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Lupia T, Corcione S, Staffilano E, Bosio R, Curtoni A, Busca A, De Rosa FG. Disseminated Enterovirus Infection in a Patient Affected by Follicular Lymphoma Treated with Obinutuzumab: A Case Report and a Narrative Review of the Literature. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:495. [PMID: 38541221 PMCID: PMC10972032 DOI: 10.3390/medicina60030495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Revised: 03/04/2024] [Accepted: 03/12/2024] [Indexed: 04/09/2024]
Abstract
Background and Objectives: the principal purpose of this literature review is to cluster adults with hematological malignancies after treatment or on maintenance with obinutuzumab who experienced disseminated EV infection to understand clinical characteristics and outcome of this rare condition in these patients. We report the first clinical case of a male affected by follicular lymphoma treated with immune-chemotherapy including obinutuzumab who was affected by disseminated EV infection with cardiovascular involvement. Materials and Methods: this narrative review summarizes all the research about disseminated EV infection in immunosuppressed adult patients treated with obinutuzumab from January 2000 to January 2024 using the Scale for the Assessment of Narrative Review Articles (SANRA) flow-chart. We performed a descriptive statistic using the standard statistical measures for quantitative data. Results: we included six studies, five case reports, and one case report with literature analysis. We collected a total of seven patients, all female, with disseminated EV infection. The most common signs and clinical presentations of EV infection were fever and encephalitis symptoms (N = 6, 85.7%), followed by hepatitis/acute liver failure (N = 5, 71.4%). Conclusions: onco-hematological patients who receive immune-chemotherapy with a combination of treatments which depress adaptative immunity, which includes the antiCD20 obinutuzumab, could be at higher risk of disseminated EV infection, including CNS and cardiac involvement.
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Affiliation(s)
- Tommaso Lupia
- Unit of Infectious Diseases, AOU City of Health and Sciences, 10100 Turin, Italy; (S.C.); (F.G.D.R.)
| | - Silvia Corcione
- Unit of Infectious Diseases, AOU City of Health and Sciences, 10100 Turin, Italy; (S.C.); (F.G.D.R.)
- Department of Medical Sciences, Infectious Diseases, University of Turin, 10126 Turin, Italy; (E.S.); (R.B.)
| | - Elena Staffilano
- Department of Medical Sciences, Infectious Diseases, University of Turin, 10126 Turin, Italy; (E.S.); (R.B.)
| | - Roberta Bosio
- Department of Medical Sciences, Infectious Diseases, University of Turin, 10126 Turin, Italy; (E.S.); (R.B.)
| | - Antonio Curtoni
- Microbiology and Virology Unit, AOU City of Health and Sciences, 10100 Turin, Italy;
| | - Alessandro Busca
- Department of Oncology, Stem Cell Transplant Center, Città Della Salute e Della Scienza Hospital, 10100 Turin, Italy;
| | - Francesco Giuseppe De Rosa
- Unit of Infectious Diseases, AOU City of Health and Sciences, 10100 Turin, Italy; (S.C.); (F.G.D.R.)
- Department of Medical Sciences, Infectious Diseases, University of Turin, 10126 Turin, Italy; (E.S.); (R.B.)
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Kilich G, Perelygina L, Sullivan KE. Rubella virus chronic inflammatory disease and other unusual viral phenotypes in inborn errors of immunity. Immunol Rev 2024; 322:113-137. [PMID: 38009321 DOI: 10.1111/imr.13290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2023]
Abstract
Infectious susceptibility is a component of many inborn errors of immunity. Nevertheless, antibiotic use is often used as a surrogate in history taking for infectious susceptibility, thereby disadvantaging patients who present with viral infections as their phenotype. Further complicating clinical evaluations are unusual manifestations of viral infections which may be less familiar that the typical respiratory viral infections. This review covers several unusual viral phenotypes arising in patients with inborn errors of immunity and other settings of immune compromise. In some cases, chronic infections lead to oncogenesis or tumor-like growths and the conditions and mechanisms of viral-induced oncogenesis will be described. This review covers enterovirus, rubella, measles, papillomavirus, and parvovirus B19. It does not cover EBV and hemophagocytic lymphohistiocytosis nor lymphomagenesis related to EBV. EBV susceptibility has been recently reviewed. Our goal is to increase awareness of the unusual manifestations of viral infections in patients with IEI and to describe treatment modalities utilized in this setting. Coincidentally, each of the discussed viral infections can have a cutaneous component and figures will serve as a reminder of the physical features of these viruses. Given the high morbidity and mortality, early recognition can only improve outcomes.
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Affiliation(s)
- Gonench Kilich
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Ludmila Perelygina
- Division of Viral Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
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Thomas SJ, Ouellette CP. Viral meningoencephalitis in pediatric solid organ or hematopoietic cell transplant recipients: a diagnostic and therapeutic approach. Front Pediatr 2024; 12:1259088. [PMID: 38410764 PMCID: PMC10895047 DOI: 10.3389/fped.2024.1259088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2023] [Accepted: 01/26/2024] [Indexed: 02/28/2024] Open
Abstract
Neurologic complications, both infectious and non-infectious, are frequent among hematopoietic cell transplant (HCT) and solid organ transplant (SOT) recipients. Up to 46% of HCT and 50% of SOT recipients experience a neurological complication, including cerebrovascular accidents, drug toxicities, as well as infections. Defects in innate, adaptive, and humoral immune function among transplant recipients predispose to opportunistic infections, including central nervous system (CNS) disease. CNS infections remain uncommon overall amongst HCT and SOT recipients, compromising approximately 1% of total cases among adult patients. Given the relatively lower number of pediatric transplant recipients, the incidence of CNS disease amongst in this population remains unknown. Although infections comprise a small percentage of the neurological complications that occur post-transplant, the associated morbidity and mortality in an immunosuppressed state makes it imperative to promptly evaluate and aggressively treat a pediatric transplant patient with suspicion for viral meningoencephalitis. This manuscript guides the reader through a broad infectious and non-infectious diagnostic differential in a transplant recipient presenting with altered mentation and fever and thereafter, elaborates on diagnostics and management of viral meningoencephalitis. Hypothetical SOT and HCT patient cases have also been constructed to illustrate the diagnostic and management process in select viral etiologies. Given the unique risk for various opportunistic viral infections resulting in CNS disease among transplant recipients, the manuscript will provide a contemporary review of the epidemiology, risk factors, diagnosis, and management of viral meningoencephalitis in these patients.
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Affiliation(s)
- Sanya J. Thomas
- Host Defense Program, Section of Infectious Diseases, Nationwide Children’s Hospital, Columbus, OH, United States
- Division of Infectious Diseases, Department of Pediatrics, Ohio State University College of Medicine, Columbus, OH, United States
| | - Christopher P. Ouellette
- Host Defense Program, Section of Infectious Diseases, Nationwide Children’s Hospital, Columbus, OH, United States
- Division of Infectious Diseases, Department of Pediatrics, Ohio State University College of Medicine, Columbus, OH, United States
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Jacksch C, Dargvainiene J, Böttcher S, Diedrich S, Leypoldt F, Stürner K, Berg D, Schäffer E. Chronic Enterovirus Meningoencephalitis in Prolonged B-Cell Depletion After Rituximab Therapy: Case Report. NEUROLOGY(R) NEUROIMMUNOLOGY & NEUROINFLAMMATION 2023; 10:e200171. [PMID: 37813597 PMCID: PMC10574820 DOI: 10.1212/nxi.0000000000200171] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 08/31/2023] [Indexed: 10/15/2023]
Abstract
OBJECTIVES Persistent impaired immunity is possible even years after B-cell depleting therapies. This may favor the occurrence of infections, including infectious meningitis and encephalitis. In this study, we report a case of chronic enterovirus meningoencephalitis in prolonged B-cell depletion years after rituximab therapy. METHODS This is a case report from a German academic hospital. In addition to repeated clinical examinations, repeated brain MRI and extended CSF and laboratory diagnostics were performed. We used the CARE checklist when writing our report. RESULTS A 38-year-old man presented with high fever (>40°C), severe headache, and progressive neurologic and cognitive deficits. As result of previous lymphoma therapy with rituximab years ago, prolonged B-cell aplasia was detected. To restore humoral immunity, the patient received repeated infusions of immunoglobulins. In the end, a complete restitution of the physical and mental condition was achieved with the established therapy. DISCUSSION This case report should emphasize the importance of assessing humoral immunity even years after B-cell depletion therapy, especially in case of opportunistic infections.
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Affiliation(s)
- Clemens Jacksch
- From the Klinik für Neurologie (C.J., F.L., K.S., D.B., E.S.); Institut für Klinische Chemie (J.D., F.L.), Universitätsklinikum Schleswig-Holstein, Kiel/Lübeck; and Robert Koch Institut (S.B., S.D.), Nationales Referenzzentrum für Poliomyelitis und Enteroviren, Berlin, Deutschland.
| | - Justina Dargvainiene
- From the Klinik für Neurologie (C.J., F.L., K.S., D.B., E.S.); Institut für Klinische Chemie (J.D., F.L.), Universitätsklinikum Schleswig-Holstein, Kiel/Lübeck; and Robert Koch Institut (S.B., S.D.), Nationales Referenzzentrum für Poliomyelitis und Enteroviren, Berlin, Deutschland
| | - Sindy Böttcher
- From the Klinik für Neurologie (C.J., F.L., K.S., D.B., E.S.); Institut für Klinische Chemie (J.D., F.L.), Universitätsklinikum Schleswig-Holstein, Kiel/Lübeck; and Robert Koch Institut (S.B., S.D.), Nationales Referenzzentrum für Poliomyelitis und Enteroviren, Berlin, Deutschland
| | - Sabine Diedrich
- From the Klinik für Neurologie (C.J., F.L., K.S., D.B., E.S.); Institut für Klinische Chemie (J.D., F.L.), Universitätsklinikum Schleswig-Holstein, Kiel/Lübeck; and Robert Koch Institut (S.B., S.D.), Nationales Referenzzentrum für Poliomyelitis und Enteroviren, Berlin, Deutschland
| | - Frank Leypoldt
- From the Klinik für Neurologie (C.J., F.L., K.S., D.B., E.S.); Institut für Klinische Chemie (J.D., F.L.), Universitätsklinikum Schleswig-Holstein, Kiel/Lübeck; and Robert Koch Institut (S.B., S.D.), Nationales Referenzzentrum für Poliomyelitis und Enteroviren, Berlin, Deutschland
| | - Klarissa Stürner
- From the Klinik für Neurologie (C.J., F.L., K.S., D.B., E.S.); Institut für Klinische Chemie (J.D., F.L.), Universitätsklinikum Schleswig-Holstein, Kiel/Lübeck; and Robert Koch Institut (S.B., S.D.), Nationales Referenzzentrum für Poliomyelitis und Enteroviren, Berlin, Deutschland
| | - Daniela Berg
- From the Klinik für Neurologie (C.J., F.L., K.S., D.B., E.S.); Institut für Klinische Chemie (J.D., F.L.), Universitätsklinikum Schleswig-Holstein, Kiel/Lübeck; and Robert Koch Institut (S.B., S.D.), Nationales Referenzzentrum für Poliomyelitis und Enteroviren, Berlin, Deutschland
| | - Eva Schäffer
- From the Klinik für Neurologie (C.J., F.L., K.S., D.B., E.S.); Institut für Klinische Chemie (J.D., F.L.), Universitätsklinikum Schleswig-Holstein, Kiel/Lübeck; and Robert Koch Institut (S.B., S.D.), Nationales Referenzzentrum für Poliomyelitis und Enteroviren, Berlin, Deutschland
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Weng KF, Tee HK, Tseligka ED, Cagno V, Mathez G, Rosset S, Nagamine CM, Sarnow P, Kirkegaard K, Tapparel C. Variant enterovirus A71 found in immune-suppressed patient binds to heparan sulfate and exhibits neurotropism in B-cell-depleted mice. Cell Rep 2023; 42:112389. [PMID: 37058406 PMCID: PMC10590055 DOI: 10.1016/j.celrep.2023.112389] [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: 07/08/2022] [Revised: 01/30/2023] [Accepted: 03/29/2023] [Indexed: 04/15/2023] Open
Abstract
Enterovirus A71 (EV-A71) causes hand, foot, and mouth disease outbreaks with neurological complications and deaths. We previously isolated an EV-A71 variant in the stool, cerebrospinal fluid, and blood of an immunocompromised patient who had a leucine-to-arginine substitution on the VP1 capsid protein, resulting in increased heparin sulfate binding. We show here that this mutation increases the virus's pathogenicity in orally infected mice with depleted B cells, which mimics the patient's immune status, and increases susceptibility to neutralizing antibodies. However, a double mutant with even greater heparin sulfate affinity is not pathogenic, suggesting that increased heparin sulfate affinity may trap virions in peripheral tissues and reduce neurovirulence. This research sheds light on the increased pathogenicity of variant with heparin sulfate (HS)-binding ability in individuals with decreased B cell immunity.
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Affiliation(s)
- Kuo-Feng Weng
- Department of Microbiology and Immunology, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Han Kang Tee
- Department of Microbiology and Molecular Medicine, University of Geneva Medical School, Geneva, Switzerland
| | - Eirini D Tseligka
- Department of Microbiology and Molecular Medicine, University of Geneva Medical School, Geneva, Switzerland
| | - Valeria Cagno
- Department of Microbiology and Molecular Medicine, University of Geneva Medical School, Geneva, Switzerland
| | - Gregory Mathez
- Department of Microbiology and Molecular Medicine, University of Geneva Medical School, Geneva, Switzerland
| | - Stéphane Rosset
- Department of Microbiology and Molecular Medicine, University of Geneva Medical School, Geneva, Switzerland
| | - Claude M Nagamine
- Department of Comparative Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Peter Sarnow
- Department of Microbiology and Immunology, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Karla Kirkegaard
- Department of Microbiology and Immunology, Stanford University School of Medicine, Stanford, CA 94305, USA; Department of Genetics, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Caroline Tapparel
- Department of Microbiology and Molecular Medicine, University of Geneva Medical School, Geneva, Switzerland.
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Grammatikos A, Moghaddas F, Reeve H, Johnston S, Gompels M, Albur M. Low circulating B cells in immunocompromised individuals are linked to poorer antibody responses to vaccines and a predisposition to viral infections. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. GLOBAL 2023; 2:111-113. [PMID: 37780112 PMCID: PMC10509987 DOI: 10.1016/j.jacig.2022.07.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 06/28/2022] [Accepted: 07/18/2022] [Indexed: 10/03/2023]
Abstract
Background B cells play an important role in protection against viral infections, not only through the production of antibodies but also through their ability to act as antigen-presenting cells and produce cytokines. Objectives To assess whether there is a link between low circulating B-cell counts and a predisposition to viral infections in immunocompromised individuals, we performed a retrospective cohort analysis at 2 National Health Service Clinical Immunology sites in England. Methods Eligible patients were adults who were either diagnosed with or under investigation for an immunodeficiency and had recorded circulating B-cell counts. Information on viral infections was collected by using the departmental, hospital, and laboratory electronic information systems. A generalized linear model was used to analyze the relationship between B-cell counts and relevant indices of viral infection while controlling for patient age, diagnosis group, and T-cell and natural killer cell counts. Results A total of 376 eligible patients were identified, 134 of whom had B-cell counts that were below the laboratory-defined refence range (<0.11 ×109/L). Patients with low numbers of circulating B cells had lower pretreatment immunoglobulin levels and poorer antibody responses to vaccines (Streptococcus pneumonia, Clostridium tetani, and Haemophilus influenzae type B). An increased number of chronic or recurrent (P = .001), severe or unusual (P = .001), and PCR-confirmed viral infections (P = .04) were recorded in these patients versus in those with normal numbers of circulating B cells. Conclusion Overall, there was a statistically significant association between low circulating B-cell counts and the incidence of clinically important viral infections in this patient cohort, even when controlling for relevant covariates. Clinicians caring for patients with immunodeficiency should be vigilant for these types of infections, particularly in patients with low peripheral B-cell counts. A prospective study will be required to confirm these findings.
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Affiliation(s)
- Alexandros Grammatikos
- Bristol Immunology and Allergy Centre, Southmead Hospital, North Bristol NHS Trust, Bristol, United Kingdom
| | - Fiona Moghaddas
- Bristol Immunology and Allergy Centre, Southmead Hospital, North Bristol NHS Trust, Bristol, United Kingdom
| | - Henry Reeve
- School of Mathematics, University of Bristol, Bristol, United Kingdom
| | - Sarah Johnston
- Bristol Immunology and Allergy Centre, Southmead Hospital, North Bristol NHS Trust, Bristol, United Kingdom
| | - Mark Gompels
- Bristol Immunology and Allergy Centre, Southmead Hospital, North Bristol NHS Trust, Bristol, United Kingdom
| | - Mahableshwar Albur
- Bristol Centre for Antimicrobial Research and Evaluation, North Bristol NHS Trust, Bristol, United Kingdom
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Luciani L, Bichon A, Mortier C, Bourenne J, Carvelli J, Gainnier M, Doudier B, Chalvignac V, Zandotti C, Nougairède A. Acute hepatitis associated with an echovirus 9 infection in a heart transplant recipient. J Med Virol 2023; 95:e28262. [PMID: 36310370 DOI: 10.1002/jmv.28262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2022] [Revised: 09/28/2022] [Accepted: 10/27/2022] [Indexed: 11/07/2022]
Affiliation(s)
- Léa Luciani
- Unité des Virus Émergents (UVE), Aix-Marseille Université, Marseille, France.,Assistance Publique-Hôpitaux de Marseille (AP-HM), IHU Méditerranée infection, Service de Virologie Aigue et Tropicale, Marseille, France
| | - Amandine Bichon
- Service de Réanimation des Urgences, Assistance Publique-Hôpitaux de Marseille (AP-HM), Centre Hospitalo-Universitaire Timone, Marseille, France
| | - Coline Mortier
- Assistance Publique-Hôpitaux de Marseille (AP-HM), IHU Méditerranée Infection, Service d'infectiologie, Marseille, France
| | - Jérémy Bourenne
- Service de Réanimation des Urgences, Assistance Publique-Hôpitaux de Marseille (AP-HM), Centre Hospitalo-Universitaire Timone, Marseille, France
| | - Julien Carvelli
- Service de Réanimation des Urgences, Assistance Publique-Hôpitaux de Marseille (AP-HM), Centre Hospitalo-Universitaire Timone, Marseille, France
| | - Marc Gainnier
- Service de Réanimation des Urgences, Assistance Publique-Hôpitaux de Marseille (AP-HM), Centre Hospitalo-Universitaire Timone, Marseille, France
| | - Barbara Doudier
- Assistance Publique-Hôpitaux de Marseille (AP-HM), IHU Méditerranée Infection, Service d'infectiologie, Marseille, France
| | - Virginie Chalvignac
- Assistance Publique-Hôpitaux de Marseille (AP-HM), Service de Chirurgie Cardio-Thoracique, Centre Hospitalo-Universitaire Timone, Marseille, France
| | - Christine Zandotti
- Unité des Virus Émergents (UVE), Aix-Marseille Université, Marseille, France.,Assistance Publique-Hôpitaux de Marseille (AP-HM), IHU Méditerranée infection, Service de Virologie Aigue et Tropicale, Marseille, France
| | - Antoine Nougairède
- Unité des Virus Émergents (UVE), Aix-Marseille Université, Marseille, France.,Assistance Publique-Hôpitaux de Marseille (AP-HM), IHU Méditerranée infection, Service de Virologie Aigue et Tropicale, Marseille, France
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Anderson SM, Gold D, Olson G, Pisano J. Chronic aseptic meningitis caused by enterovirus in a humorally immunosuppressed adult patient presenting with sensorineural hearing loss: a case report. BMC Infect Dis 2022; 22:16. [PMID: 34983409 PMCID: PMC8725248 DOI: 10.1186/s12879-021-06956-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 12/07/2021] [Indexed: 11/10/2022] Open
Abstract
Background Enterovirus has been described as a cause of aseptic meningitis in humorally immunosuppressed patients. Case presentation A 67-year-old female with a history of mantle cell lymphoma on rituximab therapy presented with subacute hepatitis, myalgias, and sensorineural hearing loss several months after an initial febrile illness. She was diagnosed with enterovirus infection by CSF PCR as a unifying etiology of her presentation, representing an unusual presentation of disease. Discussion and conclusions This patient’s unique presentation and clinical course presents important implications in the care of similarly immunosuppressed patients with cryptic complaints.
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Affiliation(s)
- Sean M Anderson
- Division of Internal Medicine, The University of Chicago Medicine, 5841 S Maryland Avenue, Suite 3C, Chicago, IL, 60637, USA.
| | - Daniel Gold
- Division of Internal Medicine, The University of Chicago Medicine, 5841 S Maryland Avenue, Suite 3C, Chicago, IL, 60637, USA
| | - Gregory Olson
- Division of Infectious Diseases, The University of Chicago Medicine, 5841 S Maryland Avenue, Suite 5D, Chicago, IL, 60637, USA.
| | - Jennifer Pisano
- Division of Infectious Diseases, The University of Chicago Medicine, 5841 S Maryland Avenue, Suite 5D, Chicago, IL, 60637, USA
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Wagner JN, Leibetseder A, Troescher A, Panholzer J, von Oertzen TJ. Characteristics and therapy of enteroviral encephalitis: case report and systematic literature review. Int J Infect Dis 2021; 113:93-102. [PMID: 34628025 DOI: 10.1016/j.ijid.2021.10.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 09/24/2021] [Accepted: 10/02/2021] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVES Enterovirus (EV) is a frequent cause of encephalitis. The optimal therapeutic approach remains a matter of debate. We present the case of an immunosuppressed patient with EV encephalitis treated successfully with intravenous immunoglobulin (IVIG) and report the results of a systematic review on the characteristics of EV encephalitis, as well as the safety and efficacy of IVIG therapy. METHODS A systematic review was conducted using the PubMed, Cochrane Database, BIOSIS Previews, and ClinicalTrials.gov databases to identify all reports on patients with EV encephalitis as of December 31, 2020. The main outcomes assessed were the efficacy and safety of the respective therapeutic approach. RESULTS A total of 73 articles were included: one prospective trial, one retrospective and prospective case series, one purely retrospective case series, and 70 case reports. The case reports included a total of 101 patients. Immunosuppressed patients were at higher risk of contracting EV encephalitis and experiencing a fatal course. Hypogammaglobulinaemia particularly predisposes to EV disease, even with a moderate reduction in serum IgG levels. IVIG therapy in the immunosuppressed may confer a survival advantage. CONCLUSIONS IVIG therapy is rarely associated with severe adverse events and may be considered in immunosuppressed patients with EV encephalitis. Future trials should investigate the optimal IVIG dosing and route of application, the benefit of antibody-enriched IVIG preparations, and the serum immunoglobulin level that should trigger prophylactic replacement.
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Affiliation(s)
- Judith N Wagner
- Department of Neurology 1, Kepler University Hospital, Johannes Kepler University Linz, Wagner-Jauregg-Weg 15, 4020 Linz, Austria.
| | - Annette Leibetseder
- Department of Neurology 1, Kepler University Hospital, Johannes Kepler University Linz, Wagner-Jauregg-Weg 15, 4020 Linz, Austria
| | - Anna Troescher
- Department of Neurology 1, Kepler University Hospital, Johannes Kepler University Linz, Wagner-Jauregg-Weg 15, 4020 Linz, Austria
| | - Juergen Panholzer
- Department of Neurology 1, Kepler University Hospital, Johannes Kepler University Linz, Wagner-Jauregg-Weg 15, 4020 Linz, Austria
| | - Tim J von Oertzen
- Department of Neurology 1, Kepler University Hospital, Johannes Kepler University Linz, Wagner-Jauregg-Weg 15, 4020 Linz, Austria
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10
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McNeil T, Hannah R, Hui CH, Qiao M. Disseminated enterovirus infection in a patient treated with obinutuzumab. J Med Virol 2021; 94:439-441. [PMID: 34590740 DOI: 10.1002/jmv.27370] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2021] [Revised: 09/22/2021] [Accepted: 09/28/2021] [Indexed: 11/06/2022]
Affiliation(s)
- Thomas McNeil
- Division of Medicine, Lyell McEwin Hospital, Adelaide, South Australia, Australia.,College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
| | - Rory Hannah
- Division of Medicine, Lyell McEwin Hospital, Adelaide, South Australia, Australia
| | - Chi-Hung Hui
- Clinical Haematology, Icon Cancer Centre, Adelaide, South Australia, Australia
| | - Ming Qiao
- Microbiology and Infectious Diseases, SA Pathology, South Australia, Australia
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Grammatikos A, Donati M, Johnston SL, Gompels MM. Peripheral B Cell Deficiency and Predisposition to Viral Infections: The Paradigm of Immune Deficiencies. Front Immunol 2021; 12:731643. [PMID: 34527001 PMCID: PMC8435594 DOI: 10.3389/fimmu.2021.731643] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2021] [Accepted: 08/09/2021] [Indexed: 12/11/2022] Open
Abstract
In the era of COVID-19, understanding how our immune system responds to viral infections is more pertinent than ever. Immunodeficiencies with very low or absent B cells offer a valuable model to study the role of humoral immunity against these types of infection. This review looks at the available evidence on viral infections in patients with B cell alymphocytosis, in particular those with X-linked agammaglobulinemia (XLA), Good’s syndrome, post monoclonal-antibody therapy and certain patients with Common Variable Immune Deficiency (CVID). Viral infections are not as infrequent as previously thought in these conditions and individuals with very low circulating B cells seem to be predisposed to an adverse outcome. Particularly in the case of SARS-CoV2 infection, mounting evidence suggests that peripheral B cell alymphocytosis is linked to a poor prognosis.
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Affiliation(s)
- Alexandros Grammatikos
- Department of Immunology, Southmead Hospital, North Bristol National Health Service (NHS) Trust, Bristol, United Kingdom
| | - Matthew Donati
- Severn Infection Sciences and Public Health England National Infection Service South West, Department of Virology, Southmead Hospital, North Bristol NHS Trust, Bristol, United Kingdom
| | - Sarah L Johnston
- Department of Immunology, Southmead Hospital, North Bristol National Health Service (NHS) Trust, Bristol, United Kingdom
| | - Mark M Gompels
- Department of Immunology, Southmead Hospital, North Bristol National Health Service (NHS) Trust, Bristol, United Kingdom
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12
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Enterovirus A71 causing meningoencephalitis and acute flaccid myelitis in a patient receiving rituximab. J Neuroimmunol 2021; 358:577639. [PMID: 34214953 DOI: 10.1016/j.jneuroim.2021.577639] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 06/15/2021] [Accepted: 06/21/2021] [Indexed: 11/23/2022]
Abstract
We present the case of a young woman being treated with rituximab for rheumatoid arthritis who developed a severe enteroviral meningoencephalitis and acute flaccid myelitis (AFM). Cerebrospinal fluid (CSF) and stool reverse transcription-polymerase chain reaction (RT-PCR) testing confirmed the diagnosis and additional sequencing studies performed at the CDC further characterized the enterovirus as enterovirus A71 (EV-A71). After treatment with intravenous immunoglobulin (IVIg) and fluoxetine (based on previous reports of possible efficacy) the patient experienced a remarkable improvement over time. This case highlights the importance of considering enteroviral infection in patients treated with rituximab, depicts a possible clinical course of enteroviral meningoencephalitis and AFM, and illustrates the importance of testing multiple sites for enterovirus infection (CSF, stool, nasopharyngeal swab, blood). Here we present the case with a brief review of the literature pertaining to EV-A71.
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13
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Tekin B, Boire N, Shah K, Hanson J, Bridges AG. Viral panniculitis in a patient with disseminated opportunistic Enterovirus infection. J Cutan Pathol 2020; 48:434-438. [PMID: 33277938 DOI: 10.1111/cup.13930] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2020] [Revised: 11/10/2020] [Accepted: 11/24/2020] [Indexed: 02/01/2023]
Abstract
Infection-induced panniculitis has been described in association with a broad range of microorganisms. Among those, viral panniculitis represents a minor category, with only a few anecdotal reports in the literature documenting viral infection in the subcutaneous fat. Herein, we report a woman in her 30s with seropositive rheumatoid arthritis on rituximab and prednisone, who presented with a 6-month history of progressive multisystem manifestations, including unintentional weight loss, fever, fatigue, myopathy, pancreatitis, and sensorineural hearing loss. She had indurated plaques on her thighs characterized by predominantly lobular panniculitis with chronic lymphohistiocytic inflammation. Molecular studies performed at the Centers for Disease Control and Prevention identified evidence of Enterovirus group with the highest identity of Coxsackievirus A9. Enterovirus RNA was also detected in the cerebrospinal fluid and muscle. Based on the findings, a diagnosis of disseminated enteroviral infection in the setting of B-cell depletion was rendered. To the best of our knowledge, this represents the first reported case of viral panniculitis with documentation of Coxsackievirus A9 in the skin. Since rituximab may be used for the treatment of autoimmune dermatological diseases, familiarity of the potential occurrence of severe enteroviral infections in the setting of immunosuppressive treatment is important for dermatopathologists.
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Affiliation(s)
- Burak Tekin
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Nicholas Boire
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Kabeer Shah
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA.,Department of Pathology, St. Mary's Hospital, Madison, Wisconsin, USA
| | - Jennifer Hanson
- Department of Dermatology, Mayo Clinic, Rochester, Minnesota, USA.,Division of Dermatology, Vitality Skincare, Austin, Texas, USA
| | - Alina G Bridges
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA.,Department of Dermatology, Mayo Clinic, Rochester, Minnesota, USA.,Division of Dermatopathology, Dermpath Diagnostics/Richfield Laboratory of Dermatopathology, Cincinnati, Ohio, USA
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14
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Higer M, Cana D, Podlech J, Schadmand-Fischer S, Schwarting A, Teschner D, Theobald M, Wölfel T, Hess G. Life-threatening disseminated enterovirus infection during combined rituximab and ibrutinib maintenance treatment for mantle cell lymphoma: a case report. J Med Case Rep 2020; 14:135. [PMID: 32859260 PMCID: PMC7456041 DOI: 10.1186/s13256-020-02457-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Accepted: 07/15/2020] [Indexed: 11/10/2022] Open
Abstract
Background Rituximab is a well-established component of treatment regimens for B-cell non-Hodgkin lymphoma. Rituximab binds the CD20 antigen on the surface of B lymphocytes, causing an enhanced clearance of malignant and benign B cells. Thus, rituximab leads to depletion of normal B lymphocytes as well, which can cause substantial immunodeficiency. Ibrutinib inhibits the Bruton tyrosine kinase and thereby B-cell activity. It is used for the treatment of different B-lymphocyte malignancies, such as mantle cell lymphoma. Recently, the combination of both drugs has been tested in various clinical scenarios. Case presentation We present a case of disseminated enterovirus infection resulting from combined rituximab and ibrutinib maintenance treatment in a 57-year-old Caucasian patient. with mantle cell lymphoma. Initially presenting with myositis symptoms, further diagnostic investigation revealed myocarditis, enteritis, myeloencephalitis, and hepatitis. These organ manifestations led to potentially life-threatening complications such as rhabdomyolysis, delirium, and heart rhythm disturbances. After treatment with high-dose intravenous immunoglobulins, virus clearance was achieved and organ functions could be restored. Conclusions This case emphasizes the risk of combined therapy with rituximab/ibrutinib for severe immune-related side effects with the necessity of continuous patient monitoring. High-dose intravenous therapy should be considered as treatment for severe enterovirus infection. In severe enterovirus infections, we recommend subtyping for the development of efficient preventive and therapeutic strategies.
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Affiliation(s)
- Maximilian Higer
- Department of Hematology, Medical Oncology & Pneumology, University Medical Center of the Johannes Gutenberg-University, Langenbeckstrasse 1, D-55131, Mainz, Germany.
| | - Denis Cana
- Division of Neuropathology, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Juergen Podlech
- Institute for Virology, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Simin Schadmand-Fischer
- Department of Diagnostic and Interventional Radiology, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Andreas Schwarting
- Department of Internal Medicine I (Gastroenterology, Hepatology, Nephrology, Rheumatology, Infectiology and Immunology), University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Daniel Teschner
- Department of Hematology, Medical Oncology & Pneumology, University Medical Center of the Johannes Gutenberg-University, Langenbeckstrasse 1, D-55131, Mainz, Germany
| | - Matthias Theobald
- Department of Hematology, Medical Oncology & Pneumology, University Medical Center of the Johannes Gutenberg-University, Langenbeckstrasse 1, D-55131, Mainz, Germany
| | - Thomas Wölfel
- Department of Hematology, Medical Oncology & Pneumology, University Medical Center of the Johannes Gutenberg-University, Langenbeckstrasse 1, D-55131, Mainz, Germany
| | - Georg Hess
- Department of Hematology, Medical Oncology & Pneumology, University Medical Center of the Johannes Gutenberg-University, Langenbeckstrasse 1, D-55131, Mainz, Germany
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15
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Luciani L, Ninove L, Zandotti C, Chalvignac V, Lagier D, Baume J, Mélade J, Piorkowski G, Coutard B, Lepidi H, Pelletier J, Audoin B, Rico-Lamy A, Nougairède A. Fatal underhanded chronic enterovirus infection associated with anti-CD20 monotherapy for central nervous system demyelinating disease. Mult Scler 2020; 27:320-323. [DOI: 10.1177/1352458520923978] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
We report a fatal case of coxsackievirus B4 chronic infection in a 30-year-old woman with a diagnosis of myelin oligodendrocyte glycoprotein antibody-associated disorder controlled by rituximab monotherapy for 3 years. Initially presenting as self-limited meningitis, the infection remained silent for 8 months before the sudden onset of fulminant myocarditis. Analysis of the complete genome showed that the same virus was responsible for both episodes.
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Affiliation(s)
- Léa Luciani
- Unité des Virus Émergents (UVE: Aix-Marseille Univ-IRD 190-Inserm 1207-IHU Méditerranée Infection), Marseille, France; Laboratoire de microbiologie (Assistance Publique – Hôpitaux de Marseille; IHU Méditerranée Infection) Marseille, France
| | - Laetitia Ninove
- Unité des Virus Émergents (UVE: Aix-Marseille Univ-IRD 190-Inserm 1207-IHU Méditerranée Infection), Marseille, France; Laboratoire de microbiologie (Assistance Publique – Hôpitaux de Marseille; IHU Méditerranée Infection) Marseille, France
| | - Christine Zandotti
- Unité des Virus Émergents (UVE: Aix-Marseille Univ-IRD 190-Inserm 1207-IHU Méditerranée Infection), Marseille, France; Laboratoire de microbiologie (Assistance Publique – Hôpitaux de Marseille; IHU Méditerranée Infection) Marseille, France
| | - Virginie Chalvignac
- Assistance publique–hôpitaux de Marseille (AP-HM), Centre Hospitalo-Universitaire Timone, Service de chirurgie cardio-thoracique, Marseille, France
| | - David Lagier
- Aix-Marseille University, APHM, Hôpital de la Timone, Service d’Anesthésie et de Réanimation, Marseille, France
| | - Julien Baume
- Laboratoire de microbiologie (Assistance Publique – Hôpitaux de Marseille; IHU Méditerranée Infection), Marseille, France
| | - Julien Mélade
- Unité des Virus Émergents (UVE: Aix-Marseille Univ-IRD 190-Inserm 1207-IHU Méditerranée Infection), Marseille, France
| | - Géraldine Piorkowski
- Unité des Virus Émergents (UVE: Aix-Marseille Univ-IRD 190-Inserm 1207-IHU Méditerranée Infection), Marseille, France
| | - Bruno Coutard
- Unité des Virus Émergents (UVE: Aix-Marseille Univ-IRD 190-Inserm 1207-IHU Méditerranée Infection), Marseille, France
| | - Hubert Lepidi
- Laboratoire d’anatomo-pathologie, APHM, Aix Marseille Univ, IRD, MEPHI, IHU Méditerranée Infection, Marseille, France
| | - Jean Pelletier
- Pôle de Neurosciences Cliniques, Service de Neurologie, APHM, Hôpital de la Timone, Marseille, France/CRMBM UMR 7339, CNRS, Aix-Marseille Université, Marseille, France
| | - Bertrand Audoin
- Pôle de Neurosciences Cliniques, Service de Neurologie, APHM, Hôpital de la Timone, Marseille, France/CRMBM UMR 7339, CNRS, Aix-Marseille Université, Marseille, France
| | - Audrey Rico-Lamy
- Pôle de Neurosciences Cliniques, Service de Neurologie, APHM, Hôpital de la Timone, Marseille, France/CRMBM UMR 7339, CNRS, Aix-Marseille Université, Marseille, France
| | - Antoine Nougairède
- Unité des Virus Émergents (UVE: Aix-Marseille Univ-IRD 190-Inserm 1207-IHU Méditerranée Infection), Marseille, France; Laboratoire de microbiologie (Assistance Publique – Hôpitaux de Marseille; IHU Méditerranée Infection) Marseille, France
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16
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Nicolini LA, Canepa P, Caligiuri P, Mikulska M, Novi G, Viscoli C, Uccelli A. Fulminant Hepatitis Associated With Echovirus 25 During Treatment With Ocrelizumab for Multiple Sclerosis. JAMA Neurol 2020; 76:866-867. [PMID: 30958517 DOI: 10.1001/jamaneurol.2019.0522] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Laura Ambra Nicolini
- Department of Health Sciences, University of Genoa, Genoa, Italy.,Infectious Diseases Unit, Ospedale Policlinico San Martino-Istituto Di Ricovero e Cura a Carattere Scientifico, Genoa, Italy
| | - Paola Canepa
- Department of Health Sciences, University of Genoa, Genoa, Italy
| | | | - Malgorzata Mikulska
- Department of Health Sciences, University of Genoa, Genoa, Italy.,Infectious Diseases Unit, Ospedale Policlinico San Martino-Istituto Di Ricovero e Cura a Carattere Scientifico, Genoa, Italy
| | - Giovanni Novi
- Department of Neurology, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health and Center of Excellence for Biomedical Research, University of Genoa, Genoa, Italy
| | - Claudio Viscoli
- Department of Health Sciences, University of Genoa, Genoa, Italy.,Infectious Diseases Unit, Ospedale Policlinico San Martino-Istituto Di Ricovero e Cura a Carattere Scientifico, Genoa, Italy
| | - Antonio Uccelli
- Department of Neurology, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health and Center of Excellence for Biomedical Research, University of Genoa, Genoa, Italy.,Ospedale Policlinico San Martino-Istituto Di Ricovero e Cura a Carattere Scientifico, Genoa, Italy
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17
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Maillet F, Pineton De Chambrun M, Monzani Q, Mercy G, Schuffenecker I, Mirand A, Deback C, Charlotte F, Fourniols E, Mathian A, Amoura Z. [Enteroviral infections in adults treated with rituximab: A new case of chronic meningitis and myofasciitis and literature review]. Rev Med Interne 2020; 41:200-205. [PMID: 31980187 DOI: 10.1016/j.revmed.2019.12.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Revised: 12/07/2019] [Accepted: 12/23/2019] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Chronic enterovirus infections can occur in primary immunodeficiency with hypogammaglobulinemia. They usually associate meningitis and myofasciitis. Such infections have also been described in adults with rituximab-induced hypogammaglobulinemia. CASE REPORT We report the case of a 33-year-old woman who was given rituximab for immune thrombocytopenia and developed rituximab-induced hypogammaglobulinemia (IgG 4.4g/L). One year after the last rituximab infusion, she developed lower limbs myofasciitis, followed two months later by a chronic lymphocytic meningitis. PCR in the serum and the cerebrospinal fluid at the time of the meningitis and the myofasciitis were positive to the same enterovirus (echovirus 11) while it was negative in the fascia biopsy. Under treatment with intravenous immunoglobulins, all symptoms and laboratory abnormalities improved and enterovirus PCR became negative. CONCLUSION We report a case of chronic enterovirus infection associating meningitis and myofasciitis in an adult with rituximab-induced hypogammaglobulinemia. Outcome was favorable under treatment with intravenous immunoglobulins.
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Affiliation(s)
- F Maillet
- Service de médecine interne 2, institut E3M, Sorbonne université, hôpital La Pitié-Salpêtrière, Assistance publique-hôpitaux de Paris (AP-HP), 47-83, boulevard de l'Hôpital, 75013 Paris, France
| | - M Pineton De Chambrun
- Service de médecine interne 2, institut E3M, Sorbonne université, hôpital La Pitié-Salpêtrière, Assistance publique-hôpitaux de Paris (AP-HP), 47-83, boulevard de l'Hôpital, 75013 Paris, France; Service de médecine intensive-réanimation, institut de cardiologie, Sorbonne université, hôpital La Pitié-Salpêtrière, AP-HP, 47-83, boulevard de l'Hôpital, 75013 Paris, France.
| | - Q Monzani
- Service de radiologie polyvalente et oncologique, Sorbonne université, hôpital La Pitié-Salpêtrière, AP-HP, 47-83, boulevard de l'Hôpital, 75013 Paris, France
| | - G Mercy
- Service de radiologie polyvalente et oncologique, Sorbonne université, hôpital La Pitié-Salpêtrière, AP-HP, 47-83, boulevard de l'Hôpital, 75013 Paris, France
| | - I Schuffenecker
- Laboratoire de virologie, centre national de référence des entérovirus, hospices civils de Lyon, 103, Grande-Rue-de-la-Croix-Rousse, 69004 Lyon, France
| | - A Mirand
- Laboratoire de virologie, centre national de référence des entérovirus, CHRU de Clermont-Ferrand, 58, rue Montalembert, 63000 Clermont-Ferrand, France
| | - C Deback
- Service de virologie, université Paris Sud, hôpital Paul Brousse, AP-HP, 12, avenue Paul-Vaillant-Couturier, 94800 Villejuif, France
| | - F Charlotte
- Service d'anatomopathologie, Sorbonne université, hôpital La Pitié-Salpêtrière, AP-HP, 47-83, boulevard de l'Hôpital, 75013 Paris, France
| | - E Fourniols
- Service de chirurgie orthopédique, Sorbonne université, hôpital La Pitié-Salpêtrière, AP-HP, 47-83, boulevard de l'Hôpital, 75013 Paris, France
| | - A Mathian
- Service de médecine interne 2, institut E3M, Sorbonne université, hôpital La Pitié-Salpêtrière, Assistance publique-hôpitaux de Paris (AP-HP), 47-83, boulevard de l'Hôpital, 75013 Paris, France
| | - Z Amoura
- Service de médecine interne 2, institut E3M, Sorbonne université, hôpital La Pitié-Salpêtrière, Assistance publique-hôpitaux de Paris (AP-HP), 47-83, boulevard de l'Hôpital, 75013 Paris, France
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18
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Abstract
Waldenstrom macroglobulinemia (WM) is a lymphoplasmacytic lymphoma that presents with symptomatic anemia, thrombocytopenia, constitutional symptoms, extramedullary disease and rarely hyperviscosity syndrome. The presence of both IgM monoclonal protein and ≥10% monoclonal lymphoplasmacytic cells is required for the diagnosis. MyD88 is present in 67-90% of patients but is not pathognomonic for WM. Many patients who fulfill the criteria of WM are asymptomatic and do not require treatment. Recent advances in the understanding of the biology of WM have paved the way for new treatment options. The use of novel agents with or without rituximab enables the use of effective chemotherapy-free regiments upfront and in the relapsed setting. New targeted treatments such as venetoclax and CXCR4 antagonists are being investigated.
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Affiliation(s)
- Iuliana Vaxman
- Division of Hematology, Mayo Clinic, Rochester, MN, USA.,Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah- Tikva, Israel.,Israel Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Morie Gertz
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
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19
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Tunkel AR, Baron EL, Buch KA, Marty FM, Martinez-Lage M. Case 31-2019: A 45-Year-Old Woman with Headache and Somnolence. N Engl J Med 2019; 381:1459-1470. [PMID: 31597024 DOI: 10.1056/nejmcpc1904045] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Allan R Tunkel
- From the Department of Medicine, Warren Alpert Medical School of Brown University, Providence, RI (A.R.T.); the Department of Medicine, Newton-Wellesley Hospital, Newton, MA (E.L.B.); and the Departments of Radiology (K.A.B.) and Pathology (M.M.-L.), Massachusetts General Hospital, the Department of Medicine, Brigham and Women's Hospital (F.M.M.), and the Departments of Radiology (K.A.B.), Medicine (F.M.M.), and Pathology (M.M.-L.), Harvard Medical School - all in Boston
| | - Elinor L Baron
- From the Department of Medicine, Warren Alpert Medical School of Brown University, Providence, RI (A.R.T.); the Department of Medicine, Newton-Wellesley Hospital, Newton, MA (E.L.B.); and the Departments of Radiology (K.A.B.) and Pathology (M.M.-L.), Massachusetts General Hospital, the Department of Medicine, Brigham and Women's Hospital (F.M.M.), and the Departments of Radiology (K.A.B.), Medicine (F.M.M.), and Pathology (M.M.-L.), Harvard Medical School - all in Boston
| | - Karen A Buch
- From the Department of Medicine, Warren Alpert Medical School of Brown University, Providence, RI (A.R.T.); the Department of Medicine, Newton-Wellesley Hospital, Newton, MA (E.L.B.); and the Departments of Radiology (K.A.B.) and Pathology (M.M.-L.), Massachusetts General Hospital, the Department of Medicine, Brigham and Women's Hospital (F.M.M.), and the Departments of Radiology (K.A.B.), Medicine (F.M.M.), and Pathology (M.M.-L.), Harvard Medical School - all in Boston
| | - Francisco M Marty
- From the Department of Medicine, Warren Alpert Medical School of Brown University, Providence, RI (A.R.T.); the Department of Medicine, Newton-Wellesley Hospital, Newton, MA (E.L.B.); and the Departments of Radiology (K.A.B.) and Pathology (M.M.-L.), Massachusetts General Hospital, the Department of Medicine, Brigham and Women's Hospital (F.M.M.), and the Departments of Radiology (K.A.B.), Medicine (F.M.M.), and Pathology (M.M.-L.), Harvard Medical School - all in Boston
| | - Maria Martinez-Lage
- From the Department of Medicine, Warren Alpert Medical School of Brown University, Providence, RI (A.R.T.); the Department of Medicine, Newton-Wellesley Hospital, Newton, MA (E.L.B.); and the Departments of Radiology (K.A.B.) and Pathology (M.M.-L.), Massachusetts General Hospital, the Department of Medicine, Brigham and Women's Hospital (F.M.M.), and the Departments of Radiology (K.A.B.), Medicine (F.M.M.), and Pathology (M.M.-L.), Harvard Medical School - all in Boston
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20
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Abstract
PURPOSE OF REVIEW Induction of lymphocyte depletion is increasingly used as a therapeutic strategy for central and peripheral neuroinflammatory disease. However, there is also a growing recognition of the treatment-related complication of secondary antibody deficiency (SAD). Although the occurrence of hypogammaglobulinaemia is a recognized phenomenon during immunomodulation, robust data on the coexistence of impaired responses to immunization, and significant and/or atypical infections is scarce. Here we review the literature on SAD in anti-CD20 therapy. RECENT FINDINGS Several factors that may increase the incidence of SAD have now been identified, including low levels of immunoglobulins prior to the commencement of B-cell ablation therapy, duration of maintenance therapy, and concurrent or prior use of other immunosuppressing agents such as cyclophosphamide and steroids. Measurement of disease-specific antibodies and vaccine response are likely to be helpful adjuncts to measurement of serum immunoglobulin levels during B-cell depleting therapy. Supportive treatment may include amending the treatment schedule to limit cumulative dose. SUMMARY B-cell depleting agents offer considerable therapeutic benefit in neurology. We propose modifications in current practice that include risk stratification and early identification of SAD, with the aim of minimising morbidity and mortality related to this underappreciated condition.
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21
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Cheema S, Bunting E, Good C, Hajela V, Ridha BH, Saha RA. Balancing immunosuppression and infection: recurrent enterovirus encephalitis in SLE. Pract Neurol 2019; 19:508-510. [PMID: 31171649 DOI: 10.1136/practneurol-2019-002229] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/25/2019] [Indexed: 11/04/2022]
Abstract
A young woman with systemic lupus erythematosus (SLE) developed recurrent enterovirus meningoencephalitis while taking prednisolone, azathioprine and rituximab. After reducing the immunosuppression, she developed a central nervous system (CNS) flare of SLE, with enterovirus still present in the cerebrospinal fluid (CSF). There are no evidence-based specific treatments for enterovirus encephalitis, but she responded well to intravenous immunoglobulin alongside pulsed methylprednisolone and rituximab. This case highlights the difficulties in managing people with co-existing infective and autoimmune conditions, especially if each affects the CNS. A viral infection and SLE flare can resemble one another clinically, although here the radiological differentiation of CNS lupus versus enterovirus encephalitis helped to guide the diagnosis.
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Affiliation(s)
- Sanjay Cheema
- Neurology, Brighton and Sussex University Hospitals NHS Trust, Haywards Heath, UK
| | - Eva Bunting
- Neurology, National Hospital for Neurology and Neurosurgery, London, UK
| | - Catriona Good
- Neuroradiology, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - Vijay Hajela
- Rheumatology, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - Basil H Ridha
- Neurology, Brighton and Sussex University Hospitals NHS Trust, Haywards Heath, UK
| | - Romi Anirban Saha
- Neurology, Brighton and Sussex University Hospitals NHS Trust, Haywards Heath, UK
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22
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Tellez R, Lastinger AM, Hogg JP. Chronic enteroviral meningoencephalitis in a patient on rituximab for the treatment of psoriatic arthritis: A case report and brief literature review. IDCases 2019; 17:e00558. [PMID: 31193253 PMCID: PMC6522838 DOI: 10.1016/j.idcr.2019.e00558] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Revised: 05/07/2019] [Accepted: 05/07/2019] [Indexed: 01/26/2023] Open
Abstract
Enteroviruses are RNA viruses within the Picornaviridae family. Enteroviruses derive their name from the way they are typically transmitted via the intestinal tract. They commonly infect millions of people every year and often do not cause severe disease in immunocompetent patients with few exceptions. Aseptic meningitis is a classic manifestation and is usually self-limited, however, can lead to severe neurological complications in an immunocompromised individual. It has been well-described that patients with hypogammaglobulinemia are predisposed to developing chronic enteroviral meningoencephalitis [1]. This is the first reported case of enteroviral meningoencephalitis in a patient being treated for psoriatic arthritis with rituximab. Here we describe a 46-year-old female who presented with altered mental status, fever, and myalgia. Polymerase chain reaction (PCR) of her cerebrospinal fluid (CSF) confirmed the presence of enterovirus. In the immunocompromised patient with encephalopathy, it is important to consider an enteroviral infection. This case adds to the present body of knowledge about enteroviral infections in immunocompromised hosts.
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Affiliation(s)
- Roberto Tellez
- West Virginia University School of Medicine, 1 Medical Center Drive, Morgantown, WV, 26505, United States
- Corresponding author.
| | - Allison M. Lastinger
- Section of Infectious Disease, West Virginia University, 1 Medical Center Drive, Morgantown, WV, 26505, United States
| | - Jeffery P. Hogg
- Department of Radiology, West Virginia University, 1 Medical Center Drive, Morgantown, WV, 26505, United States
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23
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Sham L, Bitnun A, Branson H, Hazrati LN, Dell SD, Yeung RSM, Johnstone J, Yeh EA. Treatment of rituximab-associated chronic CNS enterovirus using IVIg and fluoxetine. Neurology 2019; 92:916-918. [PMID: 30944242 DOI: 10.1212/wnl.0000000000007468] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Accepted: 02/12/2019] [Indexed: 11/15/2022] Open
Affiliation(s)
- Lauren Sham
- From the Departments of Pediatrics (L.S., A.B., S.D.D., R.S.M.Y., E.A.Y.), Medical Imaging (H.B.), Laboratory Medicine and Pathobiology (L.-N.H.), Immunology (R.S.M.Y.), and Medical Science (R.S.M.Y.), and Lawrence Bloomberg School of Nursing (J.J.), University of Toronto; the Divisions of Neurology (L.S., J.J., E.A.Y.), Infectious Diseases (A.B.), Diagnostic Imaging (H.B.), Pathology (L.-N.H.), Respirology (S.D.D.), and Rheumatology (R.S.M.Y.), and the Division of Neuroscience and Mental Health, Research Institute (E.A.Y.), The Hospital for Sick Children, Toronto, Canada.
| | - Ari Bitnun
- From the Departments of Pediatrics (L.S., A.B., S.D.D., R.S.M.Y., E.A.Y.), Medical Imaging (H.B.), Laboratory Medicine and Pathobiology (L.-N.H.), Immunology (R.S.M.Y.), and Medical Science (R.S.M.Y.), and Lawrence Bloomberg School of Nursing (J.J.), University of Toronto; the Divisions of Neurology (L.S., J.J., E.A.Y.), Infectious Diseases (A.B.), Diagnostic Imaging (H.B.), Pathology (L.-N.H.), Respirology (S.D.D.), and Rheumatology (R.S.M.Y.), and the Division of Neuroscience and Mental Health, Research Institute (E.A.Y.), The Hospital for Sick Children, Toronto, Canada
| | - Helen Branson
- From the Departments of Pediatrics (L.S., A.B., S.D.D., R.S.M.Y., E.A.Y.), Medical Imaging (H.B.), Laboratory Medicine and Pathobiology (L.-N.H.), Immunology (R.S.M.Y.), and Medical Science (R.S.M.Y.), and Lawrence Bloomberg School of Nursing (J.J.), University of Toronto; the Divisions of Neurology (L.S., J.J., E.A.Y.), Infectious Diseases (A.B.), Diagnostic Imaging (H.B.), Pathology (L.-N.H.), Respirology (S.D.D.), and Rheumatology (R.S.M.Y.), and the Division of Neuroscience and Mental Health, Research Institute (E.A.Y.), The Hospital for Sick Children, Toronto, Canada
| | - Lili-Naz Hazrati
- From the Departments of Pediatrics (L.S., A.B., S.D.D., R.S.M.Y., E.A.Y.), Medical Imaging (H.B.), Laboratory Medicine and Pathobiology (L.-N.H.), Immunology (R.S.M.Y.), and Medical Science (R.S.M.Y.), and Lawrence Bloomberg School of Nursing (J.J.), University of Toronto; the Divisions of Neurology (L.S., J.J., E.A.Y.), Infectious Diseases (A.B.), Diagnostic Imaging (H.B.), Pathology (L.-N.H.), Respirology (S.D.D.), and Rheumatology (R.S.M.Y.), and the Division of Neuroscience and Mental Health, Research Institute (E.A.Y.), The Hospital for Sick Children, Toronto, Canada
| | - Sharon D Dell
- From the Departments of Pediatrics (L.S., A.B., S.D.D., R.S.M.Y., E.A.Y.), Medical Imaging (H.B.), Laboratory Medicine and Pathobiology (L.-N.H.), Immunology (R.S.M.Y.), and Medical Science (R.S.M.Y.), and Lawrence Bloomberg School of Nursing (J.J.), University of Toronto; the Divisions of Neurology (L.S., J.J., E.A.Y.), Infectious Diseases (A.B.), Diagnostic Imaging (H.B.), Pathology (L.-N.H.), Respirology (S.D.D.), and Rheumatology (R.S.M.Y.), and the Division of Neuroscience and Mental Health, Research Institute (E.A.Y.), The Hospital for Sick Children, Toronto, Canada
| | - Rae S M Yeung
- From the Departments of Pediatrics (L.S., A.B., S.D.D., R.S.M.Y., E.A.Y.), Medical Imaging (H.B.), Laboratory Medicine and Pathobiology (L.-N.H.), Immunology (R.S.M.Y.), and Medical Science (R.S.M.Y.), and Lawrence Bloomberg School of Nursing (J.J.), University of Toronto; the Divisions of Neurology (L.S., J.J., E.A.Y.), Infectious Diseases (A.B.), Diagnostic Imaging (H.B.), Pathology (L.-N.H.), Respirology (S.D.D.), and Rheumatology (R.S.M.Y.), and the Division of Neuroscience and Mental Health, Research Institute (E.A.Y.), The Hospital for Sick Children, Toronto, Canada
| | - Joley Johnstone
- From the Departments of Pediatrics (L.S., A.B., S.D.D., R.S.M.Y., E.A.Y.), Medical Imaging (H.B.), Laboratory Medicine and Pathobiology (L.-N.H.), Immunology (R.S.M.Y.), and Medical Science (R.S.M.Y.), and Lawrence Bloomberg School of Nursing (J.J.), University of Toronto; the Divisions of Neurology (L.S., J.J., E.A.Y.), Infectious Diseases (A.B.), Diagnostic Imaging (H.B.), Pathology (L.-N.H.), Respirology (S.D.D.), and Rheumatology (R.S.M.Y.), and the Division of Neuroscience and Mental Health, Research Institute (E.A.Y.), The Hospital for Sick Children, Toronto, Canada
| | - E Ann Yeh
- From the Departments of Pediatrics (L.S., A.B., S.D.D., R.S.M.Y., E.A.Y.), Medical Imaging (H.B.), Laboratory Medicine and Pathobiology (L.-N.H.), Immunology (R.S.M.Y.), and Medical Science (R.S.M.Y.), and Lawrence Bloomberg School of Nursing (J.J.), University of Toronto; the Divisions of Neurology (L.S., J.J., E.A.Y.), Infectious Diseases (A.B.), Diagnostic Imaging (H.B.), Pathology (L.-N.H.), Respirology (S.D.D.), and Rheumatology (R.S.M.Y.), and the Division of Neuroscience and Mental Health, Research Institute (E.A.Y.), The Hospital for Sick Children, Toronto, Canada
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24
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Strenger V, Kessler HH, Stelzl E, Aberle SW, Keldorfer M, Zach K, Karastaneva A, Sperl D, Lackner H, Benesch M, Urban C, Dornbusch HJ. Enterovirus infections in pediatric hematologic/oncologic patients. Pediatr Blood Cancer 2019; 66:e27448. [PMID: 30270558 DOI: 10.1002/pbc.27448] [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] [Received: 07/11/2018] [Revised: 08/16/2018] [Accepted: 08/17/2018] [Indexed: 11/06/2022]
Abstract
BACKGROUND Enteroviruses (EV) are a large group of Picornaviruses associated with respiratory, gastrointestinal, and neurologic symptoms in the immunocompetent host. Little is known about the epidemiologic and clinical impact in pediatric hematologic/oncologic patients. PROCEDURE From 2001 through 2017, different clinical specimens were collected from pediatric hematologic/oncologic patients and were tested for enteroviral RNA. RESULTS Of 13 004 specimens collected from 761 patients, 38 (0.3%) obtained from 14 patients (1.8%) tested positive for EV RNA. Viral shedding was observed without viremia and vice versa. None of 80 cerebrospinal fluid specimens obtained from 60 patients with neurologic symptoms were positive for EV RNA. None of 14 patients positive for EV RNA showed EV-specific symptoms. In 11/14 patients, EV RNA was found to be negative in the follow-up specimen. The remaining patient with a severe primary immune deficiency showed repeated positive EV RNA results for >5 years. CONCLUSIONS In this pediatric hematologic/oncologic cohort, EV infection occurred rarely and without related symptoms. Specimens concurrently obtained from one patient are commonly not in accordance with each other. In the vast majority of patients, EV RNA appears to turn negative in the follow-up specimen. EV infections seem to have a low impact in this patient cohort.
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Affiliation(s)
- Volker Strenger
- Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Harald H Kessler
- Molecular Diagnostics Laboratory, Diagnostic and Research Center for Molecular Biomedicine, Medical University of Graz, Graz, Austria
| | - Evelyn Stelzl
- Molecular Diagnostics Laboratory, Diagnostic and Research Center for Molecular Biomedicine, Medical University of Graz, Graz, Austria
| | - Stephan W Aberle
- Center for Virology, Medical University of Vienna, Vienna, Austria
| | - Markus Keldorfer
- Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Klara Zach
- Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Anna Karastaneva
- Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Daniela Sperl
- Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Herwig Lackner
- Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Martin Benesch
- Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Christian Urban
- Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Hans Jürgen Dornbusch
- Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
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25
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Giorgiutti S, Ledoux M, Toussaint E, Maestraggi Q, Besch C, Solis M, Herbrecht R, Fornecker L. Une hépatite inhabituelle chez un patient traité par obinutuzumab et ibrutinib. Rev Med Interne 2018. [DOI: 10.1016/j.revmed.2018.03.174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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26
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Bajema KL, Simonson PD, Greninger AL, Çoruh B, Pottinger PS, Bhattacharya R, Liou IW, Jalikis FG, Fligner CL, Rakita RM. Acute Liver Failure Due to Echovirus 9 Associated With Persistent B-Cell Depletion From Rituximab. Open Forum Infect Dis 2017; 4:ofx174. [PMID: 28948184 PMCID: PMC5604094 DOI: 10.1093/ofid/ofx174] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Accepted: 08/11/2017] [Indexed: 12/03/2022] Open
Abstract
We describe a case of fatal acute liver failure due to echovirus 9 in the setting of persistent B-cell depletion and hypogammaglobulinemia 3 years after rituximab therapy. Metagenomic next-generation sequencing further specified the etiologic agent. Early recognition may provide an opportunity for interventions including intravenous immunoglobulin and liver transplantation.
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Affiliation(s)
| | | | | | - Basak Çoruh
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, and
| | - Paul S Pottinger
- Division of Allergy and Infectious Diseases, Department of Medicine
| | - Renuka Bhattacharya
- Division of Gastroenterology, Department of Medicine, University of Washington, Seattle
| | - Iris W Liou
- Division of Gastroenterology, Department of Medicine, University of Washington, Seattle
| | | | | | - Robert M Rakita
- Division of Allergy and Infectious Diseases, Department of Medicine
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27
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Christou EAA, Giardino G, Worth A, Ladomenou F. Risk factors predisposing to the development of hypogammaglobulinemia and infections post-Rituximab. Int Rev Immunol 2017; 36:352-359. [PMID: 28800262 DOI: 10.1080/08830185.2017.1346092] [Citation(s) in RCA: 71] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Rituximab (RTX) is a monoclonal antibody against CD20, commonly used in the treatment of hematological malignancies and autoimmune diseases. The use of RTX is related to the development of hypogammaglobulinemia and infections. Aim of this review is to summarize the evidence supporting the association of specific risk factors with the development of hypogammaglobulinemia and infections post-RTX. Immunological complications are more common in patients with malignant diseases as compared to non-malignant diseases. Moreover, the use of more than one dose of RTX, maintenance regimens, low pre-treatment basal immunoglobulin levels and the association with Mycophenolate and purine analogues represent risk factors for the development of hypogammaglobulinemia. The number of RTX courses, the evidence of low IgG levels for more than 6 months, the use of G-CSF, the occurrence of chronic lung disease, cardiac insufficiency, extra-articular involvement in patients with rheumatoid arthritis, low levels of IgG and older age have been correlated with a higher risk of infections. Even though the heterogeneity of the studies in terms of study population age and underlying disease, RTX schedules as well as differences in pre-treatment or concomitant therapy doesn't allow drawing definitive conclusions, the study of the literature highlight the association of specific risk factors with the occurrence of hypogammaglobulinemia and/or infections. A long term randomized controlled clinical trial could be useful to define a personalized evidence-based risk management plan for patients treated with RTX.
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Affiliation(s)
- Evangelos A A Christou
- a Division of Internal Medicine, Medical School , University of Ioannina , Ioannina , Greece
| | - Giuliana Giardino
- b Department of Translational Medical Sciences , Federico II University , Naples , Italy
| | - Austen Worth
- c Department of Paediatric Immunology , Great Ormond Street Hospital , London , UK
| | - Fani Ladomenou
- c Department of Paediatric Immunology , Great Ormond Street Hospital , London , UK
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