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Emmanouilidou E, Kosmara D, Papadaki E, Mastorodemos V, Constantoulakis P, Repa A, Christopoulou G, Kalpadakis C, Avgoustidis N, Thomas K, Boumpas D, Sidiropoulos P, Bertsias G. Progressive Multifocal Leukoencephalopathy in Systemic Lupus Erythematosus: A Consequence of Patient-Intrinsic or -Extrinsic Factors? J Clin Med 2023; 12:6945. [PMID: 37959410 PMCID: PMC10647998 DOI: 10.3390/jcm12216945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Revised: 11/03/2023] [Accepted: 11/04/2023] [Indexed: 11/15/2023] Open
Abstract
Progressive multifocal leukoencephalopathy (PML) is a severe demyelinating disease of the central nervous system (CNS) caused by reactivation of the polyomavirus JC (JCV) typically in immunocompromised individuals. The risk of PML among rheumatic diseases may be higher for systemic lupus erythematosus (SLE), without, however, a clear association with the type and intensity of background therapy. We present the development and outcome of PML in a 32-year-old female lupus patient under mild immunosuppressive treatment, yet with marked B-cell lymphopenia in the peripheral blood and bone marrow (<1% of total lymphocytes). Despite treatment with the immune checkpoint inhibitor pembrolizumab, the patient showed progressive neurological and brain imaging deterioration and eventually died 15 months after PML diagnosis. To unveil possible underlying genetic liabilities, whole exome sequencing was performed which identified deleterious variants in GATA2 and CDH7 genes, which both have been linked to defective T- and/or B-lymphocyte production. These findings reiterate the possible role of disease-/patient-intrinsic factors, rather than that of drug-induced immunosuppression, in driving immune dysregulation and susceptibility to PML in certain patients with SLE.
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Affiliation(s)
- Evgenia Emmanouilidou
- Rheumatology and Clinical Immunology, University Hospital of Heraklion and University of Crete Medical School, 71500 Heraklion, Greece; (E.E.); (D.K.)
| | - Despoina Kosmara
- Rheumatology and Clinical Immunology, University Hospital of Heraklion and University of Crete Medical School, 71500 Heraklion, Greece; (E.E.); (D.K.)
- Institute of Molecular Biology and Biotechnology, Foundation for Research and Technology—Hellas, 71110 Heraklion, Greece
| | - Efrosini Papadaki
- Department of Radiology, University Hospital of Heraklion and University of Crete Medical School, 71500 Heraklion, Greece
- Computational Bio-Medicine Laboratory, Institute of Computer Science, Foundation for Research and Technology—Hellas, 71110 Heraklion, Greece
| | | | | | - Argyro Repa
- Rheumatology and Clinical Immunology, University Hospital of Heraklion and University of Crete Medical School, 71500 Heraklion, Greece; (E.E.); (D.K.)
| | | | - Christina Kalpadakis
- Department of Laboratory Hematology, University Hospital of Heraklion and University of Crete Medical School, 71500 Heraklion, Greece
| | - Nestor Avgoustidis
- Rheumatology and Clinical Immunology, University Hospital of Heraklion and University of Crete Medical School, 71500 Heraklion, Greece; (E.E.); (D.K.)
| | - Konstantinos Thomas
- 4th Department of Internal Medicine, National and Kapodistrian University of Athens School of Medicine, Attikon University General Hospital, 12462 Chaidari, Greece
| | - Dimitrios Boumpas
- 4th Department of Internal Medicine, National and Kapodistrian University of Athens School of Medicine, Attikon University General Hospital, 12462 Chaidari, Greece
- Laboratory of Autoimmunity and Inflammation, Center of Clinical, Experimental Surgery and Translational Research, Biomedical Research Foundation Academy of Athens, 11527 Athens, Greece
| | - Prodromos Sidiropoulos
- Rheumatology and Clinical Immunology, University Hospital of Heraklion and University of Crete Medical School, 71500 Heraklion, Greece; (E.E.); (D.K.)
- Institute of Molecular Biology and Biotechnology, Foundation for Research and Technology—Hellas, 71110 Heraklion, Greece
| | - George Bertsias
- Rheumatology and Clinical Immunology, University Hospital of Heraklion and University of Crete Medical School, 71500 Heraklion, Greece; (E.E.); (D.K.)
- Institute of Molecular Biology and Biotechnology, Foundation for Research and Technology—Hellas, 71110 Heraklion, Greece
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Akimoto T, Hara M, Hirose S, Nakamichi K, Nakajima H. Cerebellar Progressive Multifocal Leukoencephalopathy Mimicking Anti-Yo-Antibody-Associated Rapidly Progressive Cerebellar Syndrome. Neurol Int 2023; 15:917-925. [PMID: 37606392 PMCID: PMC10443244 DOI: 10.3390/neurolint15030059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 07/15/2023] [Accepted: 07/24/2023] [Indexed: 08/23/2023] Open
Abstract
A 58-year-old woman with a history of systemic lupus erythematosus (SLE) who was taking prednisolone and mycophenolate mofetil presented with gait disturbances that progressively worsened over a period of 3 months. Her blood test and cerebrospinal fluid (CSF) examination results did not indicate active SLE. Initial brain magnetic resonance imaging (MRI) revealed a small spotty lesion in the left cerebellar peduncle. The clinical course was consistent with rapidly progressive cerebellar syndrome (RPCS), which sometimes involves neuronal antibodies. The line blot assay detected anti-Yo antibodies, but no malignancy was found. Immunohistological techniques using rat brain sections yielded a negative result for anti-Yo antibodies. The second MRI revealed a focal lesion and surrounding spotty lesion in the left cerebellar peduncle, which was consistent with the punctate pattern observed in progressive multifocal leukoencephalopathy (PML). The CSF JCV-DNA test indicated the presence of cerebellar PML. Immunosuppressants were reduced, and mefloquine and mirtazapine were initiated. After approximately 2 years and 1 month, the CSF JCV-DNA results became negative. Cerebellar PML may exhibit a clinical course that is consistent with RPCS. The punctate pattern should be recognized as an early manifestation of PML. The CSF JCV-DNA copy number may serve as a useful indicator of PML stabilization.
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Affiliation(s)
- Takayoshi Akimoto
- Division of Neurology, Department of Medicine, Nihon University School of Medicine, Tokyo 173-8610, Japan
| | - Makoto Hara
- Division of Neurology, Department of Medicine, Nihon University School of Medicine, Tokyo 173-8610, Japan
| | - Satoshi Hirose
- Division of Neurology, Department of Medicine, Nihon University School of Medicine, Tokyo 173-8610, Japan
| | - Kazuo Nakamichi
- Department of Virology 1, National Institute of Infectious Diseases, Tokyo 162-8640, Japan
| | - Hideto Nakajima
- Division of Neurology, Department of Medicine, Nihon University School of Medicine, Tokyo 173-8610, Japan
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Rosenkranz SC, Häußler V, Kolster M, Willing A, Matschke J, Röcken C, Stürner K, Leypoldt F, Tolosa E, Friese MA. Treating sarcoidosis-associated progressive multifocal leukoencephalopathy with infliximab. Brain Commun 2022; 4:fcab292. [PMID: 34993476 PMCID: PMC8727989 DOI: 10.1093/braincomms/fcab292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 10/12/2021] [Accepted: 11/09/2021] [Indexed: 11/27/2022] Open
Abstract
Although most of the progressive multifocal leukoencephalopathy cases in sarcoidosis patients are explained by the treatment with immunosuppressive drugs, it is also reported in treatment-naive sarcoidosis patients, which implies a general predisposition of sarcoidosis patients for progressive multifocal leukoencephalopathy. Indeed, it was shown that active sarcoidosis patients have increased regulatory T cell frequencies which could lead to a subsequent systemic immunosuppression. However, if sarcoidosis with systemic changes of T cell subsets frequencies constitute a risk factor for the development of progressive multifocal leukoencephalopathy, which could then be counteracted by sarcoidosis treatment, is not known. In this cohort study, we included, characterized and followed-up six patients with bioptically confirmed definite progressive multifocal leukoencephalopathy and definite or probable sarcoidosis presenting between April 2013 and January 2019, four of them had no immunosuppressive therapy at the time of developing first progressive multifocal leukoencephalopathy symptoms. Analysis of immune cell subsets in these patients revealed significant imbalances of CD4+ T cell and regulatory T cell frequencies. Due to the progression of progressive multifocal leukoencephalopathy in four patients, we decided to treat sarcoidosis anticipating normalization of immune cell subset frequencies and thereby improving progressive multifocal leukoencephalopathy. Notably, by treatment with infliximab, an antibody directed against tumour necrosis factor-α, three patients continuously improved clinically, JC virus was no longer detectable in the cerebrospinal fluid and regulatory T cell frequencies decreased. One patient was initially misdiagnosed as neurosarcoidosis and died 9 weeks after treatment initiation due to aspiration pneumonia. Our study provides insight that sarcoidosis can lead to changes in T cell subset frequencies, which predisposes to progressive multifocal leukoencephalopathy. Although immunosuppressive drugs should be avoided in progressive multifocal leukoencephalopathy, paradoxically in patients with sarcoidosis treatment with the immunosuppressive infliximab might restore normal T cell distribution and thereby halt progressive multifocal leukoencephalopathy progression.
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Affiliation(s)
- Sina C Rosenkranz
- Institute of Neuroimmunology and Multiple Sclerosis, University Medical Center Hamburg-Eppendorf, Germany.,Department of Neurology, University Medical Center Hamburg-Eppendorf, Germany
| | - Vivien Häußler
- Institute of Neuroimmunology and Multiple Sclerosis, University Medical Center Hamburg-Eppendorf, Germany.,Department of Neurology, University Medical Center Hamburg-Eppendorf, Germany
| | - Manuela Kolster
- Department of Immunology, University Medical Center Hamburg-Eppendorf, Germany
| | - Anne Willing
- Institute of Neuroimmunology and Multiple Sclerosis, University Medical Center Hamburg-Eppendorf, Germany
| | - Jakob Matschke
- Institute of Neuropathology, University Medical Center Hamburg-Eppendorf, Germany
| | - Christoph Röcken
- Institute of Pathology, University Medical Center Schleswig-Holstein, Kiel, Germany
| | - Klarissa Stürner
- Neuroimmunology, Institute of Clinical Chemistry, University Medical Center Schleswig-Holstein, Kiel, Germany.,Department of Neurology, University Medical Center Schleswig-Holstein and Kiel University, Kiel, Germany
| | - Frank Leypoldt
- Neuroimmunology, Institute of Clinical Chemistry, University Medical Center Schleswig-Holstein, Kiel, Germany.,Department of Neurology, University Medical Center Schleswig-Holstein and Kiel University, Kiel, Germany
| | - Eva Tolosa
- Department of Immunology, University Medical Center Hamburg-Eppendorf, Germany
| | - Manuel A Friese
- Institute of Neuroimmunology and Multiple Sclerosis, University Medical Center Hamburg-Eppendorf, Germany
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Kapoor T, Mahadeshwar P, Hui-Yuen J, Quinnies K, Tatonetti N, Gartshteyn Y, Guo C, Geraldino-Pardilla L, Askanase AD. Prevalence of progressive multifocal leukoencephalopathy (PML) in adults and children with systemic lupus erythematosus. Lupus Sci Med 2021; 7:7/1/e000388. [PMID: 32513809 PMCID: PMC7282388 DOI: 10.1136/lupus-2020-000388] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Revised: 05/06/2020] [Accepted: 05/20/2020] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To define the risk of progressive multifocal leukoencephalopathy (PML) in SLE. METHODS This is a retrospective observational study to evaluate PML cases in patients with SLE admitted to two large academic hospitals. Using electronic medical record (EMR) data, International Classification of Diseases (ICD) codes identified PML cases among patients with SLE, rheumatoid arthritis (RA) (controls), had renal transplant and with HIV. Medication exposure was reviewed. RESULTS A total of 5409 Columbia University Medical Center (CUMC) patients and 2046 Northwell Health patients were identified using one ICD code for SLE. Of 7455 patients, three had an ICD code for PML. On EMR review, however, PML was substantiated in only one fatal SLE case with significant immunosuppressant use and severe lymphopenia (<0.5 cells x 109/L); one patient was evaluated for PML but cerebrospinal fluid (CSF) was negative for JC virus and improved with treatment of central nervous system (CNS) lupus. EMR data were very limited for the third patient and diagnosis could not be confirmed. None of the 13 342 patients with RA ICD codes had PML. Of the 5409 patients with an SLE ICD code at CUMC, 212 also had a renal transplant ICD code, and 83 had concomitant HIV/AIDS. Based on inpatient pharmacy records of 5409 hospitalised patients at CUMC, 59.2% were treated with steroids, and 16.09% with immunosuppressants (7.76% mycophenolate, 3.42% cyclophosphamide, 2.88% azathioprine and 2.03% rituximab). No patients with paediatric SLE (pSLE) (n=538) had PML. The combined prevalence of PML in hospitalised patients with SLE at the two hospitals was 13-27/100 000 patients. CONCLUSION Among 7455 adult patients with SLE ICD codes, there were two PML cases, with only one confirmed case associated with severe lymphopenia and immunosuppressants, corresponding to a prevalence of 13-27 per 100 000 patients. No PML cases in pSLE were found. A high index of suspicion in patients with SLE and CNS manifestations is required for the prompt diagnosis of PML.
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Affiliation(s)
- Teja Kapoor
- Rheumatology, Columbia University Medical Center, New York, New York, USA
| | - Pooja Mahadeshwar
- Internal Medicine, Mount Sinai Beth Israel Hospital, New York, New York, USA
| | - Joyce Hui-Yuen
- Pediatric Rheumatology, Northwell Health, Lake Success, New York, USA
| | - Kayla Quinnies
- Bioinformatics, Columbia University Medical Center, New York, New York, USA
| | - Nicholas Tatonetti
- Bioinformatics, Columbia University Medical Center, New York, New York, USA
| | | | - Cathy Guo
- Rheumatology, Columbia University Medical Center, New York, New York, USA
| | | | - Anca D Askanase
- Rheumatology, Columbia University Medical Center, New York, New York, USA
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Sakuraba M, Watanabe S, Nishiyama Y, Takahashi K, Nakamichi K, Suzuki M, Nawata T, Komai K, Gono T, Takeno M, Suzuki T, Kimura K, Kuwana M. Infratentorial onset of progressive multifocal leukoencephalopathy in a patient with systematic lupus erythematosus complicated with lymphoma: a case report. Mod Rheumatol Case Rep 2021; 5:272-277. [PMID: 33719867 DOI: 10.1080/24725625.2021.1899763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Progressive multifocal leukoencephalopathy (PML) is a rare opportunistic infection of the central nervous system caused by reactivation of JC virus (JCV). Typical PML shows confluent, bilateral but asymmetric, subcortical lesions in the supratentorial white matter on magnetic resonance imaging (MRI). We report here a 50-year-old woman with systemic lupus erythematosus complicated with lymphoma who developed PML with atypical brain MRI findings limited to the infratentorial area at presentation. She presented with numbness on the right side of the face, including her tongue, clumsiness of the right hand, and gait disturbance, after completion of remission induction therapy for lymphoma, including rituximab. Brain MRI demonstrated a solitary lesion limited to the cerebellum and brainstem, but a definitive diagnosis could not be made from cerebrospinal fluid study or tentative histologic evaluation of brain biopsy specimens. Despite methylprednisolone pulse therapy, her neurological deficits progressively worsened. One month later, in-depth analysis of her cerebrospinal fluid and brain biopsy specimens confirmed the presence of JCV. Eventually, the localised unilateral crescent-shaped cerebellar lesions on MRI expanded to the contralateral cerebellum, middle cerebellar hemisphere, pons, and midbrain and finally developed multifocal invasion into the white matter of the cerebral hemispheres. Our case suggests that PML could first present with a solitary infratentorial lesion in immunocompromised patients.
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Affiliation(s)
- Mita Sakuraba
- Department of Allergy and Rheumatology, Nippon Medical School Graduate School of Medicine, Tokyo, Japan
| | - Shinji Watanabe
- Department of Allergy and Rheumatology, Nippon Medical School Graduate School of Medicine, Tokyo, Japan
| | - Yasuhiro Nishiyama
- Department of Neurological Science, Nippon Medical School Graduate School of Medicine, Tokyo, Japan
| | - Kenta Takahashi
- Department of Pathology, National Institute of Infectious Diseases, Tokyo, Japan
| | - Kazuo Nakamichi
- Department of Virology 1, National Institute of Infectious Diseases, Tokyo, Japan
| | - Mikito Suzuki
- Department of Allergy and Rheumatology, Nippon Medical School Graduate School of Medicine, Tokyo, Japan
| | - Takashi Nawata
- Department of Allergy and Rheumatology, Nippon Medical School Graduate School of Medicine, Tokyo, Japan
| | - Kota Komai
- Department of Neurological Science, Nippon Medical School Graduate School of Medicine, Tokyo, Japan
| | - Takahisa Gono
- Department of Allergy and Rheumatology, Nippon Medical School Graduate School of Medicine, Tokyo, Japan
| | - Mitsuhiro Takeno
- Department of Allergy and Rheumatology, Nippon Medical School Graduate School of Medicine, Tokyo, Japan
| | - Tadaki Suzuki
- Department of Pathology, National Institute of Infectious Diseases, Tokyo, Japan
| | - Kazumi Kimura
- Department of Neurological Science, Nippon Medical School Graduate School of Medicine, Tokyo, Japan
| | - Masataka Kuwana
- Department of Allergy and Rheumatology, Nippon Medical School Graduate School of Medicine, Tokyo, Japan
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Abstract
The risk of JC polyomavirus encephalopathy varies among biologic classes and among agents within the same class. Of currently used biologics, the highest risk is seen with natalizumab followed by rituximab. Multiple other agents have also been implicated. Drug-specific causality is difficult to establish because many patients receive multiple immunomodulatory medications concomitantly or sequentially, and have other immunocompromising factors related to their underlying disease. As use of biologic therapies continues to expand, further research is needed into pathogenesis, treatment, and prevention of JC polyomavirus encephalopathy such that risk for its development is better understood and mitigated, if not eliminated altogether.
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7
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Progressive multifocal leukoencephalopathy in a patient with systemic lupus erythematosus: Could CD4+ lymphopenia be the main risk factor? NEUROLOGÍA (ENGLISH EDITION) 2020. [DOI: 10.1016/j.nrleng.2019.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Simopoulou T, Tsimourtou V, Katsiari C, Vlychou M, Bogdanos DP, Sakkas LI. Progressive multifocal leukoencephalopathy in a patient with systemic sclerosis treated with methotrexate: A case report and literature review. JOURNAL OF SCLERODERMA AND RELATED DISORDERS 2020; 5:NP1-NP6. [PMID: 35382519 PMCID: PMC8922622 DOI: 10.1177/2397198320926883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Accepted: 04/14/2020] [Indexed: 08/10/2023]
Abstract
Reactivation of viruses occurs in autoimmune disorders in the setting of certain immunosuppressive drugs. We describe a 54-year-old female with systemic sclerosis and extensive cutaneous calcinosis who had been treated with methotrexate for 18 months and presented with headache and neurological deficits. She was diagnosed with progressive multifocal leukoencephalopathy, a rare disease caused by JC virus. Methotrexate was discontinued and mirtazapine plus mefloquine were added. The patient showed a slow recovery and five years later she had complete resolution of progressive multifocal leukoencephalopathy clinical manifestations. Calcinosis had a limited response to various agents and severely affected daily activities of the patient. This case report, highlights the importance of clinical suspicion for progressive multifocal leukoencephalopathy in every patient with immune-mediated disease, even on weak immunosuppressant, who presents with central nervous system manifestations and also the unmet therapeutic need for systemic sclerosis-associated calcinosis.
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Affiliation(s)
- Theodora Simopoulou
- Department of Rheumatology and Clinical Immunology, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Vana Tsimourtou
- Department of Neurology, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Christina Katsiari
- Department of Rheumatology and Clinical Immunology, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Marianna Vlychou
- Department of Radiology, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Dimitrios P Bogdanos
- Department of Rheumatology and Clinical Immunology, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Lazaros I Sakkas
- Department of Rheumatology and Clinical Immunology, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
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Rodríguez S, Muñoz A, Bustos RH, Jaimes D. Pharmacovigilance of Biopharmaceuticals in Rheumatic Diseases, Adverse Events, Evolution, and Perspective: An Overview. Biomedicines 2020; 8:E303. [PMID: 32842558 PMCID: PMC7555940 DOI: 10.3390/biomedicines8090303] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 08/07/2020] [Accepted: 08/17/2020] [Indexed: 02/07/2023] Open
Abstract
Since we have gained an understanding of the immunological pathophysiology of rheumatic diseases such as rheumatoid arthritis and systemic lupus erythematosus, treatment based on biological drugs has become a fundamental axis. These therapies are oriented towards the regulation of cytokines such as tumour necrosis factor-alpha (TNF-α), interleukin (IL)-6, IL-1, and the modulation of cell-mediated immunity (B cells and T cells) by anti CD20 or anti CTAL-4 agents, and can increase the risk of associated infections or adverse events (AE). In this context, the entry of biotherapeutics represented a challenge for pharmacovigilance, risk management and approval by the main global regulatory agencies regarding biosimilars, where efficacy and safety are based on comparability exercises without being an exact copy in terms of molecular structure. The objective of this review is divided into three fundamental aspects: (i) to illustrate the evolution and focus of pharmacovigilance at the biopharmaceutical level, (ii) to describe the different approved recommendations of biopharmaceuticals (biological and biosimilars) and their use in rheumatic diseases (RDs) such as rheumatoid arthritis (RA), juvenile idiopathic arthritis (JIA), psoriatic arthritis (PsA), ankylosing spondylitis (AS), systemic lupus erythematosus (SLE) and other less frequent RD like cryopyrin-associated autoinflammatory syndromes (CAPS), and (iii) to identify the main AE reported in the post-marketing phase of RD biopharmaceuticals.
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Affiliation(s)
| | | | - Rosa-Helena Bustos
- Evidence-Based Therapeutics Group, Clinical Pharmacology, Universidad de La Sabana, Chía 140013, Colombia; (S.R.); (A.M.); (D.J.)
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Casado L, Hervás C, Quintas S, Vivancos J. [Progressive multifocal leukoencephalopathy in a patient with systemic lupus erythematosus: Could CD4+ lymphopenia be the main risk factor?]. Neurologia 2020; 35:667-669. [PMID: 31892429 DOI: 10.1016/j.nrl.2019.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Revised: 08/03/2019] [Accepted: 11/04/2019] [Indexed: 10/25/2022] Open
Affiliation(s)
- L Casado
- Servicio de Neurología, Hospital Universitario de la Princesa, Madrid, España
| | - C Hervás
- Servicio de Neurología, Hospital Universitario de la Princesa, Madrid, España
| | - S Quintas
- Servicio de Neurología, Hospital Universitario de la Princesa, Madrid, España.
| | - J Vivancos
- Servicio de Neurología, Hospital Universitario de la Princesa, Madrid, España
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Kartau M, Sipilä JOT, Auvinen E, Palomäki M, Verkkoniemi-Ahola A. Progressive Multifocal Leukoencephalopathy: Current Insights. Degener Neurol Neuromuscul Dis 2019; 9:109-121. [PMID: 31819703 PMCID: PMC6896915 DOI: 10.2147/dnnd.s203405] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Accepted: 11/14/2019] [Indexed: 12/20/2022] Open
Abstract
Cases of PML should be evaluated according to predisposing factors, as these subgroups differ by incidence rate, clinical course, and prognosis. The three most significant groups at risk of PML are patients with hematological malignancies mostly previously treated with immunotherapies but also untreated, patients with HIV infection, and patients using monoclonal antibody (mAb) treatments. Epidemiological data is scarce and partly conflicting, but the distribution of the subgroups appears to have changed. While there is no specific anti-JCPyV treatment, restoration of the immune function is the most effective approach to PML treatment. Research is warranted to determine whether immune checkpoint inhibitors could benefit certain PML subgroups. There are no systematic national or international records of PML diagnoses or a risk stratification algorithm, except for MS patients receiving natalizumab (NTZ). These are needed to improve PML risk assessment and to tailor better prevention strategies.
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Affiliation(s)
- Marge Kartau
- Clinical Neurosciences, Neurology, Helsinki University Hospital and Helsinki University, Helsinki, Finland
| | - Jussi OT Sipilä
- Department of Neurology, Siun Sote, North Carelia Central Hospital, Joensuu, Finland
- Division of Clinical Neurosciences, Turku University Hospital, Turku, Finland
- Clinical Neurosciences, University of Turku, Turku, Finland
| | - Eeva Auvinen
- Department of Virology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Maarit Palomäki
- Neuroradiology, HUS Medical Imaging Center, Helsinki, Finland
| | - Auli Verkkoniemi-Ahola
- Clinical Neurosciences, Neurology, Helsinki University Hospital and Helsinki University, Helsinki, Finland
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12
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Qin L, Qiu Z, Hsieh E, Geng T, Zhao J, Zeng X, Wan L, Xie J, Ramendra R, Routy JP, Li T. Association between lymphocyte subsets and cytomegalovirus infection status among patients with systemic lupus erythematosus: A pilot study. Medicine (Baltimore) 2019; 98:e16997. [PMID: 31574798 PMCID: PMC6775378 DOI: 10.1097/md.0000000000016997] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Revised: 06/26/2019] [Accepted: 08/06/2019] [Indexed: 11/04/2022] Open
Abstract
This study aimed to determine the association between different lymphocyte subsets and cytomegalovirus (CMV) infection status in patients with systemic lupus erythematosus (SLE). We performed a retrospective study among SLE patients with CMV infection and collected patient socio-demographic and clinical characteristics, as well as their recorded circulating lymphocyte subsets. Univariate and multivariable logistic regression analyses examined the relationship between CMV infection status and lymphocyte subset counts. We included 125 hospitalized patients with SLE, consisting of 88 with documented CMV infection and 37 without any evidence of CMV or other infections. Among the 88 CMV-infected patients, 65 (73.8%) patients developed CMV disease and 23 (26.2%) presented as CMV viremia. Compared to uninfected patients (1520 ± 101 cells/μL), lymphocytes remained stable among those with CMV viremia (1305 ± 272 cells/μL, P = .995). However, compared to their uninfected counterparts, there was a marked decrease in lymphocytes among patients with CMV disease (680 ± 513 cells/μL, P < .001). Analysis of lymphocyte subsets via flow cytometry showed that CD4+ T cell, CD8+ T cell, and natural killer cell counts were lower among those with CMV disease compared to those with CMV viremia and those without infection. Further, multivariable analysis showed that total lymphocyte (odds ratio [OR] 0.999, 95% confidence interval [CI] 0.998-1.000, P = .007) and CD4+ T cell counts (OR 0.99, 95% CI 0.992-0.998, P = .003) were negatively associated with CMV disease. Our findings support a potential inverse relationship between lymphopenia, specifically CD4+ T-cell lymphopenia, and CMV disease among hospitalized SLE patients.
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Affiliation(s)
- Ling Qin
- Department of Infectious Diseases, Peking Union Medical College Hospital
- Center for AIDS Research
| | - Zhifeng Qiu
- Department of Infectious Diseases, Peking Union Medical College Hospital
- Center for AIDS Research
- Clinical Immunology Center, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Evelyn Hsieh
- Department of Infectious Diseases, Peking Union Medical College Hospital
- Section of Rheumatology, Allergy & Immunology, Department of Internal Medicine, Yale School of Medicine, New Haven, CT
| | - Taoran Geng
- Department of Infectious Diseases, Peking Union Medical College Hospital
- Center for AIDS Research
| | | | | | - Lu Wan
- Department of Internal Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Jing Xie
- Department of Infectious Diseases, Peking Union Medical College Hospital
- Center for AIDS Research
- Clinical Immunology Center, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Rayoun Ramendra
- Department of Microbiology and Immunology, McGill University
| | - Jean Pierre Routy
- Chronic Viral Illnesses Service and Division of Hematology, McGill University Health Centre, Montreal, QC, Canada
| | - Taisheng Li
- Department of Infectious Diseases, Peking Union Medical College Hospital
- Center for AIDS Research
- Clinical Immunology Center, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
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13
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Ishii J, Shishido-Hara Y, Kawamoto M, Fujiwara S, Imai Y, Nakamichi K, Kohara N. A Punctate Magnetic Resonance Imaging Pattern in a Patient with Systemic Lupus Erythematosus Is an Early Sign of Progressive Multifocal Leukoencephalopathy: A Clinicopathological Study. Intern Med 2018; 57:2727-2734. [PMID: 29709947 PMCID: PMC6191581 DOI: 10.2169/internalmedicine.0696-17] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
A 37-year-old woman with systemic lupus erythematosus presented with gait disturbance and cognitive dysfunction. Brain magnetic resonance imaging (MRI) revealed small, punctate, T2-/fluid-attenuated inversion recovery-hyperintense and T1-hypointense lesions without gadolinium enhancement, which is atypical for progressive multifocal leukoencephalopathy (PML). On a pathological examination of biopsied brain tissues, JC virus-infected cells were hardly detected via immunohistochemistry but were certainly detected via in situ hybridization, conclusively verifying the PML diagnosis. After tapering off the immunosuppressant and mefloquine administration, the MRI findings revealed gradual improvement, and she has been stable for over 18 months. A punctate MRI pattern is not specific to natalizumab-associated PML but may be a ubiquitous early sign useful for the early diagnosis of PML.
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Affiliation(s)
- Junko Ishii
- Department of Neurology, Kobe City Medical Center General Hospital, Japan
| | | | - Michi Kawamoto
- Department of Neurology, Kobe City Medical Center General Hospital, Japan
| | - Satoru Fujiwara
- Department of Neurology, Kobe City Medical Center General Hospital, Japan
| | - Yukihiro Imai
- Department of Pathology, Kobe City Medical Center General Hospital, Japan
| | - Kazuo Nakamichi
- Department of Virology 1, National Institute of Infectious Diseases, Japan
| | - Nobuo Kohara
- Department of Neurology, Kobe City Medical Center General Hospital, Japan
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Lupus érythémateux systémique et lymphopénie : aspects cliniques et physiopathologiques. Rev Med Interne 2017; 38:603-613. [DOI: 10.1016/j.revmed.2017.01.005] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2016] [Revised: 01/07/2017] [Accepted: 01/11/2017] [Indexed: 12/20/2022]
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15
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Colin O, Favrelière S, Quillet A, Neau JP, Houeto JL, Lafay-Chebassier C, Pérault-Pochat MC. Drug-induced progressive multifocal leukoencephalopathy: a case/noncase study in the French pharmacovigilance database. Fundam Clin Pharmacol 2016; 31:237-244. [PMID: 27736027 DOI: 10.1111/fcp.12247] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2016] [Revised: 10/04/2016] [Accepted: 10/06/2016] [Indexed: 12/13/2022]
Abstract
Progressive multifocal leukoencephalopathy (PML) is an often fatal demyelinating disease of the central nervous system. As effective treatment is unavailable, identification of all drugs that could be associated with PML is essential. The objective of this study was to investigate the putative association of reports of PML and drugs. We used the case/noncase method in the French PharmacoVigilance database (FPVD). Cases were reports of PML in the FPVD between January 2008 and December 2015. Noncases were all other reports during the same period. To assess the association between PML and drug intake, we calculated an adverse drug report odds ratio (ROR) with its 95% confidence interval. We have studied the delay of onset of PML for each drug concerned. Among the 101 cases of PML, 39 drugs were mentioned as suspect. The main therapeutic classes suspected with significant ROR were antineoplastic agents (n = 85), immunosuppressants (n = 67), and corticosteroids. A latent interval from the time of drug initiation to the development of PML is established: the median time to onset was 365 days (123-1095 days). The onset of PML is highly variable and differs among drug classes [from 1 to 96 months (IQR: 39.0-126)]. An association between PML and some immunosuppressant drugs was found as expected, but also with antineoplastic agents and glucocorticoids. An important delay of PML onset after stopping treatment is suspected and should alert prescribers. Prescribers but also patients should be informed about the potential associations with all these drugs. Monitoring could be necessary for many drugs to early detect PML.
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Affiliation(s)
- Olivier Colin
- Service de Pharmacologie Clinique et Vigilances, CHU de Poitiers, 2 rue de la milétrie, 86021, Poitiers, France.,Service de Neurologie, CHU de Poitiers, 2 rue de la milétrie, 86021, Poitiers, France
| | - Sylvie Favrelière
- Service de Pharmacologie Clinique et Vigilances, CHU de Poitiers, 2 rue de la milétrie, 86021, Poitiers, France
| | - Alexandre Quillet
- Service de Pharmacologie Clinique et Vigilances, CHU de Poitiers, 2 rue de la milétrie, 86021, Poitiers, France
| | - Jean-Philippe Neau
- Service de Neurologie, CHU de Poitiers, 2 rue de la milétrie, 86021, Poitiers, France
| | - Jean-Luc Houeto
- Service de Neurologie, CHU de Poitiers, 2 rue de la milétrie, 86021, Poitiers, France
| | - Claire Lafay-Chebassier
- Service de Pharmacologie Clinique et Vigilances, CHU de Poitiers, 2 rue de la milétrie, 86021, Poitiers, France.,INSERM U1084 Experimental and Clinical Neurosciences Laboratory, University of Poitiers, Poitiers, 1 rue Georges Bonnet, BP 633 TSA 51106 86073 POITIERS cedex9, France
| | - Marie-Christine Pérault-Pochat
- Service de Pharmacologie Clinique et Vigilances, CHU de Poitiers, 2 rue de la milétrie, 86021, Poitiers, France.,INSERM U1084 Experimental and Clinical Neurosciences Laboratory, University of Poitiers, Poitiers, 1 rue Georges Bonnet, BP 633 TSA 51106 86073 POITIERS cedex9, France
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16
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Saylor D, Venkatesan A. Progressive Multifocal Leukoencephalopathy in HIV-Uninfected Individuals. Curr Infect Dis Rep 2016; 18:33. [PMID: 27686675 DOI: 10.1007/s11908-016-0543-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Progressive multifocal leukoencephalopathy (PML) is a demyelinating disease of the central nervous system (CNS) caused by the human neurotropic polyomavirus JC (JCV). The disease occurs virtually exclusively in immunocompromised individuals, and, prior to the introduction of antiretroviral therapy, was seen most commonly in the setting of HIV/AIDS. More recently, however, the incidence of PML in HIV-uninfected persons has increased with broader use of immunosuppressive and immunomodulatory medications utilized in a variety of systemic and neurologic autoimmune disorders. In this review, we discuss the epidemiology and clinical characteristics of PML in HIV-uninfected individuals, as well as diagnostic modalities and the limited treatment options. Moreover, we describe recent findings regarding the neuropathogenesis of PML, with specific focus on the unique association between PML and natalizumab, a monoclonal antibody that prevents trafficking of activated leukocytes into the CNS that is used for the treatment of multiple sclerosis.
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Affiliation(s)
- Deanna Saylor
- Division of Neuroimmunology and Neuro-Infectious Diseases, Department of Neurology, The Johns Hopkins University School of Medicine, Meyer 6-113, 600 N. Wolfe Street, Baltimore, MD, 21287, USA
| | - Arun Venkatesan
- Division of Neuroimmunology and Neuro-Infectious Diseases, Department of Neurology, The Johns Hopkins University School of Medicine, Meyer 6-113, 600 N. Wolfe Street, Baltimore, MD, 21287, USA.
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17
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Melis M, Biagi C, Småbrekke L, Nonino F, Buccellato E, Donati M, Vaccheri A, Motola D. Drug-Induced Progressive Multifocal Leukoencephalopathy: A Comprehensive Analysis of the WHO Adverse Drug Reaction Database. CNS Drugs 2016; 29:879-91. [PMID: 26507833 DOI: 10.1007/s40263-015-0286-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To identify safety signals concerning the association between the use of various drug classes and the onset of progressive multifocal leukoencephalopathy (PML). METHODS All reports containing suspected or interacting PML-related or leukoencephalopathy-related drugs, held in the World Health Organization spontaneous individual case safety reports database as at 1 September 2014, were retrieved. We identified safety signals by analysing the drug-reaction pairs, using the reporting odds ratio as a measure of disproportionality. A safety signal was defined if a drug was reported more than twice in PML cases with a reporting odds ratio >2 and a lower 95 % confidence limit >1. RESULTS We retrieved 2452 reports associated with PML (N = 1612), leukoencephalopathy (N = 835) or both (N = 5), corresponding to 343 different drugs. PML was reported similarly in male and female adults (18-64 years), and almost 30 % of the cases had a fatal outcome. The most frequent Anatomical Therapeutic Chemical (ATC) classification groups concerned antineoplastic agents (23.5 %), antivirals for systemic use (10.1 %) or immunostimulants (4.6 %). Significant disproportionality was found for 88 drugs in the overall analysis (of cases with 'progressive multifocal leukoencephalopathy' or 'leukoencephalopathy' as the Preferred Term), and a new safety signal was identified for 59 active substances (e.g. muromonab-CD3, basiliximab and antithymocyte Ig), as no information on a possible risk of PML was acknowledged in their Summary of Product Characteristics documents. Some safety signals were confirmed also after sensitivity analysis adjustment for several confounding factors (underlying diseases and considering only 'progressive multifocal leukoencephalopathy' as the Preferred Term). CONCLUSION We report a possible association between several drugs and PML that has not been previously described. In addition, we have confirmed previously reported signals in a number of drugs. We highlight the need for follow-up by regulatory agencies.
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Affiliation(s)
- Mauro Melis
- Unit of Pharmacology, Department of Medical and Surgical Sciences, University of Bologna, via Irnerio 48, 40126, Bologna, Italy
| | - Chiara Biagi
- Unit of Pharmacology, Department of Medical and Surgical Sciences, University of Bologna, via Irnerio 48, 40126, Bologna, Italy
| | - Lars Småbrekke
- Department of Pharmacy, UiT-The Arctic University of Norway, Tromsø, Norway
| | - Francesco Nonino
- Medicines and Medical Devices Area - Health and Social Policies Directorate, Emilia-Romagna Region, via Aldo Moro 21, 40127, Bologna, Italy
| | - Elena Buccellato
- Unit of Pharmacology, Department of Medical and Surgical Sciences, University of Bologna, via Irnerio 48, 40126, Bologna, Italy
| | - Monia Donati
- Unit of Pharmacology, Department of Medical and Surgical Sciences, University of Bologna, via Irnerio 48, 40126, Bologna, Italy
| | - Alberto Vaccheri
- Unit of Pharmacology, Department of Medical and Surgical Sciences, University of Bologna, via Irnerio 48, 40126, Bologna, Italy
| | - Domenico Motola
- Unit of Pharmacology, Department of Medical and Surgical Sciences, University of Bologna, via Irnerio 48, 40126, Bologna, Italy.
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18
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Berntsson SG, Katsarogiannis E, Lourenço F, Moraes-Fontes MF. Progressive Multifocal Leukoencephalopathy and Systemic Lupus Erythematosus: Focus on Etiology. Case Rep Neurol 2016; 8:59-65. [PMID: 27065427 PMCID: PMC4821142 DOI: 10.1159/000444874] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Progressive multifocal leukoencephalopathy (PML) caused by reactivation of the JC virus (JCV), a human polyomavirus, occurs in autoimmune disorders, most frequently in systemic lupus erythematosus (SLE). We describe a HIV-negative 34-year-old female with SLE who had been treated with immunosuppressant therapy (IST; steroids and azathioprine) since 2004. In 2011, she developed decreased sensation and weakness of the right hand, followed by vertigo and gait instability. The diagnosis of PML was made on the basis of brain MRI findings (posterior fossa lesions) and JCV isolation from the cerebrospinal fluid (700 copies/ml). IST was immediately discontinued. Cidofovir, mirtazapine, mefloquine and cycles of cytarabine were sequentially added, but there was progressive deterioration with a fatal outcome 1 year after disease onset. This report discusses current therapeutic choices for PML and the importance of early infection screening when SLE patients present with neurological symptoms. In the light of recent reports of PML in SLE patients treated with rituximab or belimumab, we highlight that other IST may just as well be implicated. We conclude that severe lymphopenia was most likely responsible for JCV reactivation in this patient and discuss how effective management of lymphopenia in SLE and PML therapy remains an unmet need.
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Affiliation(s)
- Shala Ghaderi Berntsson
- Departments of Neuroscience, Uppsala University Hospital, Uppsala, Sweden; Neurology, Uppsala University Hospital, Uppsala, Sweden
| | - Evangelos Katsarogiannis
- Departments of Neuroscience, Uppsala University Hospital, Uppsala, Sweden; Neurology, Uppsala University Hospital, Uppsala, Sweden
| | - Filipa Lourenço
- Unidade de Doenças Auto-imunes/Serviço Medicina 7.2, Hospital Curry Cabral, Centro Hospitalar Lisboa Central, Lisbon, Portugal
| | - Maria Francisca Moraes-Fontes
- Unidade de Doenças Auto-imunes/Serviço Medicina 7.2, Hospital Curry Cabral, Centro Hospitalar Lisboa Central, Lisbon, Portugal
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19
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Henegar CE, Eudy AM, Kharat V, Hill DD, Bennett D, Haight B. Progressive multifocal leukoencephalopathy in patients with systemic lupus erythematosus: a systematic literature review. Lupus 2016; 25:617-26. [PMID: 26743322 DOI: 10.1177/0961203315622819] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2015] [Accepted: 11/24/2015] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To determine risk factors for progressive multifocal leukoencephalopathy (PML) in systemic lupus erythematosus (SLE) patients, and understand how underlying disease or treatment for SLE may be associated with PML in this population. METHODS Studies published in English between January 1, 1984 and October 31, 2014 that reported PML in adult SLE patients were included. Immunosuppression was defined as exposure to ≥1 immunosuppressant drug of interest at PML diagnosis: belimumab, rituximab, mycophenolate mofetil, azathioprine, cyclophosphamide, methotrexate and high-dose corticosteroids (>15 mg/day). Minimal immunosuppression was defined as low-dose corticosteroids (≤15 mg/day) and/or anti-malarials. RESULTS Thirty-five publications met our inclusion criteria: four observational studies, two large case series, and 29 case reports that described 35 cases. Reported PML incidence rates among SLE patients based on observational studies ranged from 1.0 to 2.4 cases/100,000 person-years. Of the 35 case reports, three cases were exposed to no immunosuppressant drugs at PML diagnosis, five cases had minimal immunosuppression, 23 cases had immunosuppression, and four cases were indeterminate. CONCLUSIONS The evidence from this literature review suggests that, while PML is a very rare disease in SLE patients, there does appear to be an increased risk of PML associated with SLE compared to the general population, potentially due to immunosuppression, other contributing factors in their underlying disease, treatments prescribed to manage disease, or some combination of these factors. Additional large observational studies, designed to assess exposure to drugs of interest and complicated treatment histories, are needed to provide further evidence about potential mechanisms contributing to the onset of PML in SLE patients.
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Affiliation(s)
- C E Henegar
- Worldwide Epidemiology, GlaxoSmithKline, Research Triangle Park, USA
| | - A M Eudy
- Worldwide Epidemiology, GlaxoSmithKline, Research Triangle Park, USA Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, USA
| | - V Kharat
- Worldwide Epidemiology, GlaxoSmithKline, Research Triangle Park, USA
| | - D D Hill
- Worldwide Epidemiology, GlaxoSmithKline, Research Triangle Park, USA
| | - D Bennett
- Worldwide Epidemiology, GlaxoSmithKline, Research Triangle Park, USA
| | - B Haight
- Global Clinical Safety and Pharmacovigilance, GlaxoSmithKline, Research Triangle Park, USA
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Kampylafka EI, Alexopoulos H, Dalakas MC, Tzioufas AG. Immunotherapies for Neurological Manifestations in the Context of Systemic Autoimmunity. Neurotherapeutics 2016; 13:163-78. [PMID: 26510559 PMCID: PMC4720664 DOI: 10.1007/s13311-015-0393-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Neurological involvement is relatively common in the majority of systemic autoimmune diseases and may lead to severe morbidity and mortality, if not promptly treated. Treatment options vary greatly, depending on the underlying systemic pathophysiology and the associated neurological symptoms. Selecting the appropriate therapeutic scheme is further complicated by the lack of definite therapeutic guidelines, the necessity to differentiate primary neurological syndromes from those related to the underlying systemic disease, and to sort out adverse neurological manifestations caused by immunosuppressants or the biological agents used to treat the primary disease. Immunotherapy is a sine qua non for treating most, if not all, neurological conditions presenting in the context of systemic autoimmunity. Specific agents include classical immune modulators such as corticosteroids, cyclophosphamide, intravenous immunoglobulin, and plasma exchange, as well as numerous biological therapies, for example anti-tumor necrosis factor agents and monoclonal antibodies that target various immune pathways such as B cells, cytokines, and co-stimulatory molecules. However, experience regarding the use of these agents in neurological complications of systemic diseases is mainly empirical or based on small uncontrolled studies and case series. The aim of this review is to present the state-of-the-art therapies applied in various neurological manifestations encountered in the context of systemic autoimmune diseases; evaluate all treatment options on the basis of existing guidelines; and compliment these data with our personal experience derived from a large number of patients.
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Affiliation(s)
- Eleni I Kampylafka
- Department of Pathophysiology, Faculty of Medicine, National and Kapodistrian University of Athens, Athens, 11527, Greece
| | - Harry Alexopoulos
- Department of Pathophysiology, Faculty of Medicine, National and Kapodistrian University of Athens, Athens, 11527, Greece
| | - Marinos C Dalakas
- Department of Pathophysiology, Faculty of Medicine, National and Kapodistrian University of Athens, Athens, 11527, Greece
| | - Athanasios G Tzioufas
- Department of Pathophysiology, Faculty of Medicine, National and Kapodistrian University of Athens, Athens, 11527, Greece.
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21
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Abstract
Systemic lupus erythematosus (SLE) is a clinically diverse and potentially life-threatening auto-immune disease that can affect almost any organ system. Although much is still unknown regarding its pathogenesis, B cell abnormalities are thought to be central. A high relapse rate along with the toxicity associated with conventional treatments signify the need for more tailored approaches in this very heterogeneous disease. Both its mechanism targeting B cells and a relatively large number of case series and observational studies have suggested that the B cell-depleting agent rituximab could be a potent SLE drug. However, two randomized controlled trials failed to meet efficacy endpoints. Nevertheless, rituximab has continued to be used as an off-label alternative mainly in patients refractory to conventional immunosuppressive treatment. This article will review the current role of rituximab in SLE.
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Affiliation(s)
- Sara Linder Ekö
- Unit for Clinical Therapy Research, Inflammatory Diseases (ClinTRID), Karolinska Institute, 171 76, Stockholm, Sweden,
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22
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Selmi C, Gershwin ME. The long-term marriage between autoimmunity and internal medicine: a homage to Manuel Carlos Dias. Clin Rev Allergy Immunol 2013; 43:207-10. [PMID: 22826113 DOI: 10.1007/s12016-012-8333-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Our understanding of autoimmune diseases results from the perfect combination of basic and clinical scientific research, and the figure that is closest to the proposed autoimmunology specialist is certainly the internist. The role of B cells in rheumatoid arthritis, the immunological mechanisms to fibrosis or to tissue specific damage, the classification of Bechet's syndrome, the clinical outcomes of antiphospholid syndrome, and new biomarkers for vascular complications in systemic sclerosis constitute, among others, are ideal examples of this combination. For these reason, this issue includes comprehensive reviews in all these areas and is dedicated to Dr. Manuel Carlos Dias and his career in the perfectioning and teaching of the clinical skills necessary to manage autoimmune disease. We are convinced that these discussions are likely of interest to basic scientists and clinicians alike for the proposed translational applications.
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Affiliation(s)
- Carlo Selmi
- Division of Rheumatology, Allergy, and Clinical Immunology, University of California Davis, Davis, CA 95616, USA.
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24
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Iacobaeus E, Hopia L, Khademi M, Lundén M, Hammarin AL, Svenungsson E, Andersson M. Analysis of JC virus DNA in NPSLE patients treated with different immunomodulatory agents. Lupus 2012; 22:307-11. [DOI: 10.1177/0961203312470977] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective The objective of this report is to assess the presence and viral load of JC polyomavirus (JCV) DNA in cerebrospinal fluid (CSF) and plasma from neuropsychiatric systemic lupus erythematosus (NPSLE) patients in comparison to controls and to investigate if different types of immunosuppressive treatments were correlated to detection and viral load of JCV DNA in SLE. Background Reactivation of a latent JCV infection with subsequent development of the fatal disease progressive multifocal leukoencephalopathy (PML) has become an increasing problem in patients with autoimmune diseases treated with newer immunosuppressants. Accumulating data point out that SLE patients are at particular risk for PML compared to patients with other rheumatic diseases. Methods CSF samples ( n = 69) and plasma samples ( n = 51) from 71 SLE patients and 58 controls (53 CSF samples and 50 plasma samples) with other non-inflammatory neurological disease (OND) were analyzed for JCV DNA with a quantitative PCR method. Results All CSF and plasma samples from NPSLE patients and controls were negative for JCV DNA. Conclusion JCV DNA was absent in CSF and plasma in NPSLE patients and controls and consequently we were not able to identify any correlation between the occurrence of JCV DNA and type of immunosuppressive medication.
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Affiliation(s)
- E Iacobaeus
- Department of Clinical Neuroscience, Neuroimmunology Unit, Karolinska Institute, Sweden
| | - L Hopia
- Department of Clinical Neuroscience, Neuroimmunology Unit, Karolinska Institute, Sweden
| | - M Khademi
- Department of Clinical Neuroscience, Neuroimmunology Unit, Karolinska Institute, Sweden
| | - M Lundén
- Department of Preparedness, Swedish Institute for Communicable Disease Control, Sweden
| | - A-L Hammarin
- Department of Preparedness, Swedish Institute for Communicable Disease Control, Sweden
| | - E Svenungsson
- Department of Medicine, Rheumatology Unit, Karolinska Institute, Sweden
| | - M Andersson
- Department of Clinical Neuroscience, Neuroimmunology Unit, Karolinska Institute, Sweden
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