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McGlothlin J, Abeykoon J, Al-Hattab E, Ashrani AA, Elliott M, Hook CC, Pardanani A, Pruthi R, Sridharan M, Wolanskyj A, Rouse R, Go R. Bortezomib and daratumumab in refractory autoimmune hemolytic anemia. Am J Hematol 2023; 98:E263-E265. [PMID: 37417424 DOI: 10.1002/ajh.27025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 06/21/2023] [Accepted: 06/30/2023] [Indexed: 07/08/2023]
Affiliation(s)
- John McGlothlin
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Jithma Abeykoon
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Eyad Al-Hattab
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Aneel A Ashrani
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Michelle Elliott
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - C Christopher Hook
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Animesh Pardanani
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Rajiv Pruthi
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Meera Sridharan
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Alexandra Wolanskyj
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Rachelle Rouse
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Ronald Go
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
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2
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Spadea M, Saglio F, Ceolin V, Barone M, Zucchetti G, Quarello P, Fagioli F. Immune-mediated cytopenias (IMCs) after HSCT for pediatric non-malignant disorders: epidemiology, risk factors, pathogenesis, and treatment. Eur J Pediatr 2023; 182:2471-2483. [PMID: 36967419 PMCID: PMC10257634 DOI: 10.1007/s00431-023-04912-6] [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: 12/21/2022] [Revised: 02/22/2023] [Accepted: 02/27/2023] [Indexed: 06/11/2023]
Abstract
Hematopoietic stem cell transplantation (HSCT) represents a curative option for pediatric patients affected by malignant and non-malignant disorders. Several complications may arise during the post-transplantation period, including immune-mediated disorders. Immune-mediated cytopenias (IMCs) account for up to 22% of pediatric HSCT complications, representing an important cause of morbidity and mortality post-HSCT. So far, their pathogenesis is not well-understood, and their management may be very challenging. Further, most patients are refractory to first-line treatment which is based on high-dose intravenous steroids, immunoglobulin, and the monoclonal anti-CD20 antibody - rituximab. No clear consensus has been reached for second- and third-line therapeutic options. CONCLUSION We reviewed the epidemiology, risk factors, pathogenesis, and treatment of IMCs, aiming to offer a deeper understanding of these complications as a guide to improving the management of these fragile patients and a cue for the design of tailored clinical trials. WHAT IS KNOWN • IMCs arising in the post-HSCT setting represent a rare but potentially life-threatening complication. Younger patients affected by non-malignant disorders are at the greatest risk of IMCs arising after HSCT. Corticosteroids, intravenous immunoglobulin, and rituximab represent the undiscussed first-line therapeutic approach. WHAT IS NEW • This review highlitghts how children present unique risk factors for post HSCT IMCs, which are the result of the complex relationship between the immaturity of their infantile immune system and all the perturbing agents and factors which characterize the post-HSCT setting. Future efforts are warranted to establish the best option for refractory patients, for whom a standard and validated approach is not currently available. Among new agents, ibrutinib or bortezomib and fostamatinib or low-dose IL-2 could represent a good therapeutic option for patients with graft-versus-host disease and hemolytic anemia or graft-versus-host disease and thrombocytopenia, respectively.
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Affiliation(s)
- Manuela Spadea
- Stem Cell Transplantation and Cellular Therapy Department, Pediatric Onco-Hematology, Azienda Ospedaliera-Universitaria Città Della Salute E Della Scienza, Regina Margherita Children's Hospital, Turin, Italy
- University of Torino, Turin, Italy
| | - Francesco Saglio
- Stem Cell Transplantation and Cellular Therapy Department, Pediatric Onco-Hematology, Azienda Ospedaliera-Universitaria Città Della Salute E Della Scienza, Regina Margherita Children's Hospital, Turin, Italy
| | - Valeria Ceolin
- Stem Cell Transplantation and Cellular Therapy Department, Pediatric Onco-Hematology, Azienda Ospedaliera-Universitaria Città Della Salute E Della Scienza, Regina Margherita Children's Hospital, Turin, Italy
- Erasmus University MC-Sophia Childrens Hospital, Rotterdam, Netherlands
| | - Marta Barone
- Stem Cell Transplantation and Cellular Therapy Department, Pediatric Onco-Hematology, Azienda Ospedaliera-Universitaria Città Della Salute E Della Scienza, Regina Margherita Children's Hospital, Turin, Italy
| | - Giulia Zucchetti
- Stem Cell Transplantation and Cellular Therapy Department, Pediatric Onco-Hematology, Azienda Ospedaliera-Universitaria Città Della Salute E Della Scienza, Regina Margherita Children's Hospital, Turin, Italy
| | - Paola Quarello
- Stem Cell Transplantation and Cellular Therapy Department, Pediatric Onco-Hematology, Azienda Ospedaliera-Universitaria Città Della Salute E Della Scienza, Regina Margherita Children's Hospital, Turin, Italy.
- University of Torino, Turin, Italy.
| | - Franca Fagioli
- Stem Cell Transplantation and Cellular Therapy Department, Pediatric Onco-Hematology, Azienda Ospedaliera-Universitaria Città Della Salute E Della Scienza, Regina Margherita Children's Hospital, Turin, Italy
- University of Torino, Turin, Italy
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3
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Even-Or E, Schejter YD, NaserEddin A, Zaidman I, Shadur B, Stepensky P. Autoimmune Cytopenias Post Hematopoietic Stem Cell Transplantation in Pediatric Patients With Osteopetrosis and Other Nonmalignant Diseases. Front Immunol 2022; 13:879994. [PMID: 35693771 PMCID: PMC9185137 DOI: 10.3389/fimmu.2022.879994] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Accepted: 04/29/2022] [Indexed: 11/30/2022] Open
Abstract
Autoimmune cytopenia (AIC) is a rare complication post hematopoietic stem cell transplantation (HSCT), with a higher incidence in nonmalignant diseases. The etiology of post-HSCT AIC is poorly understood, and in many cases, the cytopenia is prolonged and refractory to treatment. Diagnosis of post-HSCT AIC may be challenging, and there is no consensus for a standard of care. In this retrospective study, we summarize our experience over the past five years with post-HSCT AIC in pediatric patients with osteopetrosis and other nonmalignant diseases. All pediatric patients who underwent HSCT for nonmalignant diseases at Hadassah Medical Center over the past five years were screened for post-HSCT AIC, and data were collected from the patient’s medical records. From January 2017 through December 2021, 140 pediatric patients underwent HSCT for osteopetrosis (n=40), and a variety of other nonmalignant diseases. Thirteen patients (9.3%) presented with post-HSCT AIC. Of these, 7 had osteopetrosis (17.5%), and 6 had other underlying nonmalignant diseases. Factors associated with developing AIC included unrelated or non-sibling family donors (n=10), mixed chimerism (n=6), and chronic GvHD (n=5). Treatment modalities included steroids, IVIG, rituximab, bortezomib, daratumumab, eltrombopag, plasmapheresis, and repeated HSCT. Response to treatment was variable; Seven patients (54%) recovered completely, and three patients (23%) recovered partially, still suffering from mild-moderate thrombocytopenia. Three patients died (23%), two following progressive lung disease and one from sepsis and multi-organ failure after a 3rd HSCT. In our experience, post-HSCT AICs in pediatric patients with nonmalignant diseases may pose a challenging post-transplant complication with a variable presentation and a wide spectrum of severity. A relatively high prevalence is seen in patients with osteopetrosis, possibly due to difficult engraftment and high rates of mixed chimerism. There is a dire need for novel treatment modalities for better management of the more severe and refractory cases.
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Affiliation(s)
- Ehud Even-Or
- Department of Bone Marrow Transplantation and Cancer Immunotherapy, Hadassah Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
- *Correspondence: Ehud Even-Or,
| | - Yael Dinur Schejter
- Department of Bone Marrow Transplantation and Cancer Immunotherapy, Hadassah Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Adeeb NaserEddin
- Department of Bone Marrow Transplantation and Cancer Immunotherapy, Hadassah Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Irina Zaidman
- Department of Bone Marrow Transplantation and Cancer Immunotherapy, Hadassah Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Bella Shadur
- Immunology Division, The Garvan Institute of Medical Research Graduate Research School, University of New South Wales, Sydney, NSW, Australia
| | - Polina Stepensky
- Department of Bone Marrow Transplantation and Cancer Immunotherapy, Hadassah Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
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4
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Faraci M, Dell'Orso G, Giardino S, Pierri F. Autoimmune diseases after allogeneic stem cell transplantation: a clinician's guide and future outlook. Expert Rev Clin Immunol 2022; 18:1-14. [PMID: 35500169 DOI: 10.1080/1744666x.2022.2072299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 04/27/2022] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Autoimmune disease (AD) may occur after allogeneic hematopoietic stem cell transplantation (HSCT). The autoimmune mechanism seems to be related to an imbalance of the immune regulation effect of T-regulatory lymphocytes on autoreactive T-lymphocytes. AREAS COVERED ADs include hematological ADs (HADs) and nonhematologic ADs (NHADs) involving organs such as thyroid, peripheral and central nervous system, skin, liver, connective tissue, gastrointestinal tract, and kidney. To identify the risk factors for ADs, to report their clinical characteristics, and to discuss new approaches represent the areas covered in this review. EXPERT OPINION Some risk factors for HAD and NHAD are common and include nonmalignant diseases, young age, cord blood as a stem cell source, conditioning regimens without total body irradiation, alemtuzumab, antithymocyte globulin, T-cell-depleted transplant, some viral infection, mixed chimerism, and chronic Graft versus Host Disease. In NHADs, the detection of autoantibodies is more frequent and the transfer of autoimmunity from the donor to the recipient represents the pathogenetic mechanism responsible for these complications. New therapeutic approaches such as bortezomib, daratumumab, sirolimus, eculizumab, and eltrombopag appear to be promising in terms of better efficacy and reduced toxicity compared to traditional therapies. New horizons based on personalized therapies will allow us to improve the prognosis of AD.
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Affiliation(s)
- Maura Faraci
- Hematopoietic Stem Cell Unit, Department of Hematology-Oncology, IRCSS Istituto G. Gaslini I Istituto GGaslini, Genova, Italy
| | - Gianluca Dell'Orso
- Hematopoietic Stem Cell Unit, Department of Hematology-Oncology, IRCSS Istituto G. Gaslini I Istituto GGaslini, Genova, Italy
| | - Stefano Giardino
- Hematopoietic Stem Cell Unit, Department of Hematology-Oncology, IRCSS Istituto G. Gaslini I Istituto GGaslini, Genova, Italy
| | - Filomena Pierri
- Hematopoietic Stem Cell Unit, Department of Hematology-Oncology, IRCSS Istituto G. Gaslini I Istituto GGaslini, Genova, Italy
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5
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Development of New Drugs for Autoimmune Hemolytic Anemia. Pharmaceutics 2022; 14:pharmaceutics14051035. [PMID: 35631621 PMCID: PMC9147507 DOI: 10.3390/pharmaceutics14051035] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 04/27/2022] [Accepted: 05/05/2022] [Indexed: 02/04/2023] Open
Abstract
Autoimmune hemolytic anemia (AIHA) is a rare disorder characterized by the autoantibody-mediated destruction of red blood cells, and treatments for it still remain challenging. Traditional first-line immunosuppressive therapy, which includes corticosteroids and rituximab, is associated with adverse effects as well as treatment failures, and relapses are common. Subsequent lines of therapy are associated with higher rates of toxicity, and some patients remain refractory to currently available treatments. Novel therapies have become promising for this vulnerable population. In this review, we will discuss the mechanism of action, existing data, and ongoing clinical trials of current novel therapies for AIHA, including B-cell-directed therapy, phagocytosis inhibition, plasma cell-directed therapy, and complement inhibition.
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6
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B cells in autoimmune hepatitis: bystanders or central players? Semin Immunopathol 2022; 44:411-427. [PMID: 35488094 PMCID: PMC9256567 DOI: 10.1007/s00281-022-00937-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 04/07/2022] [Indexed: 02/07/2023]
Abstract
B cells are central for the adaptive immune system to mount successful immune responses not only as antibody producers but also as regulators of cellular immunity. These multifaceted features are also reflected in autoimmunity where autoreactive B cells can fuel disease by production of cytotoxic autoantibodies, presentation of autoantigens to autoreactive T cells, and secretion of cytokines and chemokines that either promote detrimental immune activation or impair regulatory T and B cells. The role of B cells and autoantibodies in autoimmune hepatitis (AIH) have been controversially discussed, with typical autoantibodies and hypergammaglobulinemia indicating a key role, while strong HLA class II association suggests T cells as key players. In this review, we summarize current knowledge on B cells in AIH and how different B cell subpopulations may drive AIH progression beyond autoantibodies. We also discuss recent findings of B cell-directed therapies in AIH.
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7
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Conti F, Gottardi F, Moratti M, Belotti T, Ferrari S, Selva P, Bassi M, Zama D, Pession A. Refractory immune thrombocytopenia successfully treated with bortezomib in a child with 22q11.2 deletion syndrome, complicated by Evans syndrome and hypogammaglobulinemia. Platelets 2022; 33:801-806. [PMID: 35132908 DOI: 10.1080/09537104.2021.2002835] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Treatment of refractory autoimmune cytopenias (AICs) and Evans syndrome (ES) represent a great challenge in pediatric setting, where an underlying primary immunodeficiency is recurrent. Frequently, second or third line treatments are employed, with an increased risk of toxicity and infections. The advent of novel drugs is the object of research in order to modify the management of these patients.We report a case of successful use of bortezomib in a child with 22q11.2 deletion syndrome and CVID-like phenotype with a multi-refractory severe ES. Last flares were prolonged and dominated by severe and symptomatic ITP, refractory to different courses of high dose steroid and IVIG, mofetil mycophenolate, thrombopoietin receptor agonists, sirolimus, and rituximab. Persistence of AICs in subjects with depletion of CD20 + B-cells and IgG strengthens the hypothesis about the production of autoantibodies by terminally differentiated plasma-cells, not targetable from immunosuppressants and rituximab.In the attempt to enhance plasma-cells inhibition, the child was addressed to bortezomib, with a good response at 6 month follow-up without side effects. Nowadays, the use of bortezomib in ES/AICs is based only on small retrospective studies and case reports. Despite the lack of long term follow-up, our work highlights the potential role of bortezomib in the management of pediatric patients with multi-resistant AICs secondary to immune-system impairment.
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Affiliation(s)
- Francesca Conti
- Pediatric Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | | | - Mattia Moratti
- Specialty School of Paediatrics, University of Bologna, Bologna, Italy
| | - Tamara Belotti
- Pediatric Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Simona Ferrari
- Medical Genetics Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Paola Selva
- Pediatric Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Mirna Bassi
- Laboratory of Immuno-haematology - Laboratorio Unico Metropolitano, Azienda USL, Bologna, Italy
| | - Daniele Zama
- Pediatric Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Andrea Pession
- Pediatric Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
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8
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Pasquale R, Giannotta JA, Barcellini W, Fattizzo B. Bortezomib in autoimmune hemolytic anemia and beyond. Ther Adv Hematol 2021; 12:20406207211046428. [PMID: 34795889 PMCID: PMC8593301 DOI: 10.1177/20406207211046428] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2021] [Accepted: 08/28/2021] [Indexed: 11/28/2022] Open
Abstract
Bortezomib is a first-in-class, potent, selective and reversible proteasome inhibitor approved for the treatment of multiple myeloma (MM) and relapsed/refractory mantle cell lymphoma. In these diseases, bortezomib targets plasma cells and lymphocytes reducing tumor burden. Recently, preclinical evidence highlighted its efficacy in reducing long-lived plasma cells responsible of autoantibodies production in several models of autoimmune conditions. These findings paved the way to a number of experiences of bortezomib use in patients with various autoimmune conditions, including autoimmune hemolytic anemia (AIHA). The latter is a nice model of autoimmunity in hematology and is caused by the production of autoantibodies against erythrocytes resulting in various degrees of hemolytic anemia. AIHA is classified in warm and cold forms according to the thermal characteristics of the autoantibody, and first-line treatment mainly relies on steroids for warm cases and the anti-CD20 rituximab for cold ones. Relapsed/refractory cases are still an unmet need, and bortezomib has been proposed in this setting with intriguing efficacy. In this review, we collected available literature on bortezomib use in AIHA and in other immune-mediated hematologic and non-hematologic diseases. Overall, most experiences highlight bortezomib efficacy even in multi-relapsed/refractory patients and suggest to consider its use in AIHA after rituximab failure.
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Affiliation(s)
- Raffaella Pasquale
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| | | | - Wilma Barcellini
- Hematology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Bruno Fattizzo
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
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9
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Gabelli M, Ademokun C, Cooper N, Amrolia PI. Pathogenesis, risk factors and therapeutic options for autoimmune haemolytic anaemia in the post-transplant setting. Br J Haematol 2021; 196:45-62. [PMID: 34195990 DOI: 10.1111/bjh.17648] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 05/26/2021] [Indexed: 11/27/2022]
Abstract
Autoimmune haemolytic anaemia (AIHA) is a rare complication of allogeneic haematopoietic stem cell transplantation (HSCT), observed with an incidence of 1-5%. Paediatric age, diagnosis of non-malignant disease, lympho-depleting agents in the conditioning regimen, use of unrelated donor, graft versus host disease and infections have been associated with a higher risk of AIHA post HSCT. Post-HSCT AIHA is associated with high mortality and morbidity, and it is often very difficult to treat. Steroids and rituximab are used with a response rate around 30-50%. These and other therapeutic strategies are mainly derived from data on primary AIHA, although response rates in post-HSCT AIHA have been generally lower. Here we review the currently available data on risk factors and therapeutic options. There is a need for prospective studies in post-HSCT AIHA to guide clinicians in managing these complex patients.
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Affiliation(s)
- Maria Gabelli
- Department of Bone Marrow Transplantation, Great Ormond Street Hospital, London, UK
| | - Christine Ademokun
- Department of Haematology, Imperial College Healthcare NHS Trust, London, UK
| | - Nichola Cooper
- Department of Immunology and Inflammation, Imperial College, London, UK
| | - Persis I Amrolia
- Department of Bone Marrow Transplantation, Great Ormond Street Hospital, London, UK
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10
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Du W, Han M, Zhu X, Xiao F, Huang E, Che N, Tang X, Zou H, Jiang Q, Lu L. The Multiple Roles of B Cells in the Pathogenesis of Sjögren's Syndrome. Front Immunol 2021; 12:684999. [PMID: 34168653 PMCID: PMC8217880 DOI: 10.3389/fimmu.2021.684999] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 05/21/2021] [Indexed: 12/12/2022] Open
Abstract
Primary Sjögren’s syndrome (pSS) is a chronic autoimmune disease characterized by lymphocytic infiltration and tissue destruction of exocrine glands such as salivary glands. Although the formation of ectopic lymphoid tissue in exocrine glands and overproduction of autoantibodies by autoreactive B cells highlight the critical involvement of B cells in disease development, the precise roles of various B cell subsets in pSS pathogenesis remain partially understood. Current studies have identified several novel B cell subsets with multiple functions in pSS, among which autoreactive age-associated B cells, and plasma cells with augmented autoantibody production contribute to the disease progression. In addition, tissue-resident Fc Receptor-Like 4 (FcRL4)+ B cell subset with enhanced pro-inflammatory cytokine production serves as a key driver in pSS patients with mucosa-associated lymphoid tissue (MALT)-lymphomas. Recently, regulatory B (Breg) cells with impaired immunosuppressive functions are found negatively correlated with T follicular helper (Tfh) cells in pSS patients. Further studies have revealed a pivotal role of Breg cells in constraining Tfh response in autoimmune pathogenesis. This review provides an overview of recent advances in the identification of pathogenic B cell subsets and Breg cells, as well as new development of B-cell targeted therapies in pSS patients.
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Affiliation(s)
- Wenhan Du
- Department of Pathology and Shenzhen Institute of Research and Innovation, The University of Hong Kong, Hong Kong, China
| | - Man Han
- Division of Rheumatology, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Xiaoxia Zhu
- Department of Rheumatology, Huashan Hospital and Fudan University, Shanghai, China
| | - Fan Xiao
- Department of Pathology and Shenzhen Institute of Research and Innovation, The University of Hong Kong, Hong Kong, China.,Chongqing International Institute for Immunology, Chongqing, China
| | - Enyu Huang
- Department of Pathology and Shenzhen Institute of Research and Innovation, The University of Hong Kong, Hong Kong, China.,Chongqing International Institute for Immunology, Chongqing, China
| | - Nan Che
- Department of Rheumatology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu, China
| | - Xiaopo Tang
- Division of Rheumatology, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Hejian Zou
- Department of Rheumatology, Huashan Hospital and Fudan University, Shanghai, China
| | - Quan Jiang
- Division of Rheumatology, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Liwei Lu
- Department of Pathology and Shenzhen Institute of Research and Innovation, The University of Hong Kong, Hong Kong, China.,Chongqing International Institute for Immunology, Chongqing, China
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11
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Consensus opinion on immune-mediated cytopenias after hematopoietic cell transplant for inherited metabolic disorders. Bone Marrow Transplant 2021; 56:1238-1247. [PMID: 33441980 DOI: 10.1038/s41409-020-01179-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 11/04/2020] [Accepted: 11/25/2020] [Indexed: 12/23/2022]
Abstract
Hematopoietic stem cell transplantation (HCT) has been increasingly used for patients with inherited metabolic disorders (IMD). Immune mediated cytopenias (IMCs) after HCT, manifesting as hemolytic anemia, thrombocytopenia, and/or neutropenia, are recognized as a significant complication in this patient population, yet our understanding of the incidence, risk factors, and pathophysiology is currently limited. Review of the published literature demonstrates a higher incidence in younger patients who undergo HCT for a nonmalignant disease indication. However, a few reports suggest that the incidence is even higher among those with IMD (incidence ranging from 10 to 56%). This review summarizes the literature, provides an approach to better understanding of the possible etiology of IMCs, and proposes a diagnostic and management plan for patients with IMD who develop single or multi-lineage cytopenias after HCT.
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12
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Knops N, Emonds MP, Herman J, Levtchenko E, Mekahli D, Pirenne J, Van Geet C, Dierickx D. Bortezomib for autoimmune hemolytic anemia after intestinal transplantation. Pediatr Transplant 2020; 24:e13700. [PMID: 32166874 DOI: 10.1111/petr.13700] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Revised: 12/03/2019] [Accepted: 02/24/2020] [Indexed: 01/19/2023]
Abstract
AIHA is rare in the general population and associated with a mortality of 8%. In contrast, AIHA occurs in up to 12.2% of cases after intestinal transplantation and is associated with mortality up to 50%. Treatment entails a "step-up" approach including corticosteroids, IvIg, plasmapheresis, and rituximab. However, AIHA after transplantation often is refractory to this strategy, contributing to a poor outcome. We describe a child with microvillous inclusion disease who developed AIHA 1 year after multivisceral transplantation that was refractory to standard therapy and was subsequently treated with bortezomib.We observed remission of AIHA within 1 week after the start of bortezomib. Bortezomib was associated with transient diarrhea, leucopenia, and elevated liver enzymes. Three years later, he remains in remission without important complications. Published data on bortezomib for autoimmune cytopenias outside SOT are discussed. This is the first report to support bortezomib as an important therapeutic alternative for AIHA after SOT. The occurrence and treatment of AIHA after SOT, and specifically intestinal transplantation, should be the subject of future registry studies to collect additional experience and explore the optimal therapeutic approach.
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Affiliation(s)
- Noël Knops
- Pediatrics (Pediatric Nephrology and Solid Organ Transplantation), University Hospitals Leuven, Leuven, Belgium.,Department of Development and Regeneration (Woman and Child), KU Leuven, Leuven, Belgium
| | - Marie-Paule Emonds
- Histocompatibility and Immunogenetics Laboratory, Belgian Red Cross-Flanders, Mechelen, Belgium.,Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
| | - Jean Herman
- Pediatrics (Pediatric Nephrology and Solid Organ Transplantation), University Hospitals Leuven, Leuven, Belgium.,Department of Development and Regeneration (Woman and Child), KU Leuven, Leuven, Belgium
| | - Elena Levtchenko
- Pediatrics (Pediatric Nephrology and Solid Organ Transplantation), University Hospitals Leuven, Leuven, Belgium.,Department of Development and Regeneration (Woman and Child), KU Leuven, Leuven, Belgium
| | - Djalila Mekahli
- Pediatrics (Pediatric Nephrology and Solid Organ Transplantation), University Hospitals Leuven, Leuven, Belgium.,Department of Development and Regeneration (Woman and Child), KU Leuven, Leuven, Belgium
| | - Jacques Pirenne
- Abdominal Transplant Surgery, University Hospitals Leuven, Leuven, Belgium.,Department of Microbiology and Immunology, KU Leuven, Leuven, Belgium
| | - Chris Van Geet
- Pediatrics (Pediatric Hemato-Oncology), University Hospitals Leuven, Leuven, Belgium.,Department of Cardiovascular Sciences, Center for Molecular and Vascular Biology, KU Leuven, Leuven, Belgium
| | - Daan Dierickx
- Hematology, University Hospitals Leuven, Leuven, Belgium.,Department of Oncology (Laboratorium of Experimental Hematology), KU Leuven, Leuven, Belgium
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13
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Muhsen IN, Alahmari A, Alnahedh M, Alkhudair NA, Samarkandi H, El Fakih R. Bortezomib for immune thrombocytopenia and autoimmune hemolytic anemia. Hematol Oncol Stem Cell Ther 2019; 13:251-254. [PMID: 31202670 DOI: 10.1016/j.hemonc.2019.05.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2019] [Accepted: 05/21/2019] [Indexed: 01/30/2023] Open
Affiliation(s)
| | - Ali Alahmari
- Oncology Center, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Mohammed Alnahedh
- Pharmaceutical Care Division, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Nora A Alkhudair
- Department of Clinical Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Hadeel Samarkandi
- Pharmaceutical Care Division, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Riad El Fakih
- Oncology Center, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia.
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14
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Neunert CE, Despotovic JM. Autoimmune hemolytic anemia and immune thrombocytopenia following hematopoietic stem cell transplant: A critical review of the literature. Pediatr Blood Cancer 2019; 66:e27569. [PMID: 30537439 DOI: 10.1002/pbc.27569] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Revised: 10/29/2018] [Accepted: 11/02/2018] [Indexed: 01/19/2023]
Abstract
Autoimmune cytopenias (AIC) post-hematopoietic stem cell transplant (HSCT) are rare but exceptionally challenging complication. We conducted a comprehensive literature review and identified a pooled incidence of post-HSCT autoimmune hemolytic anemia and/or immune thrombocytopenia of 2.66% (SE = 0.27) in pediatric patients. Nonmalignant disease, unrelated donor transplant, peripheral or cord blood stem cell source, conditioning regimen without total body irradiation, and presence of chronic graft-versus-host disease were prominent risk factors. Treatment was highly variable, and cytopenias were commonly refractory. AIC represent a significant post-HSCT complication. We report here the incidence, risk factors, and possible biology behind the development of AIC in pediatric post-HSCT patients.
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Affiliation(s)
- C E Neunert
- Department of Pediatrics, Hematology/Oncology/Bone Marrow Transplant, Columbia University School of Medicine, New York, New York
| | - J M Despotovic
- Department of Pediatrics, Hematology/Oncology Section, Baylor College of Medicine, Houston, Texas
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15
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Hofmann K, Clauder AK, Manz RA. Targeting B Cells and Plasma Cells in Autoimmune Diseases. Front Immunol 2018; 9:835. [PMID: 29740441 PMCID: PMC5924791 DOI: 10.3389/fimmu.2018.00835] [Citation(s) in RCA: 163] [Impact Index Per Article: 27.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2017] [Accepted: 04/05/2018] [Indexed: 12/29/2022] Open
Abstract
Success with B cell depletion using rituximab has proven the concept that B lineage cells represent a valid target for the treatment of autoimmune diseases, and has promoted the development of other B cell targeting agents. Present data confirm that B cell depletion is beneficial in various autoimmune disorders and also show that it can worsen the disease course in some patients. These findings suggest that B lineage cells not only produce pathogenic autoantibodies, but also significantly contribute to the regulation of inflammation. In this review, we will discuss the multiple pro- and anti-inflammatory roles of B lineage cells play in autoimmune diseases, in the context of recent findings using B lineage targeting therapies.
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Affiliation(s)
- Katharina Hofmann
- Institute for Systemic Inflammation Research, University of Luebeck, Luebeck, Schleswig-Holstein, Germany
| | - Ann-Katrin Clauder
- Institute for Systemic Inflammation Research, University of Luebeck, Luebeck, Schleswig-Holstein, Germany
| | - Rudolf Armin Manz
- Institute for Systemic Inflammation Research, University of Luebeck, Luebeck, Schleswig-Holstein, Germany
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16
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Barcellini W, Fattizzo B. Autoimmune hemolytic anemia - progress in emerging treatment options. Expert Opin Orphan Drugs 2018. [DOI: 10.1080/21678707.2018.1452734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Affiliation(s)
- Wilma Barcellini
- Hematology Unit, IRCCS Ca’ Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
| | - Bruno Fattizzo
- Hematology Unit, IRCCS Ca’ Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
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17
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Kruizinga MD, van Tol MJ, Bekker V, Netelenbos T, Smiers FJ, Bresters D, Jansen-Hoogendijk AM, van Ostaijen-ten Dam MM, Kollen WJ, Zwaginga JJ, Lankester AC, Bredius RG. Risk Factors, Treatment, and Immune Dysregulation in Autoimmune Cytopenia after Allogeneic Hematopoietic Stem Cell Transplantation in Pediatric Patients. Biol Blood Marrow Transplant 2018; 24:772-778. [DOI: 10.1016/j.bbmt.2017.12.782] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2017] [Accepted: 12/09/2017] [Indexed: 10/18/2022]
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18
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Khazal S, Polishchuk V, Soffer G, Prinzing S, Gill J, Mahadeo KM. Allogeneic hematopoietic stem cell transplantation is associated with cure and durable remission of late-onset primary isolated central nervous system hemophagocytic lymphohistiocytosis. Pediatr Transplant 2018; 22. [PMID: 29239076 DOI: 10.1111/petr.13101] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/22/2017] [Indexed: 11/27/2022]
Abstract
Primary isolated CNS presentation of HLH is exceedingly rare and typically associated with significant morbidity and mortality. We describe an adolescent patient with late-onset, primary isolated CNS HLH and a compound heterozygous PRF1 mutation (c50delT (p.L17 fs); c.1229G>C (p.R410P)), not previously reported with this phenotype. He was successfully treated with allogeneic HSCT following a reduced-intensity conditioning regimen, despite a high pre-HSCT comorbidity index. Two years after transplant, he is alive and in disease remission. While patients with systemic HLH and active CNS disease have relatively poorer outcomes, a high index of suspicion may aid with early diagnosis of primary isolated CNS HLH; prompt treatment with HSCT may be associated with improved cure and durable remission of this rare disease.
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Affiliation(s)
- Sajad Khazal
- Pediatric Stem Cell Transplantation and Cellular Therapy, University of Texas MD Anderson Children's Cancer Hospital, Houston, TX, USA
| | - Veronika Polishchuk
- Pediatric Marrow and Blood Cell Transplantation Program, Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Gary Soffer
- Division of Allergy and Immunology, Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Samantha Prinzing
- Pediatric Marrow and Blood Cell Transplantation Program, Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Jonathan Gill
- Pediatric Stem Cell Transplantation and Cellular Therapy, University of Texas MD Anderson Children's Cancer Hospital, Houston, TX, USA
| | - Kris M Mahadeo
- Pediatric Stem Cell Transplantation and Cellular Therapy, University of Texas MD Anderson Children's Cancer Hospital, Houston, TX, USA
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19
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Shima H, Isshiki K, Yamada Y, Yamazaki F, Takahashi T, Shimada H. Successful haploidentical BMT with post-transplant cyclophosphamide for refractory autoimmune pancytopenia after cord blood transplant in pediatric myelodysplastic syndrome. Bone Marrow Transplant 2017; 52:653-655. [PMID: 28067878 DOI: 10.1038/bmt.2016.341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- H Shima
- Department of Pediatrics, Keio University School of Medicine, Tokyo, Japan
| | - K Isshiki
- Department of Pediatrics, Keio University School of Medicine, Tokyo, Japan
| | - Y Yamada
- Department of Pediatrics, Keio University School of Medicine, Tokyo, Japan
| | - F Yamazaki
- Department of Pediatrics, Keio University School of Medicine, Tokyo, Japan
| | - T Takahashi
- Department of Pediatrics, Keio University School of Medicine, Tokyo, Japan
| | - H Shimada
- Department of Pediatrics, Keio University School of Medicine, Tokyo, Japan
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20
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[Recent progresses of autoimmune hemolytic anemia]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2016; 37:1012-1016. [PMID: 27995893 PMCID: PMC7348504 DOI: 10.3760/cma.j.issn.0253-2727.2016.11.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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21
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DiNofia AM, Salazar E, Seif AE, Li Y, Huang YSV, Bagatell R, Fisher BT, Aplenc R. Bortezomib Inpatient Prescribing Practices in Free-Standing Children's Hospitals in the United States. PLoS One 2016; 11:e0151362. [PMID: 26978062 PMCID: PMC4792468 DOI: 10.1371/journal.pone.0151362] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2015] [Accepted: 02/27/2016] [Indexed: 01/30/2023] Open
Abstract
This study is a pharmacoepidemiologic description of pediatric bortezomib use. Exposure was identified through billing codes in patients admitted to US children's hospitals that participated with the Pediatric Health Information System between 2004 and 2013. Associated information on underlying diseases, demographics, institutional use, mortality, and physician type was collected. Exposure to bortezomib was identified in 314 patients. Hematologist/Oncologists prescribed half of the bortezomib used. Use increased during the study period. Inpatient volume was positively correlated with bortezomib utilization. Bortezomib use in pediatrics is increasing for a variety of diseases. Variation in use exists across institutions. Further studies are needed to characterize bortezomib's efficacy in pediatric diseases.
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Affiliation(s)
- Amanda M. DiNofia
- Division of Oncology, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, United States of America
- * E-mail:
| | - Elizabeth Salazar
- Division of Oncology, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, United States of America
| | - Alix E. Seif
- Division of Oncology, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, United States of America
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, United States of America
| | - Yimei Li
- Division of Oncology, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, United States of America
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, United States of America
| | - Yuan-Shung Vera Huang
- Center for Pediatric Clinical Effectiveness, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, United States of America
| | - Rochelle Bagatell
- Division of Oncology, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, United States of America
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, United States of America
| | - Brian T. Fisher
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, United States of America
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, United States of America
- Center for Pediatric Clinical Effectiveness, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, United States of America
- Division of Infectious Diseases, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, United States of America
| | - Richard Aplenc
- Division of Oncology, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, United States of America
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, United States of America
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, United States of America
- Center for Pediatric Clinical Effectiveness, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, United States of America
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