immune response is involved in human heart disease. CVB3 may directly or indirectly trigger this response, suggesting a possible mechanistic link between CVB infection and myocarditis development progressing to IDC.
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Affiliation(s)
- P Luppi
- Department of Pediatrics, University of Pittsburgh School of Medicine and Children's Hospital, PA, USA
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10
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Shpilberg O, Dorman JS, Ferrell RE, Trucco M, Shahar A, Kuller LH. The next stage: molecular epidemiology. J Clin Epidemiol 1997; 50:633-8. [PMID: 9250260 DOI: 10.1016/s0895-4356(97)00052-8] [Citation(s) in RCA: 24] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
The traditional approach in epidemiology of relating exposure to an environmental agent such as a drug or infective agent has been to measure an overall risk (i.e., average and then "adjust risk for demographic variables and other confounders"). An attempt is sometimes made to define a "susceptible" subgroup. The analyses are usually based on good statistical methodology rather than an understanding of the interaction of body of host and agent. A twofold risk for 1000 exposed versus nonexposed people could be an average twofold risk for all 1000 exposed or a 20-fold risk for 100 exposed individuals (i.e., a drug-host interaction). Clearly, finding the 100 individuals with a 20-fold risk has much greater clinical importance than a twofold risk for 1000 people. The world of epidemiology may be changing-we may soon be able to define risk based on genetic susceptibility, at least sometimes.
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Affiliation(s)
- O Shpilberg
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pennsylvania 15261, USA
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11
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Luppi P, Trucco M. Superantigens in insulin-dependent diabetes mellitus. SPRINGER SEMINARS IN IMMUNOPATHOLOGY 1996; 17:333-62. [PMID: 8966660 DOI: 10.1007/bf01795133] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- P Luppi
- Department of Pediatrics, Children's Hospital of Pittsburgh, PA 15213, USA
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12
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Abstract
The involvement of viruses in the etiology of insulin-dependent diabetes was hypothesized more than 15 years ago based on solid scientific evidence, however; the true existence and the real nature of this involvement still eludes our efforts. This may be due to the frequently long interval between viral exposure and diabetes onset that makes the direct cause-effect relationship difficult to prove.
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Affiliation(s)
- M Pietropaolo
- The Division of Immunogenetics, Department of Pediatrics, Rangos Research Center, Children's Hospital of Pittsburgh, University of Pittsburgh, School of Medicine, Pittsburgh, PA 15213, USA
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13
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Luppi P, Rossiello MR, Faas S, Trucco M. Genetic background and environment contribute synergistically to the onset of autoimmune diseases. J Mol Med (Berl) 1995; 73:381-93. [PMID: 8528740 DOI: 10.1007/bf00240137] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Autoimmune diseases result from the breakdown of "self" tolerance. Environmental factors appear to be responsible for triggering this errant immune response, directed against self-tissue determinants, only when a susceptible genetic background is present in an individual. Autoimmune diseases, normally characterized by their association with certain HLA alleles, also share other features: the presence of autoantibodies, autoreactive T lymphocytes, and an intermittent clinical course of exacerbations and remissions. In cases of organ-specific diseases, as well as in cases of multi-system autoimmune diseases, viruses are increasingly implicated as such environmental triggers. Current molecular biology techniques have permitted a fine dissection of the genetic background of susceptible individuals and have enabled a more complete characterization of the immunocompetent cells involved in this autoaggression. Molecular approaches will soon allow us to pinpoint the characteristics of the environmental stimuli, so that protective strategies could be formulated to spare susceptible individuals from their ill effects.
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Affiliation(s)
- P Luppi
- Department of Pediatrics, Rangos Research Center, Children's Hospital of Pittsburgh, University of Pittsburg, School of Medicine, PA 15213, USA
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