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Tunç A, Akbaş AA, Bozkurt B, Oncel S. Beyond conventional therapies: IVIG in treating severe fingolimod-rebound in a postpartum patient with MS. BMJ Case Rep 2024; 17:e259932. [PMID: 39059796 DOI: 10.1136/bcr-2024-259932] [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: 07/28/2024] Open
Abstract
This case report details a female patient with multiple sclerosis in her 30s, who experienced a significant fingolimod rebound syndrome post partum, characterised by worsening neurological symptoms and severe demyelinating lesions. Traditional treatments, including steroids and plasmapheresis, were ineffective. However, the introduction of intravenous immunoglobulin (IVIG) led to remarkable improvement in her symptoms and disability status. This case highlights the complex immunological changes associated with fingolimod cessation and underscores IVIG's potential as a valuable treatment in managing such rebounds.
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Affiliation(s)
- Abdulkadir Tunç
- Department of Neurology, Sakarya University Faculty of Medicine, Sakarya, Turkey
| | | | - Beyzanur Bozkurt
- Department of Neurology, Sakarya University Faculty of Medicine, Sakarya, Turkey
| | - Samet Oncel
- Department of Neurology, Ministry of Health Sakarya Education and Research Hospital, Adapazari, Sakarya, Turkey
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2
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Uysal SP, Morren JA. Promising therapies for the treatment of myasthenia gravis. Expert Opin Pharmacother 2024; 25:395-408. [PMID: 38523508 DOI: 10.1080/14656566.2024.2332610] [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] [Received: 01/13/2024] [Accepted: 03/14/2024] [Indexed: 03/26/2024]
Abstract
INTRODUCTION Myasthenia gravis (MG) is an autoimmune condition targeting the neuromuscular junction, which manifests with neuromuscular symptoms of varying severity and significant morbidity. The mainstay of treatment in MG is mitigation of the immune cascade with steroids and non-steroidal immunosuppressive therapies. The therapeutic strategies in MG are transitioning from broad and indiscriminate immunosuppression to novel agents targeting key steps in MG pathogenesis, including T cell activation, B cell proliferation, complement activation, maintenance of pathogenic antibody production, and proinflammatory cytokine production. AREAS COVERED In this review, an overview of the pathogenesis of MG and traditional MG therapies is presented, followed by a discussion of the novel MG drugs that have been evaluated in phase 3 clinical trials with an emphasis on those which have received regulatory approval. EXPERT OPINION Novel MG therapeutics belonging to the classes of complement inhibitors, neonatal Fc receptor (FcRn) inhibitors and B cell depletors, as well as the other emerging MG drugs in the pipeline constitute promising treatment strategies with potentially better efficacy and safety compared to the conventional MG treatments. However, further long-term research is needed in order to optimize the implementation of these new treatment options for the appropriate patient populations.
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Affiliation(s)
- Sanem Pinar Uysal
- Department of Neurology, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - John A Morren
- Neuromuscular Center, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
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Zubair AS, McAlpine LS, Gobeske KT. Virology, ecology, epidemiology, pathology, and treatment of eastern equine encephalitis. J Neurol Sci 2024; 457:122886. [PMID: 38278094 DOI: 10.1016/j.jns.2024.122886] [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] [Received: 10/06/2023] [Revised: 12/27/2023] [Accepted: 01/11/2024] [Indexed: 01/28/2024]
Abstract
Eastern equine encephalitis (EEE) was one of the first-recognized neuroinvasive arboviral diseases in North America, and it remains the most lethal. Although EEE is known to have periodic spikes in infection rates, there is increasing evidence that it may be undergoing a change in its prevalence and its public health burden. Numerous factors shape the scope of EEE in humans, and there are important similarities with other emergent viral diseases that have surfaced or strengthened in recent years. Because environmental and ecological conditions that broadly influence the epidemiology of arboviral diseases also are changing, and the frequency, severity, and scope of outbreaks are expected to worsen, an expanded understanding of EEE will have untold importance in coming years. Here we review the factors shaping EEE transmission cycles and the conditions leading to outbreaks in humans from an updated, multidomain perspective. We also provide special consideration of factors shaping the virology, host-vector-environment relationships, and mechanisms of pathology and treatment as a reference for broadening audiences.
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Affiliation(s)
- Adeel S Zubair
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA
| | | | - Kevin T Gobeske
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA.
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Batu ED, Ozen S. Other Immunomodulatory Treatment for Cytokine Storm Syndromes. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2024; 1448:601-609. [PMID: 39117842 DOI: 10.1007/978-3-031-59815-9_40] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/10/2024]
Abstract
Cytokine storm syndromes (CSS) include different entities such as macrophage activation syndrome, primary and secondary hemophagocytic lymphohistiocytosis (HLH), and multisystem inflammatory syndrome in children (MIS-C) associated with COVID-19. An effective management strategy is critical in CSS. While biologics have become an essential part of CSS treatment, hematopoietic stem cell transplantation (HSCT) has changed the fate of primary HLH patients. This chapter will focus on the available alternative immunomodulatory therapies in CSS, which include corticosteroids, cyclosporine A, intravenous immunoglobulin, interleukin 18 binding protein, therapeutic plasmapheresis, HSCT, and mesenchymal stromal cell-based therapies.
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Affiliation(s)
- Ezgi Deniz Batu
- Department of Pediatric Rheumatology, Hacettepe University, Ankara, Turkey
| | - Seza Ozen
- Department of Pediatric Rheumatology, Hacettepe University, Ankara, Turkey
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Svačina MKR, Meißner A, Schweitzer F, Ladwig A, Pitarokoili K, Kofler DM, Sprenger‐Svačina A, Schneider C, Kohle F, Klein I, Wüstenberg H, Lehmann HC. Immunomodulatory effects of intravenous and subcutaneous immunoglobulin in chronic inflammatory demyelinating polyneuropathy: An observational study. Eur J Neurol 2024; 31:e16079. [PMID: 37789648 PMCID: PMC11235934 DOI: 10.1111/ene.16079] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 08/23/2023] [Accepted: 09/14/2023] [Indexed: 10/05/2023]
Abstract
BACKGROUND AND PURPOSE It is not known whether the route of administration affects the mechanisms of action of therapeutic immunoglobulin in chronic inflammatory demyelinating polyneuropathy (CIDP). The aim of this study, therefore, was to compare the immunomodulatory effects of intravenous (IVIg) and subcutaneous immunoglobulin (SCIg) in patients with CIDP and in IVIg-treated common variable immunodeficiency (CVID) patients. METHODS Serum and peripheral blood mononuclear cell samples were obtained from 30 CIDP patients receiving IVIg, 10 CIDP patients receiving SCIg, and 15 patients with CVID receiving IVIg. Samples and clinical data were obtained prior to IVIg/SCIg and at 3 days, 7 days, and, in CIDP patients receiving IVIg, 21 days post-administration. Serum cytokines were assessed by Luminex-based multiplex assay and enzyme-linked immunosorbent assay. Immune cells were characterized by flow cytometry. RESULTS Immune cell profiles of CIDP and CVID patients differed in frequencies of myeloid dendritic cells and cytotoxic natural killer cells. During treatment with IVIg or SCIg in CIDP patients, cellular immunomarkers were largely similar. CIDP patients receiving IVIg had higher macrophage inflammatory protein (MIP)-1α (p = 0.01), interleukin (IL)-4 (p = 0.04), and IL-33 (p = 0.04) levels than SCIg recipients. IVIg treatment more broadly modulated cytokines in CIDP than SCIg treatment. CONCLUSIONS Our study demonstrates that the modulation of cellular immunomarkers in CIDP is independent of the application route of therapeutic immunoglobulin. Minor differences were observed between CIDP and CVID patients. In contrast, cytokines were differentially modulated by IVIg and SCIg in CIDP.
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Affiliation(s)
- Martin K. R. Svačina
- Department of NeurologyFaculty of Medicine, University Hospital of CologneCologneGermany
| | - Anika Meißner
- Department of NeurologyFaculty of Medicine, University Hospital of CologneCologneGermany
| | - Finja Schweitzer
- Department of NeurologyFaculty of Medicine, University Hospital of CologneCologneGermany
| | - Anne Ladwig
- Department of NeurologyFaculty of Medicine, University Hospital of CologneCologneGermany
| | | | - David M. Kofler
- Medical Clinic I, Department of Immunology and RheumatologyFaculty of Medicine, University Hospital of CologneCologneGermany
| | - Alina Sprenger‐Svačina
- Department of NeurologyFaculty of Medicine, University Hospital of CologneCologneGermany
| | - Christian Schneider
- Department of NeurologyFaculty of Medicine, University Hospital of CologneCologneGermany
- Department of NeurologySt. Katharinen HospitalFrechenGermany
| | - Felix Kohle
- Department of NeurologyFaculty of Medicine, University Hospital of CologneCologneGermany
| | - Ines Klein
- Department of NeurologyFaculty of Medicine, University Hospital of CologneCologneGermany
| | - Hauke Wüstenberg
- Department of NeurologyFaculty of Medicine, University Hospital of CologneCologneGermany
| | - Helmar C. Lehmann
- Department of NeurologyFaculty of Medicine, University Hospital of CologneCologneGermany
- Department of NeurologyClinic of Leverkusen gGmbHLeverkusenGermany
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Arimura Y, Sobue G, Hattori N, Takashima H, Harigai M, Nagata K, Makino H. Intravenous immunoglobulin for chronic residual peripheral neuropathy in microscopic polyangiitis: A multicentre randomised double-blind trial. Mod Rheumatol 2023; 33:1125-1136. [PMID: 36346309 DOI: 10.1093/mr/roac137] [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] [Received: 08/03/2022] [Accepted: 11/03/2022] [Indexed: 11/08/2023]
Abstract
OBJECTIVES We conducted a Phase 3, multicentre, randomised, double-blind, placebo-controlled, parallel-group trial to evaluate the efficacy and safety of intravenous immunoglobulin (IVIg) in patients with glucocorticoid-refractory neuropathy associated with microscopic polyangiitis. METHODS Patients received immunoglobulin or placebo intravenously for 5 consecutive days at baseline and after 4 weeks. The IVIg and placebo groups received IVIg and placebo, respectively, after 8 weeks. The primary and major secondary end-points were the least squares mean of the change in the manual muscle test (MMT) sum score after 8 and 4 weeks, respectively. RESULTS A total of 37 patients were randomised into two groups (IVIg [19] and placebo [18]). The least squares mean for the change in the MMT sum score was 9.02 for IVIg and 6.71 for placebo (difference 2.32, 95% confidence interval -2.60 to 7.23, p = .345) after 8 weeks and 6.81 and 2.83 (difference 3.99, 95% confidence interval -1.22 to 9.19, p = .129), respectively, after 4 weeks. There were no new safety concerns for IVIg. CONCLUSIONS MMT sum scores improved with IVIg compared with placebo after 8 weeks of dosing and two courses of treatment, but the differences were not statistically significant, and the results showed no clear efficacy of IVIg in this patient population. No new safety concerns were raised.
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Affiliation(s)
- Yoshihiro Arimura
- Department of Nephrology and Rheumatology, Kyorin University School of Medicine, Tokyo, Japan
- Department of Internal Medicine, Kichijoji Asahi Hospital, Tokyo, Japan
| | - Gen Sobue
- Aichi Medical University, Aichi, Japan
| | - Naoki Hattori
- Department of Neurology, Toyota Kosei Hospital, Aichi, Japan
| | - Hiroshi Takashima
- Department of Neurology and Geriatrics, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan
| | - Masayoshi Harigai
- Division of Rheumatology, Department of Internal Medicine, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
| | - Koichi Nagata
- Clinical Development Department, Teijin Pharma Limited, Tokyo, Japan
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Ladzinski AT, Tai A, Rumschlag MT, Smith CS, Mehta A, Boapimp P, Edewaard EJ, Douce RW, Morgan LF, Wang MS, Fisher-Hubbard AO, Cummings MJ, Jagger BW. Clinical Characteristics of the 2019 Eastern Equine Encephalitis Outbreak in Michigan. Open Forum Infect Dis 2023; 10:ofad206. [PMID: 37180595 PMCID: PMC10173547 DOI: 10.1093/ofid/ofad206] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 04/17/2023] [Indexed: 05/16/2023] Open
Abstract
Background Eastern equine encephalitis virus is a mosquito-borne alphavirus responsible for unpredictable outbreaks of severe neurologic disease in animals and humans. While most human infections are asymptomatic or clinically nonspecific, a minority of patients develops encephalitic disease, a devastating illness with a mortality rate of ≥30%. No treatments are known to be effective. Eastern equine encephalitis virus infection is rare in the United States, with an annual average nationwide incidence of 7 cases between 2009 and 2018. However, in 2019, 38 cases were confirmed nationwide, including 10 in Michigan. Methods Data from 8 cases identified by a regional network of physicians in southwest Michigan were abstracted from clinical records. Clinical imaging and histopathology were aggregated and reviewed. Results Patients were predominantly older adults (median age, 64 years), and all were male. Results of initial arboviral cerebrospinal fluid serology were frequently negative, and diagnosis was not made until a median of 24.5 days (range, 13-38 days) after presentation, despite prompt lumbar punctures in all patients. Imaging findings were dynamic and heterogeneous, with abnormalities of the thalamus and/or basal ganglia, and prominent pons and midbrain abnormalities were displayed in 1 patient. Six patients died, 1 survived the acute illness with severe neurologic sequelae, and 1 recovered with mild sequelae. A limited postmortem examination revealed diffuse meningoencephalitis, neuronophagia, and focal vascular necrosis. Conclusions Eastern equine encephalitis is a frequently fatal condition whose diagnosis is often delayed, and for which no effective treatments are known. Improved diagnostics are needed to facilitate patient care and encourage the development of treatments.
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Affiliation(s)
- Adam T Ladzinski
- Department of Medicine, Western Michigan University Homer Stryker MD School of Medicine, Kalamazoo, MichiganUSA
| | - Aisha Tai
- Department of Internal Medicine, Corewell Health Lakeland, St Joseph, Michigan, USA
| | - Matthew T Rumschlag
- Department of Medicine, Western Michigan University Homer Stryker MD School of Medicine, Kalamazoo, MichiganUSA
| | - Christopher S Smith
- Department of Medicine, Western Michigan University Homer Stryker MD School of Medicine, Kalamazoo, MichiganUSA
| | - Aditya Mehta
- Department of Medicine, Western Michigan University Homer Stryker MD School of Medicine, Kalamazoo, MichiganUSA
| | - Pimpawan Boapimp
- Department of Medicine, Western Michigan University Homer Stryker MD School of Medicine, Kalamazoo, MichiganUSA
| | - Eric J Edewaard
- Department of Medicine, Western Michigan University Homer Stryker MD School of Medicine, Kalamazoo, MichiganUSA
| | - Richard W Douce
- Department of Internal Medicine, Corewell Health Lakeland, St Joseph, Michigan, USA
| | - Larry F Morgan
- Department of Medicine, Western Michigan University Homer Stryker MD School of Medicine, Kalamazoo, MichiganUSA
- Neuroscience Center, Bronson Methodist Hospital, Kalamazoo, MichiganUSA
| | - Michael S Wang
- Department of Internal Medicine, Corewell Health Lakeland, St Joseph, Michigan, USA
| | - Amanda O Fisher-Hubbard
- Department of Pathology, Western Michigan University Homer Stryker MD School of Medicine, Kalamazoo, MichiganUSA
| | - Matthew J Cummings
- Department of Neuroradiology, Premier Radiology, Kalamazoo, Michigan, USA
- Department of Radiology, Western Michigan University Homer Stryker MD School of Medicine, Kalamazoo, MichiganUSA
| | - Brett W Jagger
- Correspondence: Brett W. Jagger, MD, PhD, Division of Infectious Diseases, Allergy and Immunology, Edward A. Doisy Research Center, 8th Floor, 1100 S Grand Blvd, St Louis, MO 63104 (); Current affiliation: Department of Internal Medicine, Saint Louis University, St Louis, Missouri
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Shastri A, Al Aiyan A, Kishore U, Farrugia ME. Immune-Mediated Neuropathies: Pathophysiology and Management. Int J Mol Sci 2023; 24:7288. [PMID: 37108447 PMCID: PMC10139406 DOI: 10.3390/ijms24087288] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2022] [Revised: 03/12/2023] [Accepted: 03/21/2023] [Indexed: 04/29/2023] Open
Abstract
Dysfunction of the immune system can result in damage of the peripheral nervous system. The immunological mechanisms, which include macrophage infiltration, inflammation and proliferation of Schwann cells, result in variable degrees of demyelination and axonal degeneration. Aetiology is diverse and, in some cases, may be precipitated by infection. Various animal models have contributed and helped to elucidate the pathophysiological mechanisms in acute and chronic inflammatory polyradiculoneuropathies (Guillain-Barre Syndrome and chronic inflammatory demyelinating polyradiculoneuropathy, respectively). The presence of specific anti-glycoconjugate antibodies indicates an underlying process of molecular mimicry and sometimes assists in the classification of these disorders, which often merely supports the clinical diagnosis. Now, the electrophysiological presence of conduction blocks is another important factor in characterizing another subgroup of treatable motor neuropathies (multifocal motor neuropathy with conduction block), which is distinct from Lewis-Sumner syndrome (multifocal acquired demyelinating sensory and motor neuropathy) in its response to treatment modalities as well as electrophysiological features. Furthermore, paraneoplastic neuropathies are also immune-mediated and are the result of an immune reaction to tumour cells that express onconeural antigens and mimic molecules expressed on the surface of neurons. The detection of specific paraneoplastic antibodies often assists the clinician in the investigation of an underlying, sometimes specific, malignancy. This review aims to discuss the immunological and pathophysiological mechanisms that are thought to be crucial in the aetiology of dysimmune neuropathies as well as their individual electrophysiological characteristics, their laboratory features and existing treatment options. Here, we aim to present a balance of discussion from these diverse angles that may be helpful in categorizing disease and establishing prognosis.
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Affiliation(s)
- Abhishek Shastri
- Central and North West London NHS Foundation Trust, London NW1 3AX, UK
| | - Ahmad Al Aiyan
- Department of Veterinary Medicine, UAE University, Al Ain P.O. Box 15551, United Arab Emirates
| | - Uday Kishore
- Department of Veterinary Medicine, UAE University, Al Ain P.O. Box 15551, United Arab Emirates
| | - Maria Elena Farrugia
- Department of Neurology, Institute of Neurological Sciences, Southern General Hospital, Glasgow G51 4TF, UK
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Baseline Characteristics and Predictive Factors of Intravenous Immunoglobulin Response in Drug and Device Refractory Gastroparesis Symptoms. J Clin Gastroenterol 2023; 57:172-177. [PMID: 34974494 DOI: 10.1097/mcg.0000000000001655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 11/12/2021] [Indexed: 01/07/2023]
Abstract
INTRODUCTION Intravenous immunoglobulin (IVIG) has been shown in a small pilot series to be helpful for some patients with gastroparesis that is refractory to drugs, devices, and surgical therapies. Many but not all patients have serologic neuromuscular markers. We hypothesize that those patients with serologic markers and/or longer duration of therapy would have better responses to IVIG. MATERIALS AND METHODS We studied 47 patients with a diagnosis of gastroparesis and gastroparesis-like syndrome that had all failed previous therapies including available and investigational drugs, devices, and/or pyloric therapies. Patients had a standardized 12-week course of IVIG, dosed as 400 mg/kg per week intravenously. Symptom assessment was done with Food and Drug Administration (FDA) compliant traditional patient-reported outcomes. Success to IVIG was defined as 20% or greater reduction in average symptom scores from baseline to the latest evaluation. RESULTS Fourteen patients (30%) had a response, and 33 (70%) had no response per our definition. Patients responding had a higher glutamic acid decarboxylase 65 positivity (64% vs. 30%, P =0.049, missing=3) and longer duration of therapy (>12 wk/continuous: 86% vs. 48%, P =0.09). CONCLUSIONS In this moderately sized open-label series of refractory patients with gastroparesis symptoms treated with IVIG, 30% of patients responded. While serologic markers and extended therapies show a trend to greater response, neither was statistically significant, except for glutamic acid decarboxylase 65 which showed a higher positivity rate in responders. We conclude that a clinical trial of IVIG may be warranted in severely refractory patients with gastroparesis symptoms.
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Delaney SL, Murray LA, Fallon BA. Neuropsychiatric Symptoms and Tick-Borne Diseases. Curr Top Behav Neurosci 2023; 61:279-302. [PMID: 36512289 DOI: 10.1007/7854_2022_406] [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: 06/17/2023]
Abstract
In North America, Lyme disease (LD) is primarily caused by the spirochetal bacterium Borrelia burgdorferi, transmitted to humans by Ixodes species tick bites, at an estimated rate of 476,000 patients diagnosed per year. Acute LD often manifests with flu-like symptoms and an expanding rash known as erythema migrans (EM) and less often with neurologic, neuropsychiatric, arthritic, or cardiac features. Most acute cases of Lyme disease are effectively treated with antibiotics, but 10-20% of individuals may experience recurrent or persistent symptoms. This chapter focuses on the neuropsychiatric aspects of Lyme disease, as these are less widely recognized by physicians and often overlooked. Broader education about the potential complexity, severity, and diverse manifestations of tick-borne diseases is needed.
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Affiliation(s)
- Shannon L Delaney
- Lyme and Tick-Borne Diseases Research Center at Columbia University Irving Medical Center, New York, NY, USA.
| | - Lilly A Murray
- Lyme and Tick-Borne Diseases Research Center at Columbia University Irving Medical Center, New York, NY, USA
| | - Brian A Fallon
- Lyme and Tick-Borne Diseases Research Center at Columbia University Irving Medical Center, New York, NY, USA
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Dziadkowiak E, Baczyńska D, Wieczorek M, Olbromski M, Moreira H, Mrozowska M, Budrewicz S, Dzięgiel P, Barg E, Koszewicz M. miR-31-5p as a Potential Circulating Biomarker and Tracer of Clinical Improvement for Chronic Inflammatory Demyelinating Polyneuropathy. OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2023; 2023:2305163. [PMID: 37077658 PMCID: PMC10110370 DOI: 10.1155/2023/2305163] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/19/2022] [Revised: 09/02/2022] [Accepted: 10/06/2022] [Indexed: 04/21/2023]
Abstract
Background MicroRNAs are endogenous, small noncoding RNA molecules that play a pivotal role in the regulation of gene expression. MicroRNAs are involved in many biological processes such as proliferation, cell differentiation, neovascularization, and apoptosis. Studies on microRNA expression may contribute to a better understanding of the pathomechanism of chronic inflammatory demyelinating polyneuropathy (CIDP) and consequently enable the development of new therapeutic measures using antisense miRNAs (antagomirs). In this study, we evaluated the level of miR-31-5p in the serum of patients with CIDP and its correlation with the miR-31-5p level and clinical presentation and electrophysiological and biochemical parameters. Methods The study group consisted of 48 patients, mean age 61.60 ± 11.76, who fulfilled the diagnostic criteria of a typical variant of CIDP. The expression of miR-31-5p in patient serum probes was investigated by droplet digital PCR. The results were correlated with neurophysiological findings and the patient's clinical and biochemical parameters. Results The mean copy number of miRNA-31 in 100 μl serum was 1288.64 ± 2001.02 in the CIDP group of patients, while in the control group, it was 3743.09 ± 4026.90. There was a significant positive correlation (0.426) between IgIV treatment duration and miR-31-5p expression. Patients without IgIV treatment showed significantly lower levels of miR-31 compared to the treated group (259.44 ± 304.02 vs. 1559.48 ± 2168.45; p = 0.002). The group of patients with body weight > 80 kg showed statistically significantly lower levels of miRNA-31-5p than the patients with lower body weight (934.37 ± 1739.66 vs. 1784.62 ± 2271.62, respectively; p = 0.014). Similarly, the patients with elevated cerebrospinal fluid (CSF) protein levels had significantly higher miRNA-31-5p expression than those with normal protein levels (1393.93 ± 1932.27 vs. 987.38 ± 2364.10, respectively; p = 0.044). Conclusion The results may support the hypothesis that miR-31-5p is strongly involved in the autoimmune process in CIDP. The positive correlation between higher miR-31-5p levels and duration of IVIg treatment may be an additional factor explaining the efficacy of prolonged IVIg therapy in CIDP.
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Affiliation(s)
- Edyta Dziadkowiak
- Department of Neurology, Wroclaw Medical University, Borowska 213, 50-556 Wroclaw, Poland
| | - Dagmara Baczyńska
- Department of Molecular and Cellular Biology, Wroclaw Medical University, Borowska 211A, Wroclaw, Poland
| | - Małgorzata Wieczorek
- Faculty of Earth Sciences and Environmental Management, University of Wroclaw, Uniwersytecki 1, 50-137 Wroclaw, Poland
| | - Mateusz Olbromski
- Department of Histology and Embryology, Wroclaw Medical University, ul. Chałubinskiego 6a, 50-368 Wroclaw, Poland
| | - Helena Moreira
- Department of Basic Medical Sciences, Wroclaw Medical University, Borowska 211, 50-556 Wroclaw, Poland
| | - Monika Mrozowska
- Department of Histology and Embryology, Wroclaw Medical University, ul. Chałubinskiego 6a, 50-368 Wroclaw, Poland
| | - Sławomir Budrewicz
- Department of Neurology, Wroclaw Medical University, Borowska 213, 50-556 Wroclaw, Poland
| | - Piotr Dzięgiel
- Department of Histology and Embryology, Wroclaw Medical University, ul. Chałubinskiego 6a, 50-368 Wroclaw, Poland
| | - Ewa Barg
- Department of Basic Medical Sciences, Wroclaw Medical University, Borowska 211, 50-556 Wroclaw, Poland
| | - Magdalena Koszewicz
- Department of Neurology, Wroclaw Medical University, Borowska 213, 50-556 Wroclaw, Poland
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12
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Co-administration of FVIII with IVIG reduces immune response to FVIII in hemophilia A mice. Sci Rep 2022; 12:20074. [PMID: 36418333 PMCID: PMC9684572 DOI: 10.1038/s41598-022-19392-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 05/03/2022] [Indexed: 11/24/2022] Open
Abstract
Hemophilia A is an X-linked recessive congenital bleeding disorder. Exogenous infusion of FVIII is the treatment of choice, and the development of immunoglobulins against FVIII (inhibitors) remains the major challenge in clinical management of the disease. Here, we investigated the effect of co-administration of FVIII with intravenous immunoglobulin (IVIG) on the development of inhibitors in previously untreated hemophilia A mice. A group of hemophilia A mice (C57BL/6FVIII-/-) received weekly injections of recombinant human FVIII (rFVIII) for twelve consecutive weeks while a second group received co-injections of rFVIII + IVIG. An in-house enzyme-linked immunosorbent assay (ELISA) was designed to detect antibodies to rFVIII. Every mouse in the first group developed antibodies to rFVIII. In contrast, mice treated with rFVIII + IVIG showed significantly lower antibody titers. Interestingly, when co-administration of IVIG was discontinued after 12 weeks in some mice (rFVIII continued), these mice experienced an increase in antibody titer. In contrast, mice that continued to receive rFVIII + IVIG retained significantly lower titers. In conclusion, prophylactic rFVIII co-administration with IVIG modulated the immune response to FVIII and resulted in decreased anti-FVIII antibody titer. These findings suggest that co-injection therapy with IVIG could potentially be effective in the management of hemophilia A patients at risk of inhibitor development.
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Fitzpatrick L, Lwin Z, Gericke C. Pembrolizumab-induced acute right L5 neuritis unresponsive to steroids. BMJ Case Rep 2022; 15:e250971. [PMID: 36414343 PMCID: PMC9685257 DOI: 10.1136/bcr-2022-250971] [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: 11/23/2022] Open
Abstract
We present a case of a patient with metastatic lung adenocarcinoma who developed severe right lower limb radicular pain in a L5-S1 dermatomal distribution 5 months into treatment with carboplatin, pemetrexed and pembrolizumab. MRI of the lumbar spine demonstrated contrast enhancement of the right L5 nerve root consistent with neuritis. The patient was treated with intravenous methylprednisolone 2 mg/kg/day for 3 days, followed by oral prednisolone 1 mg/kg/day with a slow wean over 6 weeks. There was no improvement and their performance status deteriorated to an Eastern Cooperative Oncology Group (ECOG) score of 3, representing capability of only limited self-care. We commenced induction therapy with intravenous immunoglobulin 2 g/kg over 5 days, which resulted in complete resolution of pain sustained for 3 weeks before recurrence of symptoms. We continued maintenance therapy with intravenous immunoglobulin 0.4 g/kg over 2 days at 4-5 weekly intervals, which led to resolution of symptoms and ECOG score to 1.
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Affiliation(s)
- Lachlan Fitzpatrick
- Internal Medicine, The Prince Charles Hospital, Brisbane, Queensland, Australia
| | - Zarnie Lwin
- Medical Oncology, The Prince Charles Hospital, Brisbane, Queensland, Australia
- Medical Oncology, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Christian Gericke
- The University of Queensland Faculty of Medicine, Brisbane, Queensland, Australia
- Neurology, The Prince Charles Hospital, Brisbane, Queensland, Australia
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Svačina MKR, Meißner A, Schweitzer F, Ladwig A, Sprenger‐Svačina A, Klein I, Wüstenberg H, Kohle F, Schneider C, Grether NB, Wunderlich G, Fink GR, Klein F, Di Cristanziano V, Lehmann HC. Antibody response after COVID-19 vaccination in intravenous immunoglobulin-treated immune neuropathies. Eur J Neurol 2022; 29:3380-3388. [PMID: 35842740 PMCID: PMC9349681 DOI: 10.1111/ene.15508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 06/24/2022] [Accepted: 07/13/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND PURPOSE This study assessed the prevalence of anti-SARS-CoV-2 antibodies in therapeutic immunoglobulin and their impact on serological response to COVID-19 mRNA vaccine in patients with intravenous immunoglobulin (IVIg)-treated chronic immune neuropathies. METHODS Forty-six samples of different brands or lots of IVIg or subcutaneous IgG were analyzed for anti-SARS-CoV-2 IgG using enzyme-linked immunosorbent assay and chemiluminescent microparticle immunoassay. Blood sera from 16 patients with immune neuropathies were prospectively analyzed for anti-SARS-CoV-2 IgA, IgG, and IgM before and 1 week after IVIg infusion subsequent to consecutive COVID-19 mRNA vaccine doses and after 12 weeks. These were compared to 42 healthy subjects. RESULTS Twenty-four (52%) therapeutic immunoglobulin samples contained anti-SARS-CoV-2 IgG. All patients with immune neuropathies (mean age = 65 ± 16 years, 25% female) were positive for anti-SARS-CoV-2 IgG after COVID-19 vaccination. Anti-SARS-CoV-2 IgA titers significantly decreased 12-14 weeks after vaccination (p = 0.02), whereas IgG titers remained stable (p = 0.2). IVIg did not significantly reduce intraindividual anti-SARS-CoV-2 IgA/IgG serum titers in immune neuropathies (p = 0.69). IVIg-derived anti-SARS-CoV-2 IgG did not alter serum anti-SARS-CoV-2 IgG decrease after IVIg administration (p = 0.67). CONCLUSIONS Our study indicates that IVIg does not impair the antibody response to COVID-19 mRNA vaccine in a short-term observation, when administered a minimum of 2 weeks after each vaccine dose. The infusion of current IVIg preparations that contain anti-SARS-CoV-2 IgG does not significantly alter serum anti-SARS-CoV-2 IgG titers.
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Affiliation(s)
- Martin K. R. Svačina
- Department of Neurology, Faculty of Medicine and University Hospital of CologneUniversity of CologneCologneGermany
| | - Anika Meißner
- Department of Neurology, Faculty of Medicine and University Hospital of CologneUniversity of CologneCologneGermany
| | - Finja Schweitzer
- Department of Neurology, Faculty of Medicine and University Hospital of CologneUniversity of CologneCologneGermany
| | - Anne Ladwig
- Department of Neurology, Faculty of Medicine and University Hospital of CologneUniversity of CologneCologneGermany
| | - Alina Sprenger‐Svačina
- Department of Neurology, Faculty of Medicine and University Hospital of CologneUniversity of CologneCologneGermany
| | - Ines Klein
- Department of Neurology, Faculty of Medicine and University Hospital of CologneUniversity of CologneCologneGermany
| | - Hauke Wüstenberg
- Department of Neurology, Faculty of Medicine and University Hospital of CologneUniversity of CologneCologneGermany
| | - Felix Kohle
- Department of Neurology, Faculty of Medicine and University Hospital of CologneUniversity of CologneCologneGermany
| | - Christian Schneider
- Department of Neurology, Faculty of Medicine and University Hospital of CologneUniversity of CologneCologneGermany
| | - Nicolai B. Grether
- Department of Neurology, Faculty of Medicine and University Hospital of CologneUniversity of CologneCologneGermany
| | - Gilbert Wunderlich
- Department of Neurology, Faculty of Medicine and University Hospital of CologneUniversity of CologneCologneGermany
| | - Gereon R. Fink
- Department of Neurology, Faculty of Medicine and University Hospital of CologneUniversity of CologneCologneGermany
- Cognitive Neuroscience, Research Center JuelichInstitute of Neuroscience and Medicine (INM‐3)JuelichGermany
| | - Florian Klein
- Institute of Virology, Faculty of Medicine and University Hospital of CologneUniversity of CologneCologneGermany
- German Center for Infection Research (DZIF), partner site Bonn‐CologneCologneGermany
| | - Veronica Di Cristanziano
- Institute of Virology, Faculty of Medicine and University Hospital of CologneUniversity of CologneCologneGermany
| | - Helmar C. Lehmann
- Department of Neurology, Faculty of Medicine and University Hospital of CologneUniversity of CologneCologneGermany
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15
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Malherbe JAJ, Cooney J. A complex case of necrobiotic xanthogranuloma with IgG‐kappa paraproteinemia: Disease regression achieved with melphalan and prednisone combination therapy. Clin Case Rep 2022; 10:e6554. [DOI: 10.1002/ccr3.6554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Accepted: 10/19/2022] [Indexed: 11/16/2022] Open
Affiliation(s)
- Jacques A. J. Malherbe
- Department of Haematology Fiona Stanley Hospital Murdoch Western Australia Australia
- School of Biomedical Sciences University of Western Australia Crawley Western Australia Australia
| | - Julian Cooney
- Department of Haematology Fiona Stanley Hospital Murdoch Western Australia Australia
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16
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Managing Chronic Neuropathic Pain: Recent Advances and New Challenges. Neurol Res Int 2022; 2022:8336561. [PMID: 36277331 PMCID: PMC9581623 DOI: 10.1155/2022/8336561] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 07/03/2022] [Accepted: 08/07/2022] [Indexed: 11/17/2022] Open
Abstract
Aim. Neuropathic pain affects 7–10% of the population, with most of the patients receiving inadequate and incomplete treatment. Owing to the high financial burden and the poor quality of life of the patients and their caretakers, there is a dire need to address the challenges in diagnosing and treating chronic neuropathic pain. Methods. This literature review was conducted to review novel treatments and related challenges through a systematic search from sources such as PubMed, Google Scholar with the combination of MESH words such as neuropathic pain, management of neuropathic pain. Articles from non-English literature, reports without human subjects, animal studies, and abstracts/posters were excluded. However, human studies and studies published in English were included. Result. This review article discusses novel treatment modalities while acknowledging the challenges medical workers face while encountering neuropathic pain. Despite the recent advances in diagnosis and treatment modalities, several challenges still exist. Hence, there is still a need to explore the various treatment modalities, emphasizing the cause and underlying pathophysiology of neuropathic pain. Conclusion. We recommend integrated multimodal treatment with the current treatment facility, including various medical disciplines. However, a personalized approach would work the best depending on the ’patient’s medical history. Therefore, this article recommends an integrated, cause-specific, cost-effective approach to address this problem of chronic neuropathic pain.
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17
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Segú-Vergés C, Caño S, Calderón-Gómez E, Bartra H, Sardon T, Kaveri S, Terencio J. Systems biology and artificial intelligence analysis highlights the pleiotropic effect of IVIg therapy in autoimmune diseases with a predominant role on B cells and complement system. Front Immunol 2022; 13:901872. [PMID: 36248801 PMCID: PMC9563374 DOI: 10.3389/fimmu.2022.901872] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 08/31/2022] [Indexed: 11/26/2022] Open
Abstract
Intravenous immunoglobulin (IVIg) is used as treatment for several autoimmune and inflammatory conditions, but its specific mechanisms are not fully understood. Herein, we aimed to evaluate, using systems biology and artificial intelligence techniques, the differences in the pathophysiological pathways of autoimmune and inflammatory conditions that show diverse responses to IVIg treatment. We also intended to determine the targets of IVIg involved in the best treatment response of the evaluated diseases. Our selection and classification of diseases was based on a previously published systematic review, and we performed the disease characterization through manual curation of the literature. Furthermore, we undertook the mechanistic evaluation with artificial neural networks and pathway enrichment analyses. A set of 26 diseases was selected, classified, and compared. Our results indicated that diseases clearly benefiting from IVIg treatment were mainly characterized by deregulated processes in B cells and the complement system. Indeed, our results show that proteins related to B-cell and complement system pathways, which are targeted by IVIg, are involved in the clinical response. In addition, targets related to other immune processes may also play an important role in the IVIg response, supporting its wide range of actions through several mechanisms. Although B-cell responses and complement system have a key role in diseases benefiting from IVIg, protein targets involved in such processes are not necessarily the same in those diseases. Therefore, IVIg appeared to have a pleiotropic effect that may involve the collaborative participation of several proteins. This broad spectrum of targets and 'non-specificity' of IVIg could be key to its efficacy in very different diseases.
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Affiliation(s)
| | - Silvia Caño
- Grifols Innovation and New Technologies (GIANT) Ltd., Dublin, Ireland
| | | | - Helena Bartra
- Health Department, Anaxomics Biotech, Barcelona, Spain
| | - Teresa Sardon
- Health Department, Anaxomics Biotech, Barcelona, Spain
| | - Srini Kaveri
- Institut National de la Santé et de la Recherche Médicale, Centre de Recherche des Cordeliers, Sorbonne Université, Université Paris Descartes, Sorbonne Paris Cité, Paris, France
| | - José Terencio
- Grifols Innovation and New Technologies (GIANT) Ltd., Dublin, Ireland
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18
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Pacillo L, Giardino G, Amodio D, Giancotta C, Rivalta B, Rotulo GA, Manno EC, Cifaldi C, Palumbo G, Pignata C, Palma P, Rossi P, Finocchi A, Cancrini C. Targeted treatment of autoimmune cytopenias in primary immunodeficiencies. Front Immunol 2022; 13:911385. [PMID: 36052091 PMCID: PMC9426461 DOI: 10.3389/fimmu.2022.911385] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2022] [Accepted: 07/15/2022] [Indexed: 11/14/2022] Open
Abstract
Primary Immunodeficiencies (PID) are a group of rare congenital disorders of the immune system. Autoimmune cytopenia (AIC) represents the most common autoimmune manifestation in PID patients. Treatment of AIC in PID patients can be really challenging, since they are often chronic, relapsing and refractory to first line therapies, thus requiring a broad variety of alternative therapeutic options. Moreover, immunosuppression should be fine balanced considering the increased susceptibility to infections in these patients. Specific therapeutic guidelines for AIC in PID patients are lacking. Treatment choice should be guided by the underlying disease. The study of the pathogenic mechanisms involved in the genesis of AIC in PID and our growing ability to define the molecular underpinnings of immune dysregulation has paved the way for the development of novel targeted treatments. Ideally, targeted therapy is directed against an overexpressed or overactive gene product or substitutes a defective protein, restoring the impaired pathway. Actually, the molecular diagnosis or a specific drug is not always available. However, defining the category of PID or the immunological phenotype can help to choose a semi-targeted therapy directed towards the suspected pathogenic mechanism. In this review we overview all the therapeutic interventions available for AIC in PID patients, according to different immunologic targets. In particular, we focus on T and/or B cells targeting therapies. To support decision making in the future, prospective studies to define treatment response and predicting/stratifying biomarkers for patients with AIC and PID are needed.
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Affiliation(s)
- Lucia Pacillo
- Academic Department of Pediatrics (DPUO), Immune and Infectious Diseases Division, Research Unit of Primary Immunodeficiencies, IRCCS Bambino Gesù Children’s Hospital, Rome, Italy
- Department of Systems Medicine, University of Tor Vergata, Rome, Italy
| | - Giuliana Giardino
- Pediatric Section, Department of Translational Medical Sciences, Federico II University, Naples, Italy
| | - Donato Amodio
- Academic Department of Pediatrics (DPUO), Research Unit of Clinical Immunology and Vaccinology, IRCCS Bambino Gesù Children’s Hospital, Rome, Italy
| | - Carmela Giancotta
- Academic Department of Pediatrics (DPUO), Research Unit of Clinical Immunology and Vaccinology, IRCCS Bambino Gesù Children’s Hospital, Rome, Italy
| | - Beatrice Rivalta
- Academic Department of Pediatrics (DPUO), Immune and Infectious Diseases Division, Research Unit of Primary Immunodeficiencies, IRCCS Bambino Gesù Children’s Hospital, Rome, Italy
- Department of Systems Medicine, University of Tor Vergata, Rome, Italy
| | - Gioacchino Andrea Rotulo
- Academic Department of Pediatrics (DPUO), Research Unit of Clinical Immunology and Vaccinology, IRCCS Bambino Gesù Children’s Hospital, Rome, Italy
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), University of Genoa, Genoa, Italy
| | - Emma Concetta Manno
- Academic Department of Pediatrics (DPUO), Research Unit of Clinical Immunology and Vaccinology, IRCCS Bambino Gesù Children’s Hospital, Rome, Italy
| | - Cristina Cifaldi
- Academic Department of Pediatrics (DPUO), Immune and Infectious Diseases Division, Research Unit of Primary Immunodeficiencies, IRCCS Bambino Gesù Children’s Hospital, Rome, Italy
| | - Giuseppe Palumbo
- Department of Onco Hematology, IRCCS Bambino Gesù Children’s Hospital, Rome, Italy
| | - Claudio Pignata
- Pediatric Section, Department of Translational Medical Sciences, Federico II University, Naples, Italy
| | - Paolo Palma
- Department of Systems Medicine, University of Tor Vergata, Rome, Italy
- Academic Department of Pediatrics (DPUO), Research Unit of Clinical Immunology and Vaccinology, IRCCS Bambino Gesù Children’s Hospital, Rome, Italy
| | - Paolo Rossi
- Department of Systems Medicine, University of Tor Vergata, Rome, Italy
- Academic Department of Pediatrics (DPUO), Research Unit of Clinical Immunology and Vaccinology, IRCCS Bambino Gesù Children’s Hospital, Rome, Italy
| | - Andrea Finocchi
- Academic Department of Pediatrics (DPUO), Immune and Infectious Diseases Division, Research Unit of Primary Immunodeficiencies, IRCCS Bambino Gesù Children’s Hospital, Rome, Italy
- Department of Systems Medicine, University of Tor Vergata, Rome, Italy
| | - Caterina Cancrini
- Academic Department of Pediatrics (DPUO), Immune and Infectious Diseases Division, Research Unit of Primary Immunodeficiencies, IRCCS Bambino Gesù Children’s Hospital, Rome, Italy
- Department of Systems Medicine, University of Tor Vergata, Rome, Italy
- *Correspondence: Caterina Cancrini,
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19
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Timofeeva O, Brown J. Immunological considerations—HLA matching and management of high immunological risk recipients. Indian J Thorac Cardiovasc Surg 2022; 38:248-259. [DOI: 10.1007/s12055-021-01201-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 04/09/2021] [Accepted: 04/13/2021] [Indexed: 10/20/2022] Open
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20
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Menon D, Bril V. Pharmacotherapy of Generalized Myasthenia Gravis with Special Emphasis on Newer Biologicals. Drugs 2022; 82:865-887. [PMID: 35639288 PMCID: PMC9152838 DOI: 10.1007/s40265-022-01726-y] [Citation(s) in RCA: 42] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/25/2022] [Indexed: 11/20/2022]
Abstract
Myasthenia gravis (MG) is a chronic, fluctuating, antibody-mediated autoimmune disorder directed against the post-synaptic neuromuscular junctions of skeletal muscles, resulting in a wide spectrum of manifestations ranging from mild to potentially fatal. Given its unique natural course, designing an ideal trial design for MG has been wrought with difficulties and evidence in favour of several of the conventional agents is weak as per current standards. Despite this, acetylcholinesterases and corticosteroids have remained the cornerstones of treatment for several decades with intravenous immunoglobulins (IVIG) and therapeutic plasma exchange (PLEX) offering rapid treatment response, especially in crises. However, the treatment of MG entails long-term immunosuppression and conventional agents are viable options but take longer to act and have a number of class-specific adverse effects. Advances in immunology, translational medicine and drug development have seen the emergence of several newer biological agents which offer selective, target-specific immunotherapy with fewer side effects and rapid onset of action. Eculizumab is one of the newer agents that belong to the class of complement inhibitors and has been approved for the treatment of refractory general MG. Zilucoplan and ravulizumab are other agents in this group in clinical trials. Neisseria meningitis is a concern with all complement inhibitors, mandating vaccination. Neonatal Fc receptor (FcRn) inhibitors prevent immunoglobulin recycling and cause rapid reduction in antibody levels. Efgartigimod is an FcRn inhibitor recently approved for MG treatment, and rozanolixizumab, nipocalimab and batoclimab are other agents in clinical trial development. Although lacking high quality evidence from randomized clinical trials, clinical experience with the use of anti-CD20 rituximab has led to its use in refractory MG. Among novel targets, interleukin 6 (IL6) inhibitors such as satralizumab are promising and currently undergoing evaluation. Cutting-edge therapies include genetically modifying T cells to recognise chimeric antigen receptors (CAR) and chimeric autoantibody receptors (CAAR). These may offer sustained and long-term remissions, but are still in very early stages of evaluation. Hematopoietic stem cell transplantation (HSCT) allows immune resetting and offers sustained remission, but the induction regimens often involve serious systemic toxicity. While MG treatment is moving beyond conventional agents towards target-specific biologicals, lack of knowledge as to the initiation, maintenance, switching, tapering and long-term safety profile necessitates further research. These concerns and the high financial burden of novel agents may hamper widespread clinical use in the near future.
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Affiliation(s)
- Deepak Menon
- Department of Neurology, National Institute of Mental Health and Neurosciences, Bangalore, India
| | - Vera Bril
- Ellen and Martin Prosserman Centre for Neuromuscular Diseases, University Health Network, 5EC-309, Toronto General Hospital, University of Toronto, 200 Elizabeth St, Toronto, M5G 2C4, Canada.
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21
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Svačina MKR, Lehmann HC. Chronic Inflammatory Demyelinating Polyneuropathy (CIDP): Current Therapies and Future Approaches. Curr Pharm Des 2022; 28:854-862. [PMID: 35339172 DOI: 10.2174/1381612828666220325102840] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 01/08/2022] [Indexed: 11/22/2022]
Abstract
Chronic inflammatory demyelinating polyneuropathy (CIDP) is an acquired immune-mediated polyradiculoneuropathy leading to disability via inflammatory demyelination of peripheral nerves. Various therapeutic approaches with different mechanisms of action are established for the treatment of CIDP. Of those, corticosteroids, intravenous or subcutaneous immunoglobulin, or plasma exchange are established first-line therapies as suggested by the recently revised EAN/PNS guidelines for the management of CIDP. In special cases, immunosuppressants or rituximab may be used. Novel therapeutic approaches currently undergoing clinical studies include molecules or monoclonal antibodies interacting with Fc receptors on immune cells to alleviate immune-mediated neuronal damage. Despite various established therapies and the current development of novel therapeutics, treatment of CIDP remains challenging due to an inter-individually heterogeneous disease course and the lack of surrogate parameters to predict the risk of clinical deterioration.
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Affiliation(s)
- Martin K R Svačina
- Department of Neurology, Faculty of Medicine and University Hospital of Cologne, Cologne, Germany
| | - Helmar C Lehmann
- Department of Neurology, Faculty of Medicine and University Hospital of Cologne, Cologne, Germany
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22
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Lee ST, Lee HS, Lee WJ, Cha HA, Kim SH, Shin SY, Chu K, Lee SK. The safety and efficacy of intravenous immunoglobulin in autoimmune encephalitis. Ann Clin Transl Neurol 2022; 9:610-621. [PMID: 35315247 PMCID: PMC9082384 DOI: 10.1002/acn3.51540] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 02/01/2022] [Accepted: 02/25/2022] [Indexed: 11/11/2022] Open
Abstract
OBJECTIVE Although intravenous immunoglobulin (IVIG) is the first-line immunotherapy in autoimmune encephalitis, all supporting evidence comes from retrospective case series. Here, we performed a prospective clinical trial of IVIG for functional recovery in autoimmune encephalitis. METHODS This single-arm, open-label study assessed the efficacy and safety of 10% intravenous IVIG treatment in newly diagnosed patients with possible autoimmune encephalitis. Patients received IVIG (0.4 g/kg/day) for 5 days. Rescue immunotherapy was permitted when the patient deteriorated before day 8 or showed no improvement at day 8. The primary outcome was the change in the modified Rankin Scale (mRS) score at day 8 and 29. The secondary outcomes were the mRS score improvement and the score changes and improvements on four other clinical scales. RESULTS Overall, 23 patients received IVIG (intension-to-treat, ITT), and 18 patients completed the study according to the protocol (per-protocol, PP). mRS improved significantly at days 8 and 29 compared to baseline in both the ITT and PP populations. Other secondary outcomes also improved significantly at day 8, 15, and 29 versus baseline. In the PP population, 6/18 patients achieved favorable outcomes with IVIG alone (mRS = 0~2 at day 8), and 12/18 patients received rescue immunotherapy. Five adverse events were reported in relation to IVIG, all of which were mild. INTERPRETATION IVIG improved neurological functional outcomes, and the improvement was evident by day 8. Adverse effects were tolerable. These data provide the prospective evidence regarding the efficacy of IVIG in improving the functional outcomes of autoimmune encephalitis.
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Affiliation(s)
- Soon-Tae Lee
- Department of Neurology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, South Korea
| | - Han Sang Lee
- Department of Neurology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, South Korea
| | - Woo-Jin Lee
- Department of Neurology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, South Korea
| | - Han-A Cha
- GC Pharma, Yongin-si, Gyeonggi-do, South Korea
| | | | - Seo-Yi Shin
- Department of Neurology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, South Korea
| | - Kon Chu
- Department of Neurology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, South Korea
| | - Sang Kun Lee
- Department of Neurology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, South Korea
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23
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Principles and Guidelines of Immunotherapy in Neuromuscular Disorders. Neuromuscul Disord 2022. [DOI: 10.1016/b978-0-323-71317-7.00007-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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24
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Agostini E, De Luca G, Bruni C, Bartoli F, Tofani L, Campochiaro C, Pacini G, Moggi-Pignone A, Guiducci S, Bellando-Randone S, Shoenfeld Y, Dagna L, Matucci-Cerinic M. Intravenous immunoglobulins reduce skin thickness in systemic sclerosis: evidence from Systematic Literature Review and from real life experience. Autoimmun Rev 2021; 20:102981. [PMID: 34718166 DOI: 10.1016/j.autrev.2021.102981] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Accepted: 07/17/2021] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Intravenous immunoglobulins (IVIG) are a new therapeutic approach in systemic sclerosis SSc. An immunomodulatory and antifibrotic activity has been postulated. IVIG are generally well tolerated and have only rare side effects. Our retrospective study focused its attention on SSc, an autoimmune connective tissue disease, characterized by several complications which has a significant impact on patient's quality of life. The pathophysiology comprises fibrotic, vascular and immunological aspects. AIM The aim of this study was to verify the effectiveness of IVIG on SSc skin involvement. Moreover, a systematic review of the literature (SLR) of the results obtained to date on the use of Intravenous immunoglobulin (IVIG) in SSc has been also performed. PATIENTS AND METHODS The data of 24 patients (21 women, 3 male) with refractory diffuse SSc skin involvement were evaluated (mean age was 52.13 years). IVIG infusion at a dosage of 2 g/Kg body weight for 4 consecutive days/month, was started between 2002 and 2019. Skin involvement was evaluated with the modified Rodnan Skin Score (mRSS) before therapy and then again after 6 and 12 months. To perform the SLR, the PubMed, Medline, Embase, and Web of Science database were searched from 1990 to 2020 (keywords: IVIG, systemic sclerosis). Three assessors (E.A., C.B. & M.M.C) identified the criteria to scan all papers. RESULTS From the total SLR (106 results), 17 papers were identified after the separation of the clinical cases from the studies (total number of treated patients 183). The studies were classified according to the organ involvement considered in each study, as well as the prescribed dose (high or low doses), and the therapeutic regimens. In the selected papers, the organs mainly involved were the skin, the gastrointestinal, the joint and the cardiovascular systems. Only in one case, plasmapheresis was associated to IVIG. All papers reported significant reduction of the skin involvement, although generally the strength of the works was limited the lack of control cases or by the low number of patients involved. From the real life experience, a statistically significant reduction of mRSS was obtained at 6 months follow-up (average value of -6.61 ± 5.2, p < 0.001), and it was further maintained with a significant stabilization after 12-months (-11.45 ± 9.63, p < 0.002). DISCUSSION This SLR and the data of the retrospective study suggest that IVIG may improve skin involvement reducing mRSS in particular in those patients that were refractory to other standard of care therapies and represents a therapeutic option in patients with concomitant myositis. The literature review revealed encouraging perspectives on the use of this therapy, given the effectiveness found in the selected works.
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Affiliation(s)
- Elana Agostini
- Dept. Experimental and Clinical Medicine, University of Florence, Italy; Division of Rheumatology, AOUC, Florence, Italy
| | - Giacomo De Luca
- Unit of Immunology, Rheumatology, Allergy and Rare diseases (UnIRAR), IRCCS San Raffaele Hospital, 20132 Milan, Italy; Vita-Salute San Raffaele University, 20132 Milan, Italy
| | - Cosimo Bruni
- Dept. Experimental and Clinical Medicine, University of Florence, Italy; Division of Rheumatology, AOUC, Florence, Italy
| | - Francesca Bartoli
- Dept. Experimental and Clinical Medicine, University of Florence, Italy; Division of Rheumatology, AOUC, Florence, Italy
| | - Lorenzo Tofani
- Dept. Experimental and Clinical Medicine, University of Florence, Italy; Division of Rheumatology, AOUC, Florence, Italy
| | - Corrado Campochiaro
- Unit of Immunology, Rheumatology, Allergy and Rare diseases (UnIRAR), IRCCS San Raffaele Hospital, 20132 Milan, Italy; Vita-Salute San Raffaele University, 20132 Milan, Italy
| | - Giovanni Pacini
- Dept. Experimental and Clinical Medicine, University of Florence, Italy; Division of Rheumatology, AOUC, Florence, Italy
| | - Alberto Moggi-Pignone
- Dept. Experimental and Clinical Medicine, University of Florence, Italy; Division of Internal Medicine, AOUC, Florence, Italy
| | - Serena Guiducci
- Dept. Experimental and Clinical Medicine, University of Florence, Italy; Division of Rheumatology, AOUC, Florence, Italy
| | - Silvia Bellando-Randone
- Dept. Experimental and Clinical Medicine, University of Florence, Italy; Division of Rheumatology, AOUC, Florence, Italy
| | - Yehuda Shoenfeld
- Ariel University, Israel; Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel Hashomer, Israel; Saint Petersburg State University, Saint-Petersburg, Russia
| | - Lorenzo Dagna
- Unit of Immunology, Rheumatology, Allergy and Rare diseases (UnIRAR), IRCCS San Raffaele Hospital, 20132 Milan, Italy; Vita-Salute San Raffaele University, 20132 Milan, Italy
| | - Marco Matucci-Cerinic
- Dept. Experimental and Clinical Medicine, University of Florence, Italy; Unit of Immunology, Rheumatology, Allergy and Rare diseases (UnIRAR), IRCCS San Raffaele Hospital, 20132 Milan, Italy; Division of Rheumatology, AOUC, Florence, Italy.
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Stoian A, Bajko Z, Maier S, Cioflinc RA, Grigorescu BL, Moțățăianu A, Bărcuțean L, Balașa R, Stoian M. High-dose intravenous immunoglobulins as a therapeutic option in critical illness polyneuropathy accompanying SARS-CoV-2 infection: A case-based review of the literature (Review). Exp Ther Med 2021; 22:1182. [PMID: 34475972 PMCID: PMC8406741 DOI: 10.3892/etm.2021.10616] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Accepted: 07/27/2021] [Indexed: 01/08/2023] Open
Abstract
The still ongoing COVID-19 pandemic has exposed the medical community to a number of major challenges. A significant number of patients require admission to intensive care unit (ICU) services due to severe respiratory, thrombotic and septic complications and require long-term hospitalization. Neuromuscular weakness is a common complication in critically ill patients who are treated in ICUs and are mechanically ventilated. This complication is frequently caused by critical illness myopathy (CIM) or critical illness polyneuropathy (CIP) and leads to difficulty in weaning from the ventilator. It is thought to represent an important neurologic manifestation of the systemic inflammatory response syndrome (SIRS). COVID-19 infection is known to trigger strong immune dysregulation, with an intense cytokine storm, as a result, the frequency of CIP is expected to be higher in this setting. The mainstay in the diagnosis of this entity beside the high level of clinical awareness is the electrophysiological examination that provides evidence of axonal motor and sensory polyneuropathy. The present article presents the case of a 54-year-old woman with severe COVID 19 infection who developed neuromuscular weakness, which turned out to be secondary to CIP and was treated successfully with a high dose of human intravenous immunoglobulins. Related to this case, we reviewed the relevant literature data regarding the epidemiology, pathophysiology and clinical features of this important complication and discussed also the treatment options and prognosis.
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Affiliation(s)
- Adina Stoian
- Department of Pathophysiology, ‘George Emil Palade’ University of Medicine, Pharmacy, Sciences and Technology, 540136 Targu Mures, Romania
| | - Zoltan Bajko
- Department of Neurology, ‘George Emil Palade’ University of Medicine, Pharmacy, Sciences and Technology, 540136 Targu Mures, Romania
| | - Smaranda Maier
- Department of Neurology, ‘George Emil Palade’ University of Medicine, Pharmacy, Sciences and Technology, 540136 Targu Mures, Romania
| | | | - Bianca Liana Grigorescu
- Department of Pathophysiology, ‘George Emil Palade’ University of Medicine, Pharmacy, Sciences and Technology, 540136 Targu Mures, Romania
| | - Anca Moțățăianu
- Department of Neurology, ‘George Emil Palade’ University of Medicine, Pharmacy, Sciences and Technology, 540136 Targu Mures, Romania
| | - Laura Bărcuțean
- Department of Neurology, ‘George Emil Palade’ University of Medicine, Pharmacy, Sciences and Technology, 540136 Targu Mures, Romania
| | - Rodica Balașa
- Department of Neurology, ‘George Emil Palade’ University of Medicine, Pharmacy, Sciences and Technology, 540136 Targu Mures, Romania
| | - Mircea Stoian
- Department of Anesthesiology and Intensive Therapy, ‘George Emil Palade’ University of Medicine, Pharmacy, Sciences and Technology, 540136 Targu Mures, Romania
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Lee AOCJ, Chua AHY, Sultana R, Lee JH, Wong JJM. Immunomodulator use in paediatric severe sepsis and septic shock. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2021; 50:765-772. [PMID: 34755170 DOI: 10.47102/annals-acadmedsg.2021178] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
INTRODUCTION The use of drugs that modulate the immune system during paediatric severe sepsis and septic shock may alter the course of disease and is poorly studied. This study aims to characterise these children who received immunomodulators and describe their clinical outcomes. METHODS This is a retrospective chart review of patients with severe sepsis and septic shock admitted into the paediatric intensive care unit (PICU). Clinical, haematological and outcome characteristics of patients with or without exposure to immune-modulating drugs were compared. Primary outcome was PICU mortality; secondary outcomes were 28-day ventilator-free days (VFD) and intensive care unit-free days (IFD). Univariate and multivariable analyses were performed for these outcomes. RESULTS A total of 109 patients with paediatric severe sepsis or septic shock were identified. Of this number, 47 (43.1%), 16 (14.7%) and 3 (2.8%) patients received systemic corticosteroids, intravenous immunoglobulins and granulocyte colony stimulating factor, respectively. Patients who received immune-modulating drugs were more likely to require invasive ventilation (38/54 [70.4%] versus 26/55 [47.3%], P=0.019) compared to those who did not. PICU mortality was indifferent between the 2 groups (20/54 [37.0%] vs 11/55 [20.0%], P=0.058) even after accounting for chronic complex conditions and admission organ dysfunction (PELOD score) (adjusted odds ratio 1.90, confidence interval [0.72-5.01], P=0.193). However, VFD (19.5 [0-28] vs 25 [12-28] days, P=0.038) and IFD (15 [0-24] vs 22 [9-26] days, P=0.024) were decreased in the immunomodulator group compared to the non-immunomodulator group. CONCLUSION Immune-modulating drugs were frequently used in paediatric severe sepsis and septic shock. Patients who received these drugs seemed to require more PICU support. Further studies are required to examine this association thoroughly.
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IgA Vasculitis: Etiology, Treatment, Biomarkers and Epigenetic Changes. Int J Mol Sci 2021; 22:ijms22147538. [PMID: 34299162 PMCID: PMC8307949 DOI: 10.3390/ijms22147538] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2021] [Accepted: 07/12/2021] [Indexed: 02/06/2023] Open
Abstract
IgA, previously called Henoch-Schönlein vasculitis, is an essential immune component that drives the host immune response to the external environment. As IgA has the unique characteristic of a flexible response to broad types of microorganisms, it sometimes causes an autoreactive response in the host human body. IgA vasculitis and related organ dysfunction are representative IgA-mediated autoimmune diseases; bacterial and viral infections often trigger IgA vasculitis. Recent drug developments and the presence of COVID-19 have revealed that these agents can also trigger IgA vasculitis. These findings provide a novel understanding of the pathogenesis of IgA vasculitis. In this review, we focus on the characteristics of IgA and symptoms of IgA vasculitis and other organ dysfunction. We also mention the therapeutic approach, biomarkers, novel triggers for IgA vasculitis, and epigenetic modifications in patients with IgA vasculitis.
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Zadeh Mehrizi T, Mousavi Hosseini K. An overview on the investigation of nanomaterials' effect on plasma components: immunoglobulins and coagulation factor VIII, 2010-2020 review. NANOSCALE ADVANCES 2021; 3:3730-3745. [PMID: 36133015 PMCID: PMC9419877 DOI: 10.1039/d1na00119a] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Accepted: 05/16/2021] [Indexed: 05/04/2023]
Abstract
FVIII and immunoglobulins (Igs) are the most prominent plasma proteins, which play a vital role in plasma hemostasis. These proteins have been implemented frequently in protein therapy. Therefore, their maintenance, durability, and stability are highly essential. Herein, various approaches to improve protein functions have been investigated, such as using recombinant protein replacement. In comparison, advances in nanotechnology have provided adequate context to boost biomaterial utilization. In this regard, the applications of various nanoparticles such as polymeric nanomaterials (PEG and PLGA), metal nanoparticles, dendrimers, and lipid based nanomaterials (liposomes and lipid nanoparticles) in stability and the functional improvement of antibodies and coagulation factor VIII (FVIII) have been reviewed from 2010 to 2020. Reviewing related articles has shown that not only can nanomaterials adequately protect the structure of proteins, but have also improved proteins' functions in some cases. For example, the high rate of FVIII instability has been successfully enhanced by bio-PEGylation. Also, utilizing PEGylated liposomes, using the PEG-lip technique for coating nanostructures, leads to FIIIV half-life prolongation. Hence, PEGylation had most impact on the stability of FVIII. Likewise, PEG-coated liposome nano-carriers also presented such a good effect on stability improvements for FVIII due to their ability to tune the immune system by reducing FVIII immunogenicity. Similarly, Ig PEGylation and conjugation to magnetic nanoparticles resulted in increased half-life and better purification of Igs, respectively, without any loss in structural or functional features. Consequently, metal-organic frameworks and recent hybrid systems have been introduced as promising nanomaterials in biomedical applications. As far as we know, this is the first study in this field, which considers the applications of nanoparticles for improving the storage and stability of antibodies and coagulation FVIII.
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Affiliation(s)
- Tahereh Zadeh Mehrizi
- Blood Transfusion Research Center, High Institute for Research and Education in Transfusion Medicine Tehran Iran +989338606292
| | - Kamran Mousavi Hosseini
- Blood Transfusion Research Center, High Institute for Research and Education in Transfusion Medicine Tehran Iran +989338606292
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Galvin RT, Cao Q, Miller WP, Knight-Perry J, Smith AR, Ebens CL. Characterizing Immune-Mediated Cytopenias After Allogeneic Hematopoietic Cell Transplantation for Pediatric Nonmalignant Disorders. Transplant Cell Ther 2021; 27:316.e1-316.e8. [PMID: 33836874 PMCID: PMC8036237 DOI: 10.1016/j.jtct.2021.01.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 01/12/2021] [Accepted: 01/17/2021] [Indexed: 11/30/2022]
Abstract
Immune-mediated cytopenias (IMC)-isolated or combined hemolytic anemia, thrombocytopenia, or neutropenia-are increasingly recognized as serious complications after allogeneic hematopoietic cell transplantation (HCT) for nonmalignant disorders (NMD). However, IMC incidence, duration, response to therapy, and risk factors are not well defined. This retrospective chart review identified cases of IMC with serologic confirmation among patients who underwent HCT for NMD at a single institution between 2010 and 2017. IMC after HCT for NMD in a large pediatric cohort (n = 271) was common with a cumulative incidence of 18%, identified at a median of 136 days after HCT. Treatment included prolonged immune suppression (>3 months) in 58% of all IMC cases, 91% when multiple cell lines were affected. Multiple therapeutic agents were used for the majority affected, and median time to resolution of IMC was 118 days from diagnosis. Fine-Gray competing risk multivariate regression analysis identified a combined risk factor of younger age (<3 years) and inherited metabolic disorder, as well as hemoglobinopathy (at any age) associated with 1-year incidence of IMC (P < .01). We expand these findings with the observation of declining donor T-lymphoid chimerism from day 60 to 100 and lower absolute CD4+ counts at day 100 (P < .01), before median onset of IMC, for patients with IMC compared to those without. In this cohort, 4 deaths (8%) were associated with IMC, including 2 requiring second transplantation for secondary graft failure. Although the pathogenesis of IMC post-HCT for NMD remains elusive, further research may identify approaches to prevent and better treat this HCT complication.
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Affiliation(s)
- Robert T Galvin
- University of Minnesota, Department of Pediatrics; Minneapolis, MN, USA
| | - Qing Cao
- University of Minnesota, Biostatistics Core at Masonic Cancer Center; Minneapolis, MN, USA
| | | | - Jessica Knight-Perry
- University of Colorado, Department of Pediatric Hematology, Oncology, and Bone Marrow Transplantation; Denver, CO, USA
| | - Angela R Smith
- University of Minnesota, Department of Pediatric Blood and Marrow Transplant; Minneapolis, MN, USA
| | - Christen L Ebens
- University of Minnesota, Department of Pediatric Blood and Marrow Transplant; Minneapolis, MN, USA.
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Sellner J, Sitte HH, Rommer PS. Targeting interleukin-6 to treat neuromyelitis optica spectrum disorders: Implications from immunology, the FcRn pathway and clinical experience. Drug Discov Today 2021; 26:1591-1601. [PMID: 33781948 DOI: 10.1016/j.drudis.2021.03.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Revised: 02/24/2021] [Accepted: 03/19/2021] [Indexed: 12/22/2022]
Abstract
Neuromyelitis optica spectrum disorder (NMOSD) is a rare disease of the central nervous system (CNS) that is associated with poor outcomes for patients. Until recently, when complement inhibitors were approved, there was no approved therapy. Most recently, clinical trials of interleukin-6 (IL-6) blockade showed a therapeutic benefit for NMOSD. In this review, we introduce the immunological basis of IL-6 blockade in NMOSD and summarize current knowledge about the clinical use of the IL-6 receptor inhibitors tocilizumab and satralizumab. The aim of extending the half-life of monoclonal antibodies (mAbs) has been actualized by successful clinical translation for Satralizumab, achieved via the neonatal Fc receptor (FcRn) pathway. The basic principles of FcRn are highlighted in this review together with the potential therapeutic benefits of this emerging technology.
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Affiliation(s)
- Johann Sellner
- Department of Neurology, Landesklinikum Mistelbach-Gänserndorf, Mistelbach, Austria; Department of Neurology, Christian Doppler Medical Center, Paracelsus Medical University, Salzburg, Austria; Department of Neurology, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Harald H Sitte
- Institute of Pharmacology, Center for Physiology and Pharmacology, Medical University Vienna, Vienna, Austria
| | - Paulus S Rommer
- Department of Neurology, Medical University of Vienna, Vienna, Austria; Neuroimmunological Section, Department of Neurology, University of Rostock, Rostock, Germany.
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Patel DD, Bussel JB. Neonatal Fc receptor in human immunity: Function and role in therapeutic intervention. J Allergy Clin Immunol 2021; 146:467-478. [PMID: 32896307 DOI: 10.1016/j.jaci.2020.07.015] [Citation(s) in RCA: 53] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 07/21/2020] [Accepted: 07/23/2020] [Indexed: 02/08/2023]
Abstract
The humoral immune response provides specific, long-lived protection against invading pathogens, via immunoglobulin production and other memory functions. IgG, the most abundant immunoglobulin isotype, has the longest half-life and protects against bacterial and viral infections. The neonatal Fc receptor (FcRn) transports IgG across barriers, for example, the placenta, enhancing fetal humoral immunity to levels similar to their mothers'. Importantly, FcRn, by protecting IgG from intracellular degradation, results in an approximately 21-day circulating IgG half-life and high plasma levels; similarly, FcRn recycles albumin and is the portal of entry for enteric cytopathic human orphan (echo) virus infection. Dysregulated immune responses may lead to antibodies against self-antigens (autoantibodies), resulting in organ-specific or systemic autoimmune diseases. Autoantibody-mediated diseases have been treated by nonspecific immunoglobulin-lowering/modulating therapies, including immunoadsorption, plasma exchange, and high-dose intravenous immunoglobulin. However, targeting FcRn with specific inhibitors results in reduction in only IgG levels. The effectiveness of FcRn inhibitors in autoimmune diseases, including myasthenia gravis and immune thrombocytopenia, provides further evidence that IgG is a primary driver in these autoantibody-mediated diseases. We describe the role of FcRn in human biology, including insights that clinical testing of FcRn inhibitors have provided into FcRn biology and autoimmune disease mechanisms, allowing fact-based speculation on their therapeutic potential.
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Affiliation(s)
- Dhavalkumar D Patel
- UCB Pharma, Brussels, Belgium; University of North Carolina, Chapel Hill, NC.
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Bhardwaj A, Sapra L, Saini C, Azam Z, Mishra PK, Verma B, Mishra GC, Srivastava RK. COVID-19: Immunology, Immunopathogenesis and Potential Therapies. Int Rev Immunol 2021; 41:171-206. [PMID: 33641587 PMCID: PMC7919479 DOI: 10.1080/08830185.2021.1883600] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 12/09/2020] [Accepted: 01/21/2021] [Indexed: 02/08/2023]
Abstract
The Coronavirus Disease-2019 (COVID-19) imposed public health emergency and affected millions of people around the globe. As of January 2021, 100 million confirmed cases of COVID-19 along with more than 2 million deaths were reported worldwide. SARS-CoV-2 infection causes excessive production of pro-inflammatory cytokines thereby leading to the development of "Cytokine Storm Syndrome." This condition results in uncontrollable inflammation that further imposes multiple-organ-failure eventually leading to death. SARS-CoV-2 induces unrestrained innate immune response and impairs adaptive immune responses thereby causing tissue damage. Thus, understanding the foremost features and evolution of innate and adaptive immunity to SARS-CoV-2 is crucial in anticipating COVID-19 outcomes and in developing effective strategies to control the viral spread. In the present review, we exhaustively discuss the sequential key immunological events that occur during SARS-CoV-2 infection and are involved in the immunopathogenesis of COVID-19. In addition to this, we also highlight various therapeutic options already in use such as immunosuppressive drugs, plasma therapy and intravenous immunoglobulins along with various novel potent therapeutic options that should be considered in managing COVID-19 infection such as traditional medicines and probiotics.
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Affiliation(s)
- Asha Bhardwaj
- Department of Biotechnology, All India Institute of Medical Sciences, New Delhi, India
| | - Leena Sapra
- Department of Biotechnology, All India Institute of Medical Sciences, New Delhi, India
| | - Chaman Saini
- Department of Biotechnology, All India Institute of Medical Sciences, New Delhi, India
| | - Zaffar Azam
- Department of Biotechnology, All India Institute of Medical Sciences, New Delhi, India
| | - Pradyumna K. Mishra
- Department of Molecular Biology, ICMR-NIREH, Nehru Hospital Building, Gandhi Medical College Campus, Bhopal, India
| | - Bhupendra Verma
- Department of Biotechnology, All India Institute of Medical Sciences, New Delhi, India
| | - Gyan C. Mishra
- Lab # 1, National Centre for Cell Science (NCCS), Savitribai Phule Pune University Campus, Pune, India
| | - Rupesh K. Srivastava
- Department of Biotechnology, All India Institute of Medical Sciences, New Delhi, India
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Cao W, Liu X, Hong K, Ma Z, Zhang Y, Lin L, Han Y, Xiong Y, Liu Z, Ruan L, Li T. High-Dose Intravenous Immunoglobulin in Severe Coronavirus Disease 2019: A Multicenter Retrospective Study in China. Front Immunol 2021; 12:627844. [PMID: 33679771 PMCID: PMC7933558 DOI: 10.3389/fimmu.2021.627844] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 01/11/2021] [Indexed: 12/15/2022] Open
Abstract
Background The effective treatment of coronavirus disease 2019 (COVID-19) remains unclear. We reported successful use of high-dose intravenous immunoglobulin (IVIg) in cases of severe COVID-19, but evidence from larger case series is still lacking. Methods A multi-center retrospective study was conducted to evaluate the effectiveness of IVIg administered within two weeks of disease onset at a total dose of 2 g/kg body weight, in addition to standard care. The primary endpoint was 28-day mortality. Efficacy of high-dose IVIg was assessed by using the Cox proportional hazards regression model and the Kaplan-Meier curve adjusted by inverse probability of treatment weighting (IPTW) analysis, and IPTW after multiple imputation (MI) analysis. Results Overall, 26 patients who received high-dose IVIg with standard therapy and 89 patients who received standard therapy only were enrolled in this study. The IVIg group was associated with a lower 28-day mortality rate and less time to normalization of inflammatory markers including IL-6, IL-10, and ferritin compared with the control. The adjusted HR of 28-day mortality in high-dose IVIg group was 0.24 (95% CI 0.06–0.99, p<0.001) in IPTW model, and 0.27 (95% CI 0.10–0.57, p=0.031) in IPTW-MI model. In subgroup analysis, patients with no comorbidities or treated in the first week of disease were associated with more benefit from high-dose IVIg. Conclusions High-dose IVIg administered in severe COVID-19 patients within 14 days of onset was linked to reduced 28-day mortality, more prominent with those having no comorbidities or treated at earlier stage.
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Affiliation(s)
- Wei Cao
- Department of Infectious Diseases, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Xiaosheng Liu
- Department of Infectious Diseases, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China.,Department of Basic Medical Sciences, School of Medicine, Tsinghua University, Beijing, China.,Tsinghua-Peking Center for Life Sciences, Beijing, China
| | - Ke Hong
- Department of Infectious Diseases, Jin Yin-tan Hospital, Wuhan, China
| | - Zhiyong Ma
- Department of Infectious Diseases, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Yuelun Zhang
- Medial Research Center, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Ling Lin
- Department of Infectious Diseases, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Yang Han
- Department of Infectious Diseases, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Yong Xiong
- Department of Infectious Diseases, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Zhengyin Liu
- Department of Infectious Diseases, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Lianguo Ruan
- Department of Infectious Diseases, Jin Yin-tan Hospital, Wuhan, China
| | - Taisheng Li
- Department of Infectious Diseases, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China.,Department of Basic Medical Sciences, School of Medicine, Tsinghua University, Beijing, China.,Tsinghua-Peking Center for Life Sciences, Beijing, China
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Howard JF, Nowak RJ, Wolfe GI, Freimer ML, Vu TH, Hinton JL, Benatar M, Duda PW, MacDougall JE, Farzaneh-Far R, Kaminski HJ, Barohn R, Dimachkie M, Pasnoor M, Farmakidis C, Liu T, Colgan S, Benatar MG, Bertorini T, Pillai R, Henegar R, Bromberg M, Gibson S, Janecki T, Freimer M, Elsheikh B, Matisak P, Genge A, Guidon A, David W, Habib AA, Mathew V, Mozaffar T, Hinton JL, Hewitt W, Barnett D, Sullivan P, Ho D, Howard JF, Traub RE, Chopra M, Kaminski HJ, Aly R, Bayat E, Abu-Rub M, Khan S, Lange D, Holzberg S, Khatri B, Lindman E, Olapo T, Sershon LM, Lisak RP, Bernitsas E, Jia K, Malik R, Lewis-Collins TD, Nicolle M, Nowak RJ, Sharma A, Roy B, Nye J, Pulley M, Berger A, Shabbir Y, Sachdev A, Patterson K, Siddiqi Z, Sivak M, Bratton J, Small G, Kohli A, Fetter M, Vu T, Lam L, Harvey B, Wolfe GI, Silvestri N, Patrick K, Zakalik K, Duda PW, MacDougall J, Farzaneh-Far R, Pontius A, Hoarty M. Clinical Effects of the Self-administered Subcutaneous Complement Inhibitor Zilucoplan in Patients With Moderate to Severe Generalized Myasthenia Gravis: Results of a Phase 2 Randomized, Double-Blind, Placebo-Controlled, Multicenter Clinical Trial. JAMA Neurol 2021; 77:582-592. [PMID: 32065623 PMCID: PMC7042797 DOI: 10.1001/jamaneurol.2019.5125] [Citation(s) in RCA: 121] [Impact Index Per Article: 40.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Question What are the clinical effects of zilucoplan, a subcutaneously self-administered macrocyclic peptide inhibitor of complement component 5, in a broad population of patients with moderate to severe acetylcholine receptor autoantibody–positive generalized myasthenia gravis? Findings In a randomized, double-blind, placebo-controlled, multicenter phase 2 trial, zilucoplan yielded rapid, clinically meaningful, statistically significant, and sustained improvements in the primary and key secondary end points. Near-complete complement inhibition was associated with a faster onset and greater magnitude of benefit than submaximal complement inhibition, and favorable safety and tolerability were observed. Meaning The findings support a potential therapeutic role for zilucoplan in generalized myasthenia gravis and further evaluation in a phase 3 study. Importance Many patients with generalized myasthenia gravis (gMG) have substantial clinical disability, persistent disease burden, and adverse effects attributable to chronic immunosuppression. Therefore, there is a significant need for targeted, well-tolerated therapies with the potential to improve disease control and enhance quality of life. Objective To evaluate the clinical effects of zilucoplan, a subcutaneously (SC) self-administered macrocyclic peptide inhibitor of complement component 5, in a broad population of patients with moderate to severe gMG. Design, Setting, and Participants This randomized, double-blind, placebo-controlled phase 2 clinical trial at 25 study sites across North America recruited participants between December 2017 and August 2018. Fifty-seven patients were screened, of whom 12 did not meet inclusion criteria and 1 was lost to follow-up after randomization but before receiving study drug, resulting in a total of 44 acetylcholine receptor autoantibody (AChR-Ab)–positive patients with gMG with baseline Quantitative Myasthenia Gravis (QMG) scores of at least 12, regardless of treatment history. Interventions Patients were randomized 1:1:1 to a daily SC self-injection of placebo, 0.1-mg/kg zilucoplan, or 0.3-mg/kg zilucoplan for 12 weeks. Main Outcomes and Measures The primary and key secondary end points were the change from baseline to week 12 in QMG and MG Activities of Daily Living scores, respectively. Significance testing was prespecified at a 1-sided α of .10. Safety and tolerability were also assessed. Results The study of 44 patients was well balanced across the 3 treatment arms with respect to key demographic and disease-specific variables. The mean age of patients across all 3 treatment groups ranged from 45.5 to 54.6 years and most patients were white (average proportions across 3 treatment groups: 78.6%-86.7%). Clinically meaningful and statistically significant improvements in primary and key secondary efficacy end points were observed. Zilucoplan at a dose of 0.3 mg/kg SC daily resulted in a mean reduction from baseline of 6.0 points in the QMG score (placebo-corrected change, –2.8; P = .05) and 3.4 points in the MG Activities of Daily Living score (placebo-corrected change, –2.3; P = .04). Clinically meaningful and statistically significant improvements were also observed in other secondary end points, the MG Composite and MG Quality-of-Life scores. Outcomes for the 0.1-mg/kg SC daily dose were also statistically significant but slower in onset and less pronounced than with the 0.3-mg/kg dose. Rescue therapy (intravenous immunoglobulin or plasma exchange) was required in 3 of 15, 1 of 15, and 0 of 14 participants in the placebo, 0.1-mg/kg zilucoplan, and 0.3-mg/kg zilucoplan arms, respectively. Zilucoplan was observed to have a favorable safety and tolerability profile. Conclusions and Relevance Zilucoplan yielded rapid, meaningful, and sustained improvements over 12 weeks in a broad population of patients with moderate to severe AChR-Ab–positive gMG. Near-complete complement inhibition appeared superior to submaximal inhibition. The observed safety and tolerability profile of zilucoplan was favorable. Trial Registration ClinicalTrials.gov Identifier: NCT03315130.
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Affiliation(s)
| | | | | | | | | | | | | | - Petra W Duda
- Ra Pharmaceuticals Inc, Cambridge, Massachusetts
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Angela Genge
- Montreal Neurological Institute, Montreal, Quebec, Canada
| | | | | | | | | | | | | | | | | | | | - Doreen Ho
- Lahey Hospital, Burlington, Massachusetts
| | | | | | | | | | - Radwa Aly
- George Washington University, Washington, DC
| | - Elham Bayat
- George Washington University, Washington, DC
| | | | - Shaida Khan
- University of Texas Southwestern, Dallas, Irving
| | - Dale Lange
- Hospital for Special Surgery, New York, New York
| | | | - Bhupendra Khatri
- Center for Neurological Disorders, St Francis Hospital at Ascension, Milwaukee, Wisconsin
| | - Emily Lindman
- Center for Neurological Disorders, St Francis Hospital at Ascension, Milwaukee, Wisconsin
| | - Tayo Olapo
- Center for Neurological Disorders, St Francis Hospital at Ascension, Milwaukee, Wisconsin
| | - Lisa M Sershon
- Center for Neurological Disorders, St Francis Hospital at Ascension, Milwaukee, Wisconsin
| | | | | | - Kelly Jia
- Wayne State University, Detroit, Michigan
| | | | | | | | | | | | - Bhaskar Roy
- Yale School of Medicine, New Haven, Connecticut
| | - Joan Nye
- Yale School of Medicine, New Haven, Connecticut
| | | | | | | | | | | | | | - Mark Sivak
- Mount Sinai Hospital, New York, New York
| | | | - George Small
- Allegheny Neurological Associates, Pittsburgh, Pennsylvania
| | - Anem Kohli
- Allegheny Neurological Associates, Pittsburgh, Pennsylvania
| | - Mary Fetter
- Allegheny Neurological Associates, Pittsburgh, Pennsylvania
| | - Tuan Vu
- University of South Florida, Tampa
| | - Lucy Lam
- University of South Florida, Tampa
| | | | | | | | | | | | - Petra W Duda
- Ra Pharmaceuticals Inc, Cambridge, Massachusetts
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Jann S, Fazio R, Cocito D, Toscano A, Schenone A, Marfia GA, Antonini G, De Toni Franceschini L, Mazzeo A, Grandis M, Velardo D, Mataluni G, Peci E. High-Dose Intravenous Immunoglobulin Is Effective in Painful Diabetic Polyneuropathy Resistant to Conventional Treatments. Results of a Double-Blind, Randomized, Placebo-Controlled, Multicenter Trial. PAIN MEDICINE 2021; 21:576-585. [PMID: 31904855 DOI: 10.1093/pm/pnz331] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVES The efficacy and safety of high-dose intravenous immunoglobulin (IVIG) in treatment-resistant diabetic painful polyneuropathy (DPN) were assessed. DESIGN This was a randomized, double-blind, placebo-controlled, multicenter trial (EudraCT 2010-023883-42). SETTING This trial was conducted at eight sites in Italy with a neurology specialist level of care. SUBJECTS Twenty-six diabetic patients with DPN who reported baseline severity of pain >60 units (mm) on a VAS scale at enrollment and were resistant to antidepressants and antiepileptic drugs were enrolled; 23 were randomized (11 in the IVIG arm and 12 in the placebo arm). All patients completed the study and were evaluated. All patients were Caucasian, 15 were male, and 21 had a diagnosis of type II diabetes. METHODS IVIG (0.4 g/kg/d) or placebo was given for five consecutive days. Pain intensity (visual analog scale, Neuropathic Pain Symptom Inventory) and quality of life (36-Item Short-Form Health Survey, Clinical/Patient Global Impression of Change questionnaires) assessments were performed at visits: baseline, start of therapy (one week later), end of therapy (five days later), and follow-up (four and eight weeks later). RESULTS The study achieved its prespecified primary end point of ≥50% pain reduction at four weeks after IVIG, achieved in seven of 11 patients (63.6%) in the IVIG group vs zero of 12 in the placebo group (P = 0.0013). Only two adverse events were reported during the study: one patient in the treatment arm reported a mild "dermatitis psoriasiform," whereas one patient from the placebo group reported a mild "influenza." CONCLUSIONS Treatment with IVIG at the dose given was efficacious and safe for patients with DPN resistant to standard therapies.
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Affiliation(s)
- Stefano Jann
- Department of Neurology, Niguarda General Hospital, Milan, Italy
| | - Raffaella Fazio
- Department of Neuromuscular Disease, San Raffaele Hospital, Milan, Italy
| | - Dario Cocito
- Department of Neuroscience, University of Turin, Torino, Italy
| | - Antonio Toscano
- Department of Neuroscience, Psychiatry and Anesthesiology, University of Messina, Messina, Italy
| | - Angelo Schenone
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics and Maternal and Child Health, University of Genoa, Genoa, Italy
| | | | - Giovanni Antonini
- Department of Neuroscience, Mental Health and Sensory Organs, Rome University "Sapienza," Sant'Andrea Hospital, Rome, Italy
| | | | - Anna Mazzeo
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Marina Grandis
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics and Maternal and Child Health, University of Genoa, Genoa, Italy
| | - Daniele Velardo
- Department of Neuromuscular Disease, San Raffaele Hospital, Milan, Italy
| | | | - Erdita Peci
- Department of Neuroscience, University of Turin, Torino, Italy
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Wilcox DR, Collens SI, Solomon IH, Mateen FJ, Mukerji SS. Eastern equine encephalitis and use of IV immunoglobulin therapy and high-dose steroids. NEUROLOGY(R) NEUROIMMUNOLOGY & NEUROINFLAMMATION 2021; 8:e917. [PMID: 33172962 PMCID: PMC7713729 DOI: 10.1212/nxi.0000000000000917] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 09/28/2020] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To determine the clinical presentation and patient outcomes after treatment with IV immunoglobulin (IVIG), high-dose steroids, or standard of care alone in Eastern equine encephalitis (EEE), a mosquito-borne viral infection with significant neurologic morbidity and mortality. METHODS A retrospective observational study of patients admitted to 2 tertiary academic medical centers in Boston, Massachusetts, with EEE from 2005 to 2019. RESULTS Of 17 patients (median [IQR] age, 63 [36-70] years; 10 (59%) male, and 16 (94%) White race), 17 patients had fever (100%), 15 had encephalopathy (88%), and 12 had headache (71%). Eleven of 14 patients with CSF cell count differential had a neutrophil predominance (mean = 60.6% of white blood cells) with an elevated protein level (median [IQR], 100 mg/dL [75-145]). Affected neuroanatomic regions included the basal ganglia (n = 9/17), thalamus (n = 7/17), and mesial temporal lobe (n = 7/17). A total of 11 patients (65%) received IVIG; 8 (47%) received steroids. Of the patients who received IVIG, increased time from hospital admission to IVIG administration correlated with worse long-term disability as assessed by the modified Rankin Scale (mRS) (r = 0.72, p = 0.02); steroid use was not associated with the mRS score. The mortality was 12%. CONCLUSIONS Clinicians should suspect EEE in immunocompetent patients with early subcortical neuroimaging abnormalities and CSF neutrophilic predominance. This study suggests a lower mortality than previously reported, but a high morbidity rate in EEE. IVIG as an adjunctive to standard of care may be considered early during hospitalization.
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Affiliation(s)
- Douglas R Wilcox
- From the Division of Neuroimmunology and Neuro-Infectious Diseases (D.R.W., S.I.C., F.J.M., S.S.M.), Department of Neurology, Massachusetts General Hospital; Department of Neurology (D.R.W.), Brigham and Women's Hospital; Department of Pathology (I.H.S.), Brigham and Women's Hospital; and Department of Neurology (D.R.W., F.J.M., S.S.M.), Harvard Medical School, Boston, MA.
| | - Sarah I Collens
- From the Division of Neuroimmunology and Neuro-Infectious Diseases (D.R.W., S.I.C., F.J.M., S.S.M.), Department of Neurology, Massachusetts General Hospital; Department of Neurology (D.R.W.), Brigham and Women's Hospital; Department of Pathology (I.H.S.), Brigham and Women's Hospital; and Department of Neurology (D.R.W., F.J.M., S.S.M.), Harvard Medical School, Boston, MA
| | - Isaac H Solomon
- From the Division of Neuroimmunology and Neuro-Infectious Diseases (D.R.W., S.I.C., F.J.M., S.S.M.), Department of Neurology, Massachusetts General Hospital; Department of Neurology (D.R.W.), Brigham and Women's Hospital; Department of Pathology (I.H.S.), Brigham and Women's Hospital; and Department of Neurology (D.R.W., F.J.M., S.S.M.), Harvard Medical School, Boston, MA
| | - Farrah J Mateen
- From the Division of Neuroimmunology and Neuro-Infectious Diseases (D.R.W., S.I.C., F.J.M., S.S.M.), Department of Neurology, Massachusetts General Hospital; Department of Neurology (D.R.W.), Brigham and Women's Hospital; Department of Pathology (I.H.S.), Brigham and Women's Hospital; and Department of Neurology (D.R.W., F.J.M., S.S.M.), Harvard Medical School, Boston, MA
| | - Shibani S Mukerji
- From the Division of Neuroimmunology and Neuro-Infectious Diseases (D.R.W., S.I.C., F.J.M., S.S.M.), Department of Neurology, Massachusetts General Hospital; Department of Neurology (D.R.W.), Brigham and Women's Hospital; Department of Pathology (I.H.S.), Brigham and Women's Hospital; and Department of Neurology (D.R.W., F.J.M., S.S.M.), Harvard Medical School, Boston, MA
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Alzuabi MA, Manolopoulos A, Elmashala A, Odabashian R, Naddaf E, Murad MH. Immunoglobulin for myasthenia gravis. Hippokratia 2020. [DOI: 10.1002/14651858.cd013801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Muayad A Alzuabi
- Department of Neuroscience, Division of Clinical Neurology; Medical University of South Carolina; Charleston SC USA
| | - Apostolos Manolopoulos
- Clinical Research and Evidence-Based Medicine Unit, Second Medical Department; Aristotle University of Thessaloniki; Thessaloniki Greece
| | - Amjad Elmashala
- Department of Neurology; Iowa University Hospitals; Iowa City IA USA
| | - Roupen Odabashian
- Department of Internal Medicine; University of Toronto; Toronto Canada
| | - Elie Naddaf
- Department of Neurology; Mayo Clinic; Rochester MN USA
| | - M Hassan Murad
- Mayo Evidence-based Practice Center (EPC); Mayo Clinic; Rochester MN USA
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Evaluating the effects of Intravenous Immunoglobulin (IVIg) on the management of severe COVID-19 cases: A randomized controlled trial. Int Immunopharmacol 2020; 90:107205. [PMID: 33214093 PMCID: PMC7665876 DOI: 10.1016/j.intimp.2020.107205] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Revised: 10/29/2020] [Accepted: 11/10/2020] [Indexed: 01/08/2023]
Abstract
BACKGROUND The newly discovered coronavirus has turned into coronavirus disease 2019 (COVID-19) pandemic and it rages at an unprecedented rate. Considering the findings of previous studies on the use of Intravenous Immunoglobulin (IVIg) for treating severe H1N1 infection and the satisfying results for reducing viral load and mortality, this study aimed to investigate the potential usefulness of IVIg for the management of severe cases. METHODS In this randomized controlled trial, 84 patients were included: 52 in the IVIg group and 32 in the control group. The intervention group received IVIg at a dose of 400 mg/kg, IV, daily for three days. Both groups received hydroxychloroquine, lopinavir/ritonavir and supportive care. The demographic data, mortality rate, the need for mechanical ventilation, length of stay in hospital and in Intensive Care Unit (ICU), and imaging findings were recorded and compared in terms of the mentioned factors. RESULTS The mean time from admission to IVIg initiation was 3.84 ± 3.35 days. There was no significant difference between the two groups in terms of mortality rate (P-value = 0.8) and the need for mechanical ventilation (P-value = 0.39). The length of hospital stay was significantly lower for the control group than that of the intervention group (P-value = 0.003). There was a significant positive relationship between the time from hospital admission to IVIg initiation and the length of stay in the hospital and ICU among the survivors (P-value < 0.001 and =0.01, respectively). CONCLUSIONS Our findings did not support the use of IVIg in combination with hydroxychloroquine and lopinavir/ritonavir in treatment of severe COVID-19 cases.
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Chang MC, Park D. Effectiveness of Intravenous Immunoglobulin for Management of Neuropathic Pain: A Narrative Review. J Pain Res 2020; 13:2879-2884. [PMID: 33209055 PMCID: PMC7669498 DOI: 10.2147/jpr.s273475] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 10/13/2020] [Indexed: 12/15/2022] Open
Abstract
Administrations of intravenous immunoglobulin (IVIG), an immune-modulating blood-derived product, may be beneficial for managing neuropathic pain. Here, we review previous studies to investigate the effectiveness of IVIG in managing neuropathic pain due to various neurological disorders. The electronic databases PubMed, Scopus, Embase, and the Cochrane Library were searched for studies published up to February 2020. Two reviewers independently assessed the studies using strict inclusion criteria. Ten studies were included and qualitatively analyzed. The review included patients with pain due to complex regional pain syndrome (CRPS), diabetic polyneuropathy, and others, such as postherpetic neuralgia and trigeminal neuralgia. We found that IVIG may be one of the beneficial options for managing neuropathic pain from various neurological disorders. In the four articles reviewed, no major adverse effects were reported, and the trend was toward a positive pain-reducing effect in eight articles. However, to confirm the benefits of IVIG on reducing neuropathic pain, more high-quality studies are required.
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Affiliation(s)
- Min Cheol Chang
- Department of Rehabilitation Medicine, College of Medicine, Yeungnam University, Daegu, Republic of Korea
| | - Donghwi Park
- Department of Physical Medicine and Rehabilitation, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Republic of Korea
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40
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Shao Z, Feng Y, Zhong L, Xie Q, Lei M, Liu Z, Wang C, Ji J, Liu H, Gu Z, Hu Z, Su L, Wu M, Liu Z. Clinical efficacy of intravenous immunoglobulin therapy in critical ill patients with COVID-19: a multicenter retrospective cohort study. Clin Transl Immunology 2020; 9:e1192. [PMID: 33082954 PMCID: PMC7557105 DOI: 10.1002/cti2.1192] [Citation(s) in RCA: 78] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 09/09/2020] [Accepted: 09/13/2020] [Indexed: 01/30/2023] Open
Abstract
Objective Coronavirus disease 2019 (COVID‐19) outbreak is a major challenge all over the world, without acknowledged treatment. Intravenous immunoglobulin (IVIG) has been recommended to treat critical coronavirus disease 2019 (COVID‐19) patients in a few reviews, but the clinical study evidence on its efficacy in COVID‐19 patients was lacking. Methods 325 patients with laboratory‐confirmed critical COVID‐19 were enrolled from 4 government‐designated COVID‐19 treatment centres in southern China from December 2019 to March 2020. The primary outcomes were 28‐ and 60‐day mortality, and the secondary outcomes were the total length of in‐hospital and the total duration of the disease. Subgroup analysis was carried out according to clinical classification of COVID‐19, IVIG dosage and timing. Results In the enrolled 325 patients, 174 cases used IVIG and 151 cases did not. The 28‐day mortality was improved with IVIG after adjusting confounding in overall cohort (P = 0.0014), and the in‐hospital and the total duration of disease were longer in the IVIG group (P < 0.001). Subgroup analysis showed that only in patients with critical type, IVIG could significantly reduce the 28‐day mortality, decrease the inflammatory response and improve some organ functions (all P < 0.05); the application of IVIG in the early stage (admission ≤ 7 days) with a high dose (> 15 g per day) exhibited significant reduction in 60‐day mortality in the critical‐type patients. Conclusion Early administration of IVIG with high dose improves the prognosis of critical‐type patients with COVID‐19. This study provides important information on clinical application of IVIG in the treatment of SARS‐CoV‐2 infection, including patient selection and administration dosage and timing.
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Affiliation(s)
- Ziyun Shao
- Department of Nephrology General Hospital of Central Theater Command of PLA Wuhan 430070 China
| | - Yongwen Feng
- Department of Critical Care Medicine and Hospital Infection Prevention and Control The Second People's Hospital of Shenzhen & First Affiliated Hospital of Shenzhen University Health Science Center Shenzhen 518035 China.,Department of Critical Care Medicine The Third People's Hospital of Shenzhen Shenzhen 518035 China
| | - Li Zhong
- Department of Critical Care Medicine The First Affiliated Hospital Guizhou University of Chinese Medicine Guiyang 550001 China
| | - Qifeng Xie
- Department of Critical Care Medicine General Hospital of Southern Theater Command of PLA Guangzhou 510010 China
| | - Ming Lei
- Department of Nephrology Guangzhou Eighth people's hospital Guangzhou Medical University Guangzhou 510060 China
| | - Zheying Liu
- Department of Critical Care Medicine General Hospital of Southern Theater Command of PLA Guangzhou 510010 China
| | - Conglin Wang
- Department of Critical Care Medicine General Hospital of Southern Theater Command of PLA Guangzhou 510010 China
| | - Jingjing Ji
- Department of Critical Care Medicine General Hospital of Southern Theater Command of PLA Guangzhou 510010 China
| | - Huiheng Liu
- Department of Emergency Zhongshan Hospital of Xiamen University Xiamen 361000 China
| | - Zhengtao Gu
- Department of Treatment Center for Traumatic Injuries The Third Affiliated Hospital Academy of Orthopedics Guangdong Province Southern Medical University Guangzhou Guangdong 515630 China
| | - Zhongwei Hu
- Department of Nephrology Guangzhou Eighth people's hospital Guangzhou Medical University Guangzhou 510060 China
| | - Lei Su
- Department of Critical Care Medicine General Hospital of Southern Theater Command of PLA Guangzhou 510010 China
| | - Ming Wu
- Department of Critical Care Medicine and Hospital Infection Prevention and Control The Second People's Hospital of Shenzhen & First Affiliated Hospital of Shenzhen University Health Science Center Shenzhen 518035 China.,Department of Critical Care Medicine General Hospital of Southern Theater Command of PLA Guangzhou 510010 China
| | - Zhifeng Liu
- Department of Critical Care Medicine General Hospital of Southern Theater Command of PLA Guangzhou 510010 China.,Key Laboratory of Hot Zone Trauma Care and Tissue Repair of PLA General Hospital of Southern Theater Command of PLA Guangzhou 510010 China
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Talotta R, Robertson E. Autoimmunity as the comet tail of COVID-19 pandemic. World J Clin Cases 2020; 8:3621-3644. [PMID: 32953841 PMCID: PMC7479552 DOI: 10.12998/wjcc.v8.i17.3621] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2020] [Revised: 07/29/2020] [Accepted: 08/26/2020] [Indexed: 02/05/2023] Open
Abstract
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection can give rise to different clinical manifestations that are directly related to viral tissue damage or indirectly induced by the antiviral immune response. Hyper-activation of the immune system in an attempt to eradicate the infection may trigger autoimmunity. Several immune-mediated disorders have been described in SARS-CoV-2-infected individuals. These include cutaneous rashes and vasculitis, autoimmune cytopenia, anti-phospholipid syndrome, central or peripheral neuropathy, myositis and myocarditis. On the other hand, rheumatic patients were reported to have similar coronavirus disease 2019 (COVID-19) incidence, morbidity and mortality rates compared to general population. This opinion review will summarize the crucial immunologic steps which occur during SARS-CoV-2-infection that may link autoimmunity to COVID-19 and provides an opportunity for further discussion regarding this association.
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Affiliation(s)
- Rossella Talotta
- Department of Clinical and Experimental Medicine, Rheumatology Unit, AOU “Gaetano Martino”, University of Messina, Messina 98100, Italy
| | - Erle Robertson
- Department of Otorhinolaryngology-Head and Neck Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19014, United States
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Early Intravenous Immunoglobulin as an Effective Drug for the Treatment of COVID-19: A Case Series and Case Review. ARCHIVES OF CLINICAL INFECTIOUS DISEASES 2020. [DOI: 10.5812/archcid.103732] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Introduction: The outbreak of coronavirus disease 2019 (COVID-19) should be considered a serious threat to global public health. Due to a large number of infected and dead people, the development of approaches to control the epidemic condition, as well as effective and available drugs, is very important. Case Presentation: In this study, we presented three cases with COVID-19 admitted to the Imam Reza Hospital. A high dose of intravenous immunoglobulin (IVIG) was used for patients as potent and safe treatment. Moreover, case reports and case series focusing on the patients with COVID-19 were reviewed in the present study. During the literature search, 27 patients with COVID-19 were identified in 14 studies. Fever, sore throat, dry cough, fatigue, chills, and muscle pain were the common primary complications of the patients. Kaletra, oseltamivir, ceftriaxone, hydroxychloroquine, azithromycin, and IVIG were the most prevalent drugs for the treatment of COVID-19. Conclusions: Except for the current study, IVIG was utilized in two other studies to treat patients with COVID-19, who did not respond to other therapies.
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Menon D, Barnett C, Bril V. Novel Treatments in Myasthenia Gravis. Front Neurol 2020; 11:538. [PMID: 32714266 PMCID: PMC7344308 DOI: 10.3389/fneur.2020.00538] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 05/14/2020] [Indexed: 01/08/2023] Open
Abstract
Myasthenia gravis (MG) is the prototypical autoimmune disorder caused by specific autoantibodies at the neuromuscular junction. Broad-based immunotherapies, such as corticosteroids, azathioprine, mycophenolate, tacrolimus, and cyclosporine, have been effective in controlling symptoms of myasthenia. While being effective in a majority of MG patients many of these immunosuppressive agents are associated with long-term side effects, often intolerable for patients, and take several months to be effective. With advances in translational research and drug development capabilities, more directed therapeutic agents that can alter the future of MG treatment have been developed. This review focuses on the aberrant immunological processes in MG, the novel agents that target them along with the clinical evidence for efficacy and safety. These agents include terminal complement C5 inhibitors, Fc receptor inhibitors, B cell depleting agents (anti CD 19 and 20 and B cell activating factor [BAFF)]inhibitors), proteosome inhibitors, T cells and cytokine based therapies (chimeric antigen receptor T [CART-T] cell therapy), autologous stem cell transplantation, and subcutaneous immunoglobulin (SCIG). Most of these new agents have advantages over conventional immunosuppressive treatment (IST) for MG therapy in terms of faster onset of action, favourable side effect profile and the potential for a sustained and long-term remission.
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Affiliation(s)
| | | | - Vera Bril
- Ellen & Martin Prosserman Centre for Neuromuscular Diseases, University Health Network, University of Toronto, Toronto, ON, Canada
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44
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Cao W, Liu X, Bai T, Fan H, Hong K, Song H, Han Y, Lin L, Ruan L, Li T. High-Dose Intravenous Immunoglobulin as a Therapeutic Option for Deteriorating Patients With Coronavirus Disease 2019. Open Forum Infect Dis 2020; 7:ofaa102. [PMID: 32258207 PMCID: PMC7111600 DOI: 10.1093/ofid/ofaa102] [Citation(s) in RCA: 276] [Impact Index Per Article: 69.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Accepted: 03/19/2020] [Indexed: 12/13/2022] Open
Abstract
The outbreak of coronavirus disease 2019 (COVID-19) has spread rapidly in China. Until now, no definite effective treatment has been identified. We reported on 3 patients with severe COVID-19 who received high-dose intravenous immunoglobulin (IVIg) with satisfactory recovery. Based on these observations, randomized studies of high-dose IVIg should be considered in deteriorating patients infected with COVID-19.
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Affiliation(s)
- Wei Cao
- Department of Infectious Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Xiaosheng Liu
- Tsinghua-Peking Center for Life Sciences, School of Medicine, Tsinghua University, Beijing, China
| | - Tao Bai
- Department of Infectious Diseases, Jin Yin-tan Hospital, Wuhan, China
| | - Hongwei Fan
- Department of Infectious Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Ke Hong
- Department of Infectious Diseases, Jin Yin-tan Hospital, Wuhan, China
| | - Hui Song
- Department of Infectious Diseases, Jin Yin-tan Hospital, Wuhan, China
| | - Yang Han
- Department of Infectious Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Ling Lin
- Department of Infectious Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Lianguo Ruan
- Department of Infectious Diseases, Jin Yin-tan Hospital, Wuhan, China
| | - Taisheng Li
- Department of Infectious Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
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Mays JW, Carey BP, Posey R, Gueiros LA, France K, Setterfield J, Woo SB, Sollecito TP, Culton D, Payne AS, Greenberg MS, De Rossi S. World Workshop of Oral Medicine VII: A systematic review of immunobiologic therapy for oral manifestations of pemphigoid and pemphigus. Oral Dis 2020; 25 Suppl 1:111-121. [PMID: 31140696 DOI: 10.1111/odi.13083] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Revised: 02/23/2019] [Accepted: 02/25/2019] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To assess the evidence for treatment of oral involvement of pemphigus and pemphigoid with biologics. STUDY DESIGN This systematic review used a comprehensive search strategy to identify literature describing oral involvement of pemphigus or pemphigoid treated with a biologic agent. The primary outcome measures were efficacy and safety of biologic therapy. RESULTS Inclusion criteria were met by 154 studies including over 1200 patients. Treatment of pemphigus with a total of 11 unique biologic agents and 3 unique combinations of agents is reported. Five randomized controlled trials (RCT) were included in the final analysis that investigated infliximab, IVIg, rituximab, and autologous platelet-rich plasma therapy for pemphigus vulgaris. Three non-RCT studies reported on successful rituximab or IVIg therapy for mucous membrane pemphigoid. Studies demonstrated considerable heterogeneity in agent, methods, and quality. CONCLUSIONS Evidence clearly describing oral tissue response to biologic therapy is sparse. Two RCTs support use of rituximab, one supports use of IVIg, and one pilot study suggests intralesional injection of autologous platelet-rich plasma aids healing of oral PV lesions. As oral lesions of pemphigus and pemphigoid can be refractory to systemic therapy, drug trials including biologic therapies should document details regarding response of the oral lesions to therapy.
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Affiliation(s)
- Jacqueline W Mays
- Oral Immunobiology Unit, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, Maryland
| | - Barbara P Carey
- Department of Oral Medicine, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Rachael Posey
- William Rand Kenan, Jr. Library of Veterinary Medicine, North Carolina State University, Raleigh, North Carolina
| | - Luiz Alcino Gueiros
- Oral Medicine Unit, Department of Clinic and Preventive Dentistry, Universidade Federal de Pernambuco, Recife, Brazil
| | - Katherine France
- Department of Oral Medicine, University of Pennsylvania School of Dental Medicine, Philadelphia, Pennsylvania
| | - Jane Setterfield
- Department of Oral Medicine, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Sook Bin Woo
- Department of Oral Medicine, Infection, and Immunity, Harvard School of Dental Medicine, Boston, Massachusetts
| | - Thomas P Sollecito
- Department of Oral Medicine, University of Pennsylvania School of Dental Medicine, Philadelphia, Pennsylvania
| | - Donna Culton
- Department of Dermatology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Aimee S Payne
- Department of Dermatology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Martin S Greenberg
- Department of Oral Medicine, University of Pennsylvania School of Dental Medicine, Philadelphia, Pennsylvania
| | - Scott De Rossi
- School of Dentistry, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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Hori A, Fujimura T, Kawamoto S. Anti-inflammatory intravenous immunoglobulin (IVIg) suppresses homeostatic proliferation of B cells. Cytotechnology 2018; 70:921-927. [PMID: 29611058 PMCID: PMC6021294 DOI: 10.1007/s10616-017-0176-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Accepted: 11/27/2017] [Indexed: 02/04/2023] Open
Abstract
An intravenous injection of plasma-derived immunoglobulins is used for the treatment of severe infectious and autoimmune disorders. Despite of its clinical efficacy, precise mechanisms by which intravenous immunoglobulin (IVIg) suppresses proinflammatory immune response are still enigmatic. Here, we provide in vitro evidence that IVIg inhibits homeostatic proliferation of B cells accompanied by induction of their cell aggregation. The IVIg-driven suppression of B cell proliferation and induction of cell aggregation are both unaffected by treatment with a neutralizing antibody against low-affinity Fc receptors for IgG (CD16/FcγRIII and CD32/FcγRII), known cell surface ligands for IVIg. Our observations propose a new immunosuppressive action of IVIg, which directly acts on steady-state B cells to suppress their homeostatic expansion.
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Affiliation(s)
- Ayane Hori
- Hiroshima Research Center for Healthy Aging (HiHA), Department of Molecular Biotechnology, Graduate School of Advanced Sciences of Matter, Hiroshima University, 1-3-1 Kagamiyama, Higashi-Hiroshima, 739-8530, Japan
| | - Takashi Fujimura
- Hiroshima Research Center for Healthy Aging (HiHA), Department of Molecular Biotechnology, Graduate School of Advanced Sciences of Matter, Hiroshima University, 1-3-1 Kagamiyama, Higashi-Hiroshima, 739-8530, Japan.
| | - Seiji Kawamoto
- Hiroshima Research Center for Healthy Aging (HiHA), Department of Molecular Biotechnology, Graduate School of Advanced Sciences of Matter, Hiroshima University, 1-3-1 Kagamiyama, Higashi-Hiroshima, 739-8530, Japan.
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Abstract
Pemphigus vulgaris (PV) is a life-threatening disease belonging to the pemphigus group of autoimmune intra-epidermal bullous diseases of the skin and mucosae. The therapeutic management of PV remains challenging and, in some cases, conventional therapy is not adequate to induce clinical remission. The cornerstone of PV treatment remains systemic corticosteroids. Although very effective, long-term corticosteroid administration is characterized by substantial adverse effects. Corticosteroid-sparing adjuvant therapies have been employed in the treatment of PV, aiming to reduce the necessary cumulative dose of corticosteroids. Specifically, immunosuppressive agents such as azathioprine and mycophenolate mofetil are widely used in PV. More recently, high-dose intravenous immunoglobulins, immunoadsorption, and rituximab have been established as additional successful therapeutic options. This review covers both conventional and emerging therapies in PV. In addition, it sheds light on potential future treatment strategies for this disease.
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Affiliation(s)
- Khalaf Kridin
- Department of Dermatology, Rambam Health Care Campus, Haifa, Israel
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Gurevich-Shapiro A, Bonstein L, Spectre G, Atweh N, Gruenewal T, Shapiro M, Tadmor B, Raanani P. Intravenous immunoglobulin-induced acute thrombocytopenia. Transfusion 2017; 58:493-497. [PMID: 29193103 DOI: 10.1111/trf.14419] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2017] [Revised: 10/09/2017] [Accepted: 10/18/2017] [Indexed: 12/01/2022]
Abstract
BACKGROUND Intravenous immunoglobulin (IVIG) has known efficacy in various hematologic conditions, including immune thrombocytopenic purpura. STUDY DESIGN AND METHODS We present the clinical course of a patient with splenic marginal zone lymphoma, who developed acute thrombocytopenia on three consecutive episodes, with nadir counts of 27 × 109 , 50 × 109 , and 9 × 109 /L, upon administration of Intratect IVIG for hypogammaglobulinemia. An immunofluorescence test applying flow cytometry and monoclonal antibody immobilization of platelet antigens (MAIPA) assay were used to evaluate the reaction between IgG present in the IVIG preparations and the patient's or healthy donors' platelets (PLTs). RESULTS A strong direct binding reaction was observed between the patient's PLTs and Intratect IgG using both methods. A similar reaction failed to materialize with controls. Binding was not antigen specific according to MAIPA. CONCLUSIONS This is the first reported case of thrombocytopenia as a possible adverse effect of IVIG.
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Affiliation(s)
- Anna Gurevich-Shapiro
- Internal Medicine H, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.,Institute of Hematology, Davidoff Cancer Center, Beilinson Hospital, Rabin Medical Center, Petah-Tiqwa, Israel.,Sackler School of Medicine, Tel Aviv University, Ramat-Aviv, Israel
| | - Lilach Bonstein
- Platelet Immunology Laboratory, Rambam Medical Center, Haifa, Israel
| | - Galia Spectre
- Institute of Hematology, Davidoff Cancer Center, Beilinson Hospital, Rabin Medical Center, Petah-Tiqwa, Israel.,Sackler School of Medicine, Tel Aviv University, Ramat-Aviv, Israel
| | - Nardeen Atweh
- Platelet Immunology Laboratory, Rambam Medical Center, Haifa, Israel
| | - Tsipora Gruenewal
- Institute of Hematology, Davidoff Cancer Center, Beilinson Hospital, Rabin Medical Center, Petah-Tiqwa, Israel
| | - Michael Shapiro
- Sackler School of Medicine, Tel Aviv University, Ramat-Aviv, Israel
| | - Boaz Tadmor
- Institute of Hematology, Davidoff Cancer Center, Beilinson Hospital, Rabin Medical Center, Petah-Tiqwa, Israel.,Sackler School of Medicine, Tel Aviv University, Ramat-Aviv, Israel
| | - Pia Raanani
- Institute of Hematology, Davidoff Cancer Center, Beilinson Hospital, Rabin Medical Center, Petah-Tiqwa, Israel.,Sackler School of Medicine, Tel Aviv University, Ramat-Aviv, Israel
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Immune Gamma Globulin Therapeutic Indications in Immune Deficiency and Autoimmunity. Curr Allergy Asthma Rep 2017; 16:55. [PMID: 27401913 DOI: 10.1007/s11882-016-0632-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Immune gamma globulin (IgG) has a long history in the treatment of both primary immune deficiency and autoimmune disorders. Disease indications continue to expand and new-generation products increase the versatility of delivery. This review encompasses a historical perspective as well as current and future implications of human immune globulin for the treatment of immune-mediated illness.
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50
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Winter M, Baksmeier C, Steckel J, Barman S, Malviya M, Harrer-Kuster M, Hartung HP, Goebels N. Dose-dependent inhibition of demyelination and microglia activation by IVIG. Ann Clin Transl Neurol 2016; 3:828-843. [PMID: 27844029 PMCID: PMC5099529 DOI: 10.1002/acn3.326] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2015] [Revised: 04/25/2016] [Accepted: 05/09/2016] [Indexed: 12/31/2022] Open
Abstract
Objective Intravenous immunoglobulin (IVIG) is an established treatment for numerous autoimmune conditions. Clinical trials of IVIG for multiple sclerosis, using diverse dose regimens, yielded controversial results. The aim of this study is to dissect IVIG effector mechanisms on demyelination in an ex vivo model of the central nervous system (CNS)‐immune interface. Methods Using organotypic cerebellar slice cultures (OSC) from transgenic mice expressing green fluorescent protein (GFP) in oligodendrocytes/myelin, we induced extensive immune‐mediated demyelination and oligodendrocyte loss with an antibody specific for myelin oligodendrocyte glycoprotein (MOG) and complement. Protective IVIG effects were assessed by live imaging of GFP expression, confocal microscopy, immunohistochemistry, gene expression analysis and flow cytometry. Results IVIG protected OSC from demyelination in a dose‐dependent manner, which was at least partly attributed to interference with complement‐mediated oligodendroglia damage, while binding of the anti‐MOG antibody was not prevented. Staining with anti‐CD68 antibodies and flow cytometry confirmed that IVIG prevented microglia activation and oligodendrocyte death, respectively. Equimolar IVIG‐derived Fab fragments or monoclonal IgG did not protect OSC, while Fc fragments derived from a polyclonal mixture of human IgG were at least as potent as intact IVIG. Interpretation Both intact IVIG and Fc fragments exert a dose‐dependent protective effect on antibody‐mediated CNS demyelination and microglia activation by interfering with the complement cascade and, presumably, interacting with local immune cells. Although this experimental model lacks blood–brain barrier and peripheral immune components, our findings warrant further studies on optimal dose finding and alternative modes of application to enhance local IVIG concentrations at the site of tissue damage.
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Affiliation(s)
- Meike Winter
- Department of Neurology, Medical Faculty Heinrich-Heine-University Duesseldorf Moorenstr. 5 D-40225 Duesseldorf Germany
| | - Christine Baksmeier
- Department of Neurology, Medical Faculty Heinrich-Heine-University Duesseldorf Moorenstr. 5 D-40225 Duesseldorf Germany
| | - Julia Steckel
- Department of Neurology, Medical Faculty Heinrich-Heine-University Duesseldorf Moorenstr. 5 D-40225 Duesseldorf Germany
| | - Sumanta Barman
- Department of Neurology, Medical Faculty Heinrich-Heine-University Duesseldorf Moorenstr. 5 D-40225 Duesseldorf Germany
| | - Manish Malviya
- Department of Neurology, Medical Faculty Heinrich-Heine-University Duesseldorf Moorenstr. 5D-40225 Duesseldorf Germany; Present address: CPTP, Centre Physiopathologie de Toulouse-Purpan INSERM U1043 - CNRS UMR 5282-Université Toulouse III Toulouse France
| | - Melanie Harrer-Kuster
- University of Zuerich, Clinical Neuroimmunology Zuerich Switzerland; Present address: Abb Vie AG Baar Switzerland
| | - Hans-Peter Hartung
- Department of Neurology, Medical Faculty Heinrich-Heine-University Duesseldorf Moorenstr. 5 D-40225 Duesseldorf Germany
| | - Norbert Goebels
- Department of Neurology, Medical Faculty Heinrich-Heine-University Duesseldorf Moorenstr. 5 D-40225 Duesseldorf Germany
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