Thromboembolic events as an emerging adverse effect during high-dose intravenous immunoglobulin therapy in elderly patients: a case report and discussion of the relevant literature

A practical guide to the management of immune thrombocytopenia co-existing with acute coronary syndrome

Introduction

Immune thrombocytopenia (ITP) management with co-existing acute coronary syndrome (ACS) remains challenging as it requires a clinically relevant balance between the risk and outcomes of thrombosis and the risk of bleeding. However, the literature evaluating the treatment approaches in this high-risk population is scarce.

Methods and Results

In this review, we aimed to summarize the available literature on the safety of ITP first- and second-line therapies to provide a practical guide on the management of ITP co-existing with ACS. We recommend holding antithrombotic therapy, including antiplatelet agents and anticoagulation, in severe thrombocytopenia with a platelet count < 30 × 109/L and using a single antiplatelet agent when the platelet count falls between 30 and 50 × 109/L. We provide a stepwise approach according to platelet count and response to initial therapy, starting with corticosteroids, with or without intravenous immunoglobulin (IVIG) with a dose limit of 35 g, followed by thrombopoietin receptor agonists (TPO-RAs) to a target platelet count of 200 × 109/L and then rituximab.

Conclusion

Our review may serve as a practical guide for clinicians in the management of ITP co-existing with ACS.

Contribution of Flexig mobile application to assess adherence of patients treated with immunoglobulins in chronic diseases

Background

Long-term therapeutic adherence remains an essential challenge for better management of chronic diseases. It is estimated at 50% in developed countries.

Objective

The study aimed to evaluate, under real conditions, the influence of satisfaction with Flexig use on adherence to subcutaneous immunoglobulin home-treatment therapy in a sample of French patients with chronic dysimmune diseases.

Methods

This is a 2-year prospective cohort involving 241 patients from several hospitals in France whose data were extracted from the Flexig 2.0 mHealth application. Satisfaction was assessed by System Usability Scale (SUS) and user experience by User Experience Questionnaire (UEQ). Adherence to Ig therapy was assessed by medication possession rate. We analyzed the relationship between Flexig user satisfaction and adherence to treatment, as well as determinants of adherence.

Results

Most patients (82.7%) were being treated for an immunodeficiency, versus 17.3% for a chronic autoimmune and inflammatory disease. Almost all patients (97.9%) received subcutaneous immunoglobulin therapy. The patients' ages (means ± SDs) were 36.5 ± 18.3 years, disease duration was about 6 years, and 58.5% were men. Flexig user satisfaction was 76.2 ± 8 (System Usability Scale), associated with good user experience reported on UEQ. Adherence rate was 99.7%. Time on app, disease duration, and Flexig user satisfaction were statistically predictive of adherence to IgG therapy. High adherence to Ig therapy was associated with good satisfaction with using Flexig (P < .0001).

Conclusion

Adherence to Ig therapy in chronic dysimmune disease was strong and was associated with good satisfaction among Flexig users, suggesting that electronic support may be a valuable compliance aid.

New Approaches to Cardiovascular Disease and Its Management in Kidney Transplant Recipients

Cardiovascular events, including ischemic heart disease, heart failure, and arrhythmia, are common complications after kidney transplantation and continue to be leading causes of graft loss. Kidney transplant recipients have both traditional and transplant-specific risk factors for cardiovascular disease. In the general population, modification of cardiovascular risk factors is the best strategy to reduce cardiovascular events; however, studies evaluating the impact of risk modification strategies on cardiovascular outcomes among kidney transplant recipients are limited. Furthermore, there is only minimal guidance on appropriate cardiovascular screening and monitoring in this unique patient population. This review focuses on the limited scientific evidence that addresses cardiovascular events in kidney transplant recipients. Additionally, we focus on clinical management of specific cardiovascular entities that are more prevalent among kidney transplant recipients (ie, pulmonary hypertension, valvular diseases, diastolic dysfunction) and the use of newer evolving drug classes for treatment of heart failure within this cohort of patients. We note that there are no consensus documents describing optimal diagnostic, monitoring, or management strategies to reduce cardiovascular events after kidney transplantation; however, we outline quality initiatives and research recommendations for the assessment and management of cardiovascular-specific risk factors that could improve outcomes.

Adverse Reactions to Intravenous Immunoglobulins - Our Experience

BACKGROUND:

Adverse reactions to intravenous immunoglobulins (IVIG) are divided by organ system involved, or by timing of onset–immediate which occur during infusion usually rate-related, true IgE-mediated anaphylaxis and delayed reaction which occur hours to days after the infusion.

AIM:

To describe the adverse events of patients given IVIG infusions.

METHODS:

Total number of patients receiving IVIG was 41 with 25 males (60.97%) and 16 females (39.02%), age 2 months-35 years. A total number of infusions was 1350.

RESULTS:

Total number of adverse reactions 15, 14 patients with immediate-type and 1 with delayed type. Total percentage of adverse reactions in a given sample was 1.1% of all IVIG infusions. Fever was the most common immediate type of reaction occurring in 11 patients (78.57%) followed by acrocyanosis 10 patients (71.42%), skin rash 9 patients (64.28%) and headache 8 patients (57.14). Delayed-type of reactions (like fever, headache and vomiting) was present in one patient. Majority of the adverse effects occurred at the infusion rate higher than 1, 5 ml/kg/hour, which is still within recommended speed.

CONCLUSION:

About 1.1% of IVG infusions where with adverse events. Most common manifestations where: fever, acrocyanosis, skin rash and headache, which occurred 1-6 hours from the beginning of the infusion. The occurrence of adverse reactions to IVIG was related to the infusion rates in a fashion that faster infusion rate gives more reactions. Adverse reactions were managed by reduction of the infusion rate and administration of medications such as paracetamol, antihistamines and steroids.

The risk of hospitalization for respiratory tract infection (RTI) in children who are treated with high-dose IVIG in Kawasaki Disease: a nationwide population-based matched cohort study

Background

Kawasaki disease (KD) is an immune-mediated systemic vasculitis, and infection plays an important role in the pathophysiology of KD. The susceptibility to infectious disease in patients with KD remains largely unclear. This study aimed to investigate the risk of respiratory tract infection (RTI)-related hospitalizations in children with KD.

Methods

Data from the Taiwanese National Health Insurance Research Database was analyzed. We excluded patients with history of congenital abnormality, allergic diseases, or hospitalization history. Children with KD were selected as KD group and age- and sex-matched non-KD patients were selected as control group with 1:4 ratio. Both cohorts were tracked for one year to investigate the incidences of RTI-related hospitalizations. Cox regression hazard model was used to adjust for confounding factors and calculate the adjusted hazard ratio (aHR).

Results

Between January 1996 and December 2012, 4,973 patients with KD were identified as the KD group and 19,683 patients were enrolled as the control group. An obviously reduced risk of RTI-related hospitalizations was observed in KD patients (aHR: 0.75, 95% CI [0.66-0.85]). The decreased risk persisted through the first six-months follow-up period with a peak protection in 3-6 months (aHR: 0.49, 95% CI [0.37-0.64]).

Conclusions

KD patients had approximately half reduction of risk for RTI-related hospitalizations. The protective effects persisted for at least six months. Further studies are warranted to elucidate the entire mechanism and investigate the influences of intravenous immunoglobulin.

Historical Aspects of Polyclonal IgG Preparations

Today we can choose between several polyclonal IgG products for both replacement and immunomodulation. However, it was a long way to go to reach this stage. In this chapter, we try to illustrate the major stages of IgG product development which began more than 70 years ago.

Update on the use of immunoglobulin in human disease: A review of evidence

Human immunoglobulin preparations for intravenous or subcutaneous administration are the cornerstone of treatment in patients with primary immunodeficiency diseases affecting the humoral immune system. Intravenous preparations have a number of important uses in the treatment of other diseases in humans as well, some for which acceptable treatment alternatives do not exist. We provide an update of the evidence-based guideline on immunoglobulin therapy, last published in 2006. Given the potential risks and inherent scarcity of human immunoglobulin, careful consideration of its indications and administration is warranted.

On the dark side of therapies with immunoglobulin concentrates: the adverse events

Therapy by human immunoglobulin G (IgG) concentrates is a success story ongoing for decades with an ever increasing demand for this plasma product. The success of IgG concentrates on a clinical level is documented by the slowly increasing number of registered indication and the more rapid increase of the off-label uses, a topic dealt with in another contribution to this special issue of Frontiers in Immunology. A part of the success is the adverse event (AE) profile of IgG concentrates which is, even at life-long need for therapy, excellent. Transmission of pathogens in the last decade could be entirely controlled through the antecedent introduction by authorities of a regulatory network and installing quality standards by the plasma fractionation industry. The cornerstone of the regulatory network is current good manufacturing practice. Non-infectious AEs occur rarely and mainly are mild to moderate. However, in recent times, the increase in frequency of hemolytic and thrombotic AEs raised worrying questions on the possible background for these AEs. Below, we review elements of non-infectious AEs, and particularly focus on hemolysis and thrombosis. We discuss how the introduction of plasma fractionation by ion-exchange chromatography and polishing by immunoaffinity chromatographic steps might alter repertoire of specificities and influence AE profiles and efficacy of IgG concentrates.

High dose intravenous immunoglobulin may be complicated by myocardial infarction

Intravenous immunoglobulin [IVIg] is useful for treating several clinical conditions and is largely considered safe, without major adverse events. Here we report a case of acute ST elevation myocardial infarction associated with high dose IVIg administration in a previously healthy 69-year-old male patient of Guillain Barre syndrome. The case is being reported to emphasize the need for treating physicians to be aware of thrombotic complications associated with IVIg. The thrombotic complications associated with IVIg are reviewed in brief, and the measures to reduce them are discussed.

Association of autoantibody specificity and response to intravenous immunoglobulin G therapy in immune thrombocytopenia: a multicenter cohort study

BACKGROUND

Immune thrombocytopenia (ITP) is a common autoimmune bleeding disorder, in which platelet glycoprotein (GP)IIb-IIIa and GPIb-IX are the two most frequently targeted autoantigens. Our previous studies in animal models of ITP demonstrated that intravenous immunoglobulin G (IVIG) could protect against anti-GPIIb-IIIa autoantibody-mediated thrombocytopenia but failed to ameliorate ITP induced by most anti-GPIb-IX autoantibodies.

OBJECTIVES

The objective of this human study was to evaluate the association between the specificity of antiplatelet autoantibodies and response to IVIG treatment.

PATIENTS/METHODS

In this retrospective study, a cohort of 156 previously untreated adults with severe ITP who underwent IVIG therapy (0.4 g kg(-1)  day(-1) for 5 days) was analyzed. The primary outcome was response defined as platelet counts of ≥ 30 × 10(9)  L(-1) and a doubling of baseline counts within 7 days of dosing, and an absence of bleeding.

RESULTS AND CONCLUSIONS

Among the 66 patients with anti-GPIb-IX autoantibodies, only 24 (36.4%) achieved a response, as compared with 72 of 90 patients (80.0%) who were negative for anti-GPIb-IX autoantibodies (relative risk 2.2; 95% confidence interval 1.6-3.1). This study found no difference in response between patients with anti-GPIIb-IIIa autoantibodies (61.7%) and those without anti-GPIIb-IIIa autoantibodies (61.3%). Logistic regressions, including main effects and the interaction between these two autoantibodies, showed no influence of anti-GPIIb-IIIa autoantibodies on the effects of anti-GPIb-IX autoantibodies with regard to their association with IVIG response. Thus, in adults with ITP, the presence of anti-GPIb-IX autoantibodies is a predictive factor for poor response to IVIG treatment.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01666795.

Diagnosis and treatment of primary immunodeficiency disease: the role of the otolaryngologist

OBJECTIVE

The objective of the study was to review the diagnosis and treatment of primary immunodeficiency disease (PID) and the role of otolaryngologists in the management of PID.

METHODS

A search was conducted of PubMed and the Web sites of organizations for PID patients for literature pertaining to the diagnosis and treatment of PID, with an emphasis on the role of otolaryngologists. The reference lists of selected articles were reviewed for additional articles.

RESULTS

Patients with PID commonly present with respiratory tract infections (eg, recurrent ear, nose, or throat infections) and chest disease. Diagnostic delays or inadequate treatment of PID may lead to significant morbidity and premature mortality. Immunoglobulin (Ig) replacement is the cornerstone of therapy for most patients with PID. Although intravenous Ig is the most popular route of administration in the United States, subcutaneous Ig administration may be appropriate for patients with poor venous access, those who are unable to tolerate intravenous Ig, or those who prefer the independence and flexibility of self-administration.

CONCLUSIONS

Recognition and diagnosis of PID by otolaryngologists are critical to optimizing patient outcomes. Several therapeutic regimens for Ig replacement are now available that offer patients increased flexibility and independence.

Non-ST Elevation Myocardial Infraction after High Dose Intravenous Immunoglobulin Infusion

Intravenous immunoglobulins (IVIgs) are used for several indications, including autoimmune conditions. IVIg treatment is associated with several possible adverse reactions including induction of a hypercoagulable state. We report a 76-year-old woman treated with IVIg for myasthenia gravis, which developed chest pain and weakness following IVIg infusion. The symptoms were associated with ST segment depression in V4–6 and elevated troponin levels. The patient was diagnosed with non-ST elevation myocardial infarction (NSTEMI). The patient had no significant risk factor besides age and a cardiac perfusion scan was interpreted as normal (the patient refused to undergo cardiac catheterization). This case is compatible with IVIg-induced hypercoagulability resulting in NSTEMI. Cardiac evaluation should therefore be considered prior to initiation of IVIg treatment especially in patients with multiple cardiovascular risks.

Analysis of thromboembolic risk related to high-dose intravenous immunoglobulin treatment: a preliminary clinical study of 10 patients with autoimmune mucocutaneous blistering diseases

BACKGROUND

Intravenous immunoglobulin (IVIg) treatment is a well-known treatment that has been used successfully in a broad spectrum of autoimmune diseases. Currently no data are available in the literature about the role of IVIg in the pathogenesis of thromboembolic events in patients with autoimmune blistering diseases refractory to conventional immunosuppressive treatment.

AIM

To determine the relationship between IVIg and thromboembolism in patients with autoimmune blistering diseases and to establish a protocol to deal with the thromboembolic risk.

METHODS

In our preliminary clinical study, 10 patients with autoimmune blistering diseases underwent IVIg cycles to a total of 133 cycles in all (total number of infusions in the patient group: 399), at a standard dose of 2 g/kg/infusion accompanied by an accurate and a complete clinical and laboratory screening for thromboembolism. Preventive measures, such as hydration before and after IVIg, and administration of 100 mg of acetyl salicylic acid (aspirin) or 1000 IU of subcutaneous heparin calcium per day for 3 weeks, were introduced to reduce the thromboembolic risk.

RESULTS

Throughout the 2 years of IVIg treatment, no patient developed a superficial and/or deep venous or arterial thrombosis, even though some of the patients had underlying thromboembolic risk factors and had tested positive for some congenital and acquired thrombophilia markers.

CONCLUSIONS

Our results indicate that thromboembolic events are uncommon, despite the presence of risk factors. However, as these disorders are very rare and the percentage of nonresponder patients is very low, further investigations are needed to better understand whether IVIg alone is able to trigger these fatal events in blistering disorders.

Is passive immunization for Alzheimer's disease 'alive and well' or 'dead and buried'?

BACKGROUND

Passive immunization strategies are under investigation as potential disease-modifying therapies for Alzheimer's disease (AD). Current approaches, based on data demonstrating behavioral improvement and reduced pathology in transgenic animal models, have focused exclusively on immune targeting of beta-amyloid.

OBJECTIVE

To examine immunization strategies for AD.

METHODS

A review of relevant publications.

RESULTS/CONCLUSIONS

Preliminary results from three Phase II trials suggest both the promise and the need to exercise caution with this method of immunotherapy. The strategies used were distinct, using monoclonal N-terminal, central epitope, and polyclonal antibodies to maximize the efficacy and safety of each approach. The tested compounds are moving into Phase III trials for mild to moderate AD. We await the discoveries that from these studies that may yield the first disease-modifying therapy for AD.

Myocardial infarction during intravenous immunoglobulin infusion in a 65-year-old man with common variable immunodeficiency and subsequent successful repeated administration

BACKGROUND

Intravenous immunoglobulin (IVIG) may cause thromboembolic events. Although such events are usually associated with large IVIG doses administered to treat neurologic diseases, thromboembolic events may also occur with standard immunodeficiency doses.

OBJECTIVE

We describe a 65-year-old man with common variable immunodeficiency (CVID) who experienced angina and myocardial infarction with IVIG infusion.

METHODS

The patient's electronic medical record was reviewed.

RESULTS

The patient developed substernal chest pain during a scheduled 40-g (400-mg/kg) infusion. The infusion was discontinued, and a cardiac evaluation was initiated. The patient was found to have elevated troponin T and creatine kinase MB levels, signifying cardiac injury. Heart catheterization revealed severe vessel disease, and surgical revascularization was subsequently performed. Three weeks after revascularization, an IVIG dose of 200 mg/kg was cautiously readministered. This dose was increased in 2 weeks to 300 mg/kg, which was tolerated every 3 to 4 weeks without any adverse thrombotic events in the subsequent 12 months.

CONCLUSIONS

This case demonstrates not only angina and myocardial infarction associated with IVIG infusion in a patient with CVID but also the successful reinitiation of IVIG infusion after surgical revascularization. This case also underscores the importance of caution with IVIG infusion in patients with CVIDand known coronary artery disease.

Tolerability and safety of the intravenous immunoglobulin Octagam: a 10-year prospective observational study

PURPOSE

Following the approval of Octagam in 1995, an open prospective observational cohort study has been initiated to observe the tolerability of the intravenous immunoglobulin Octagam. This study aimed to evaluate the long-term safety profile of Octagam in daily use in the treatment of various primary (PID) and secondary (SID) immunodeficiencies and autoimmune diseases (AID).

METHODS

Within a time period of 10 years, data were collected in 310 study sites. The treating physicians documented patient characteristics, treatment parameters and the occurrence of an adverse drug reaction (ADR) by using detailed case record forms (CRF).

RESULTS

A total of 6357 patients of all ages received 92 958 infusions of Octagam. ADR occurred in 4.2% of the patients and in 0.35% of all infusions. Most of them (94.8%) were classified as nonserious, the majority (90.2%) were of mild or moderate intensity. The ADR frequency differed slightly between the indication groups, for example in PID patients ADR occurred in 8.3% of patients and 0.5% of infusions, in SID patients in 5.0% of patients and 0.62% of infusions. Rigors were reported most frequently, followed by fever, headache, nausea and flush. The ADR symptoms differed between the indication groups, rigors were predominantly described in SID patients, headache in PID and AID patients including idiopathic thrombocytopenic purpura (ITP). A relation between the ADR frequency and elevated infusion rates or high dosages was not detected.

CONCLUSIONS

This unique 10-year observational study demonstrates that Octagam is well tolerated in routine clinical use with an overall ADR frequency of 0.35%.

A case of deep vein thrombosis and pulmonary thromboembolism after intravenous immunoglobulin therapy

Although high-dose intravenous immunoglobulin (IVIG) is generally considered a safe medication for various immune-mediated diseases, thrombotic events have been reported as a complication of the therapy. We report a case who developed thrombotic complications after receiving IVIG. A 56-yr-old woman with idiopathic thrombocytopenic purpura received IVIG at a dose of 400 mg/kg/day for five days. Three days after the administration of IVIG, the patient developed painful edema in the left leg. Lower extremity doppler ultrasound revealed deep vein thrombosis in the left leg. Chest computed tomography (CT) scan demonstrated a filling defect indicating thromboembolism of the right pulmonary artery. After three weeks of enoxaparin therapy, her symptoms and pulmonary embolism on CT improved. This case suggests clinicians should be cautious in the development of thromboembolism by administration of IVIG, especially in patients with thrombophilia.

Intravenous immunoglobulins contain naturally occurring antibodies that mimic antineutrophil cytoplasmic antibodies and activate neutrophils in a TNFα-dependent and Fc-receptor–independent way

Intravenous immunoglobulin (IVIg) preparations are increasingly used for therapy of several neuroimmunologic diseases. IVIg therapy is considered safe, although serious side effects like aseptic meningitis, cerebral vasospasm, or ischemic encephalopathy have been reported. These side effects are frequently associated with neutrophilic pleocytosis in the cerebrospinal fluid (CSF), suggesting a neutrophil-mediated mechanism. To elucidate the potential role of neutrophil activation, we analyzed IVIg preparations from 5 different commercial sources for the presence of antineutrophil cytoplasmic antibody (ANCA)–like immunoglobulins against ethanol-fixed peripheral-blood neutrophils, purified human antigens, and a panel of human and nonhuman tissues. All IVIg batches tested (n = 13) contained atypical ANCAs (IgG titer up to 1:2048, IgA up to 1:512). Moreover, all preparations were capable of inducing hydrogen peroxide production in TNFα-primed human neutrophils, with a significant correlation (P < .005) between atypical ANCA titers in IVIg preparations and neutrophil activation. Fc-mediated binding and activation was ruled out by the use of IVIg-F(ab′)2 fragments. Our findings strongly suggest that in vivo activation of TNFα-primed neutrophils by atypical ANCAs of IVIg may contribute to the side effects of IVIg therapy and for the first time demonstrate that the activation of neutrophil granulocytes by IVIg occurs in an Fc receptor (FcR)–independent, hence antigen-dependent, way.

Pathogenesis and recent therapeutic trends in Stevens-Johnson syndrome and toxic epidermal necrolysis

OBJECTIVE

To review the current pathophysiologic mechanisms and recent therapeutic trends in Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN).

DATA SOURCES

A MEDLINE search for SJS and TEN in combination with Fas, Fas ligand (FasL), cytotoxic T cells, intravenous immunoglobulin, and cyclosporine for articles published in English during 1966 to 2006.

STUDY SELECTION

Information was derived from original research articles and reviews published in peer-reviewed journals.

RESULTS

The hallmark of SJS and TEN is epidermal cell apoptosis, which may be mediated through keratinocyte Fas-FasL interaction or through cytotoxic T-cell release of perforin and granzyme B. Whereas systemic corticosteroid therapy showed contradictory results, intravenous immunoglobulin (IVIG) and cyclosporine have shown promising outcomes. IVIG contains anti-Fas antibodies that can abrogate apoptosis when preincubated with keratinocytes. Most studies on IVIG in SJS and TEN reported improvement in arresting disease progression and reduction in time to skin healing. Because of variations among studies, the findings cannot be optimally compared. In general, mortality varied from 0% to 12% in studies that supported the use of IVIG and 25% to 41.7% in those that did not demonstrate a beneficial effect. Cyclosporine inhibits CD8 activation and thus may reduce epidermal destruction. Relatively few case reports and 1 case series have been published regarding the use of cyclosporine in SJS and TEN. In general, cyclosporine was associated with a significant improvement in time to disease arrest and to complete reepithelization, with no reported fatalities.

CONCLUSIONS

Both IVIG and cyclosporine have been associated with enhanced healing and better survival through inhibition of apoptosis. Multicenter, randomized, placebo-controlled trials using a standardized design are needed to validate these findings.

Relative efficacy of intravenous immunoglobulin G in ameliorating thrombocytopenia induced by antiplatelet GPIIbIIIa versus GPIbalpha antibodies

Intravenous immunoglobulin G (IVIG) is used to treat idiopathic thrombocytopenic purpura (ITP). Although many patients benefit from IVIG, some are refractory to this therapy. ITP is characterized by platelet clearance mediated primarily by antiplatelet antibodies against GPIIbIIIa and/or the GPIbalpha complex. These 2 groups of antibodies may induce ITP through different mechanisms. We tested the hypothesis that IVIG may not be equally effective in preventing ITP caused by anti-GPIIbIIIa versus anti-GPIbalpha antibodies in mice. Thrombocytopenia was induced in BALB/c mice using monoclonal antibodies against either mouse GPIIbIIIa (JON1, JON2, and JON3) or GPIbalpha (p0p3, p0p4, p0p5, p0p9, and p0p11). Pretreatment with IVIG significantly ameliorated ITP in all anti-GPIIbIIIa-injected animals. Conversely, IVIG failed to prevent ITP in all anti-GPIbalpha-treated mice, except for p0p4. These results were repeated in C57BL/6 mice, and with different IVIG preparations. These data in mice suggest that patients with ITP mediated by anti-GPIbalpha antibodies may be less responsive to IVIG treatment.

Intravenous immunoglobulin-associated arterial and venous thrombosis; report of a series and review of the literature

BACKGROUND

To date, the prevalence of intravenous immunoglobulin (IvIg)-related thrombotic complications has not been evaluated in patients with autoimmune disorders followed up in Departments of Internal Medicine.

OBJECTIVES

To assess prevalence and characteristics of IvIg-related thrombotic complications in patients with autoimmune disorders receiving IvIg therapy; to evaluate the predictive factors for onset of IvIg-related thrombotic manifestation in patients, and to detect patients at risk for these types of complications.

PATIENTS AND METHODS

The medical records of 46 patients with autoimmune disorders who were given IvIg therapy at our Department of Internal Medicine between January 2002 and December 2004 were reviewed.

RESULTS

Among the 46 patients, nine exhibited IvIg-associated severe complications (19.6%). Six patients (13%) developed IvIg-related thrombotic complications. Thrombotic complications frequently occurred during IvIg infusion (50%), although they were also observed within 1-8 days following IvIg infusion in other patients. IvIg-related thrombotic complications consisted of: deep venous thrombosis or pulmonary embolism (n = 3), myocardial infarction (n = 2) and stroke (n = 1). The outcome of thrombotic complications was favourable in all patients, after appropriate therapy institution. Older age, history of associated arterial hypertension and hypercholesterolaemia were more common in the group of patients with IvIg-related thrombotic complications.

CONCLUSIONS

Our study demonstrates that IvIg-related thrombotic arterial/venous complications are not uncommon in patients with autoimmune disorders (13% of patients). Nevertheless, patients, who are followed up in Departments of Internal Medicine often have concomitant disorders placing them at increased risk to develop IvIg-related thrombotic complications; the latter may also explain the high rate of IvIg-related thrombosis in our cohort. Our series further indicates that patients should be monitored closely for these types of adverse events during the whole period of IvIg therapy, as thrombotic manifestations occurred in patients who had received multiple IvIg infusions without exhibiting complications. In addition, our results suggest that it is questionable to initiate IvIg therapy in patients presenting with predictive factors of thrombotic complications; in this subgroup of patients, IvIg should be prescribed cautiously, after re-weighing risk-benefit considerations.

Autoimmunthrombozytopenie (AITP) des Erwachsenen: Klinik, Diagnose und Therapie

The incidence of AITP is 20-30/million/year. The diagnosis is based on the finding of an isolated thrombocytopenia without other blood abnormalities and absence of a palpable spleen. Additional tests such as bone marrow examination, determination of platelet antibodies and of thrombopoetin are required only in special cases. The usual first line therapy in patients with bleeding tendency and a low platelet count is prednisolone at a dose of 1 mg/kg/day. Patients who have platelet counts of less than 20,000/microl 3-6 months after steroid therapy are candidates for splenectomy, in particular if more than 0.1 mg/kg/day prednisolone is required to keep the patient free of bleedings. Laparoscopic splenectomy has a low mortality (0.2%) and morbidity (10%). The risk of post-splenectomy overwhelming pneumococcal septicaemia can be minimized by preoperative vaccination. Older patients, who have low platelet counts after splenectomy, have a high bleeding risk. The most effective treatment options for these patients are cyclophosphamide, azathioprine and rituximab, but the choice of treatment should be carefully considered, since the risk of adverse effects may be greater than the risk of fatal bleeding.

Safety and Adverse Events Profiles of Intravenous Gammaglobulin Products Used for Immunomodulation: A Single-Center Experience

Intravenous Ig (IVIg) products are used in various medical conditions. Differences in excipients account for most adverse events (AE). Reports of complications including acute myocardial infarction (AMI) and acute renal failure (ARF) have emerged. Herein is described one institution's experience with IVIg-related complications. This study is a retrospective analysis of infusion-related AE that are associated with various IVIg products. Infusion-related AE were monitored during and after the administration of three IVIg products: Gamimune-N 10% (n = 76), Polygam (n = 105), and Carimune (n = 98). AE segregated to specific IVIg products. No patients who received Gamimune-N experienced AMI or ARF. Five (4.7%) patients (P < 0.01) in the Polygam group experienced AMI. Eight (8.2%) patients (P < 0.0001) in the Carimune group developed ARF. IVIg was safe to give on hemodialysis. IVIg products differ in osmolality, pH, and sugar and sodium content; this results in specific AE. Polygam resulted in no ARF but an increase in AMI. Carimune products at 9% concentration resulted in an increase in ARF. Gamimune-N 10% and other IVIg products were frequently associated with headaches. Administration of IVIg to patients who are on hemodialysis seems to be safe and effective.

Cerebral infarction after high-dose intravenous immunoglobulin therapy for Kawasaki disease

A 3-year-old boy with Kawasaki disease developed a cerebral infarction after high-dose intravenous immunoglobulin. Aspirin did not prevent the stroke. Based on the numerous reports of thrombosis due to high-dose immunoglobulin in older individuals, we conclude that it is necessary to be aware of this complication when treating children with Kawasaki disease.

Use of intravenous immunoglobulin G (IVIG)

Intravenous immunoglobulin G (IVIG) has become increasingly important both as replacement therapy in primary and acquired humoral immunodeficiency and as an immunomodulatory therapy in autoimmune disease and transplantation. Multiple potential mechanisms for the effects of IVIG have now been recognized but the contribution of each mechanism in different diseases is uncertain. IVIG is generally well tolerated but serious side effects can occur and need to be addressed. IVIG has Food and Drug Administration (FDA) approval for a half dozen indications but these account for only about half the use of IVIG. This chapter reviews the development of IVIG for primary immunodeficiency, the evidence for efficacy of IVIG in autoimmune and inflammatory conditions, the risks associated with administration of IVIG, and steps that can be taken to minimize adverse events.

Myocardial infarction associated with intravenous immune globulin

OBJECTIVE

To report a case of acute myocardial infarction (MI) experienced by a patient receiving intravenous immune globulin (IVIG) and review other published cases of MI associated with IVIG.

CASE SUMMARY

An 81-year-old Vietnamese man was prescribed IVIG for treatment of toxic epidermal necrolysis secondary to allopurinol. Thirty minutes following the start of the IVIG infusion, the patient developed crushing retrosternal chest pain and shortness of breath. The pain improved upon discontinuation of IVIG infusion but recurred when IVIG was restarted. The troponin level reached 140 microg/L, and a persantine sestamibi stress test (MIBI) indicated anterolateral ischemia. The patient was diagnos ed with non-ST-elevation MI. An objective causality assessment using the Naranjo probability scale revealed a probable association between this adverse reaction and IVIG treatment.

DISCUSSION

Although an association between IVIG administration and MI has not been demonstrated in clinical trials, accumulating clinical experience suggests that a relationship between IVIG and myocardial ischemia exists. Twenty published case reports were identified. Risk of acute MI seems to be increased with use of high-dose IVIG and in older individuals, especially those with at least one cardiovascular risk factor, such as ischemic heart disease or hypertension.

CONCLUSIONS

Case reports suggest a causal relationship between the use of IVIG and MI and other thrombotic events. While cardiovascular disease is not considered an absolute contraindication to therapy, expanding indications and subsequent use of IVIG merit that clinicians be aware of patient characteristics that may increase the risk for adverse reactions and recognize early signs of infarction.

Dementia associated with scleromyxoedema reversed by high-dose intravenous immunoglobulin

Scleromyxoedema is a rare skin disease, characterized by deposition of acid mucopolysaccharides in the dermis. Although the disease primarily affects the skin, cardiovascular, renal and rheumatological manifestations have been described. In addition to these noncutaneous manifestations, about 15% of patients have central neurological symptoms such as psychosis, convulsions and encephalopathy. Successful therapy is difficult but high-dose intravenous immunoglobulin (IVIg) has been reported to be a successful treatment. We describe a patient with scleromyxoedema who presented with novel central nervous system manifestations of chronic cognitive impairment and dementia (Folstein Mini Mental State test score 8/30), which improved within a week after treatment with high-dose IVIg, with full restoration (Folstein Mini Mental State test score 27/30) at 2 months.

Sickle Cell Vaso-Occlusion

The vaso-occlusion model has evolved impressively over the past several decades from polymerization-based concepts to a complex, wide-ranging schema that involves multistep, heterogeneous, and interdependent interactions among sickle erythrocytes (SSRBCs), adherent leukocytes, endothelial cells, plasma proteins, and other factors. Endothelial activation, induced directly or indirectly by the proinflammatory behavior of SSRBCs, is the most likely initiating step toward vaso-occlusion. Given the complexity and dynamic relationships of the potential mechanisms leading to vaso-occlusion, further in vivo studies in relevant sickle cell animal models will most likely yield the greatest advances and promote the development of novel, more effective therapeutic strategies.

Single high-dose intravenous immunoglobulin therapy for kawasaki disease increases plasma viscosity

BACKGROUND

Intravenous immunoglobulin therapy, widely used for various autoimmune and systemic inflammatory diseases including Kawasaki disease (KD), is occasionally associated with thromboembolic adverse effects caused by an abrupt increase in blood viscosity. Scarce information is available, however, regarding the effect of single high-dose immunoglobulin therapy for KD on blood viscosity.

METHODS AND RESULTS

Eleven boys and 5 girls (mean age: 2.1 years) with acute-phase KD underwent single high-dose immunoglobulin therapy. Plasma viscosity before the treatment was 1.18 centipoises (SD = 0.06), but it significantly rose to 1.34 centipoises (SD = 0.06) (p < 0.001). Multiple regression analysis revealed that, among various factors including hematocrit, plasma concentrations of total protein, immunoglobulin G (IgG), immunoglobulin A (IgA), and immunoglobulin M (IgM), only plasma IgG concentration was included in the model to explain plasma viscosity (R2 = 0.59, p < 0.001).

CONCLUSIONS

Single high-dose regimen for acute-phase KD increases blood viscosity and therefore might increase the risk of thromboembolism.

Diffuse venous thromboemboli associated with IVIg therapy in the treatment of streptococcal toxic shock syndrome: case report and review

Streptococcal toxic shock syndrome (STSS) is a severe invasive disease with a 40-80% mortality rate. Inflammatory cytokines induced by streptococcal pyrogenic exotoxins (SPEs) produce the clinical manifestations of a flu-like syndrome, followed by high fevers and multiorgan failure. Previously published reports have described the use of intravenous immunoglobulin (IVIg) as adjunctive treatment for STSS. However, concerns have been raised about the thromboembolic complications of this therapy. We report a severe case of STSS treated with two adjunctive courses of IVIg complicated by severe bilateral pulmonary thromboemboli. To our knowledge, this is the only reported case of thromboemboli associated with IVIg for STSS. The results of this case support the cautious use of IVIg for STSS and demonstrate the need for controlled trials to determine the appropriate timing, dosage, and course of treatment.

Immunoglobulin replacement therapy in primary antibody deficiency diseases--maximizing success

Antibody or humoral immunodeficiencies comprise the largest group of primary immunodeficiency diseases. Since the first description of patients with low gammaglobulin levels more than four decades ago, a great wealth of information has been accumulated. Especially in the last several years, the application of molecular and genetic techniques has unraveled many of these disorders, identifying disorders of B cell development, failure of class switch recombination and abnormalities of specific antibody production. Regardless of the underlying defect, the mainstay of therapy has been and remains immunoglobulin (Ig) replacement therapy, currently by intravenous infusion or subcutaneous injection. With advances in manufacturing, a number of products are not only safe for intravenous administration but doses can be increased to provide even more effective infection prophylaxis. However, manufacturing processes, methods of viral inactivation and removal and final composition differ widely among the available preparations. How these variables impact clinical outcome is not clear, but they have the potential to do so. As a result, careful selection of an intravenous immunoglobulin (IVIG), matching patient needs and risks to those risks associated with a specific IVIG, is necessary to optimize outcomes and maximize the success of Ig replacement therapy.