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Martin de Frémont G, Chabrolles H, Mirand A, L'Honneur AS, Mélé N, Dunogue B, Boutboul D, Farhat M, Hachulla E, Lazrek M, Rieu V, Mathian A, Chaussade H, Ruet A, Burrel S, Coury-Lucas F, Schuffenecker I, Lemaignen A, Stefic K, le Besnerais M, Carrette M, Mouthon L, Avettand-Fenoel V, Terrier B, Hadjadj J. Severe enterovirus infections in patients with immune-mediated inflammatory diseases receiving anti-CD20 monoclonal antibodies. RMD Open 2024; 10:e004036. [PMID: 38772678 DOI: 10.1136/rmdopen-2023-004036] [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: 01/09/2024] [Accepted: 04/29/2024] [Indexed: 05/23/2024] Open
Abstract
OBJECTIVE Patients with X linked agammaglobulinemia are susceptible to enterovirus (EV) infections. Similarly, severe EV infections have been described in patients with impaired B-cell response following treatment with anti-CD20 monoclonal antibodies (mAbs), mostly in those treated for haematological malignancies. We aimed to describe severe EV infections in patients receiving anti-CD20 mAbs for immune-mediated inflammatory diseases (IMIDs). METHODS Patients were included following a screening of data collected through the routine surveillance of EV infections coordinated by the National Reference Center and a review of the literature. Additionally, neutralising antibodies were assessed in a patient with chronic EV-A71 meningoencephalitis. RESULTS Nine original and 17 previously published cases were retrieved. Meningoencephalitis (n=21/26, 81%) associated with EV-positive cerebrospinal fluid (n=20/22, 91%) was the most common manifestation. The mortality rate was high (27%). EV was the only causal agents in all reported cases. Patients received multiple anti-CD20 mAbs infusions (median 8 (5-10)), resulting in complete B-cell depletion and moderate hypogammaglobulinemia (median 4.9 g/L (4.3-6.7)), and had limited concomitant immunosuppressive treatments. Finally, in a patient with EV-A71 meningoencephalitis, a lack of B-cell response to EV was shown. CONCLUSION EV infection should be evoked in patients with IMIDs presenting with atypical organ involvement, especially meningoencephalitis. Anti-CD20 mAbs may lead to impaired B-cell response against EV, although an underlying primary immunodeficiency should systematically be discussed.
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Affiliation(s)
- Grégoire Martin de Frémont
- Department of Internal Medicine, National Referral Center for Rare Systemic Autoimmune Diseases, Université Paris Cité, Hôpital Cochin, Paris, France
| | - Hélène Chabrolles
- 3IHP-Infection Inflammation et Interaction Hôtes Pathogènes, Virology Department, National Reference Centre for Enteroviruses and Parechoviruses, Coordination Laboratory, CHU, Clermont-Ferrand, France
- LMGE UMR CNRS 6023, Team Epidemiology and Pathophysiology of Enterovirus Infection, Université Clermont Auvergne, Clermont-Ferrand, France
| | - Audrey Mirand
- 3IHP-Infection Inflammation et Interaction Hôtes Pathogènes, Virology Department, National Reference Centre for Enteroviruses and Parechoviruses, Coordination Laboratory, CHU, Clermont-Ferrand, France
- LMGE UMR CNRS 6023, Team Epidemiology and Pathophysiology of Enterovirus Infection, Université Clermont Auvergne, Clermont-Ferrand, France
| | - Anne Sophie L'Honneur
- Department of Virology, Hôpital Cochin, Paris, France
- Institut Cochin, CNRS 8104/INSERM U1016, Université Paris Cité, Paris, France
| | - Nicolas Mélé
- Department of Neurology, GHU Paris Psychatrie et Neurosciences, Saint Anne Hospital Centre, Paris, France
- INSERM 1266 FHU NeuroVasc, Université Paris Cité, Paris, France
| | - Bertrand Dunogue
- Hôpital Cochin, Department of Internal Medicine, National Referral Center for Rare Systemic Autoimmune Diseases, Université Paris Cité, Hôpital Cochin, Paris, France
| | - David Boutboul
- Department of Hematology, Université Paris Cité, Hôpital Cochin, Paris, France
| | - Meryem Farhat
- Department of Internal Medicine, Université de Lille, CHU de Lille, Lille, France
| | - Eric Hachulla
- Department of Internal Medicine, Université de Lille, CHU de Lille, Lille, France
| | - Mouna Lazrek
- Department of Virology, CHU de Lille, Lille, France
| | - Virginie Rieu
- Department of Internal Medicine, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Alexis Mathian
- Department of Internal Medicine 2, Centre de référence pour le Lupus, Syndrome des anti-phospholipides et autres maladies auto-immunes rares, Institut E3M, Groupe Hospitalier La Pitié Salpêtrière-Charles Foix, Paris, France
- INSERM, Centre d'Immunologie et des Maladies Infectieuses, Sorbonne Université, Paris, France
| | - Helene Chaussade
- Department of Internal Medicine, Université de Bordeaux, CHU Bordeaux GH Pellegrin, Bordeaux, France
| | - Aurelie Ruet
- Department of Neurology, Université de Bordeaux, CHU de Bordeaux, Bordeaux, France
| | - Sonia Burrel
- Department of Virology, CHU de Bordeaux, Bordeaux, France
- UMR 5234, Fundamental Microbiology and Pathogenicity, CNRS, Université de Bordeaux, Bordeaux, France
| | - Fabienne Coury-Lucas
- Department of Rheumatology, Université Claude Bernard Lyon 1, CHU Lyon, Lyon, France
| | - Isabelle Schuffenecker
- Department of Virology, National Reference Centre for Enteroviruses and Parechoviruses, Associated Laboratory, Université Claude Bernard Lyon 1, CHU Lyon, Lyon, France
| | | | - Karl Stefic
- Department of Virology, CHU de Tours, Tours, France
| | | | | | - Luc Mouthon
- Department of Internal Medicine, National Referral Center for Rare Systemic Autoimmune Diseases, Université Paris Cité, Hôpital Cochin, Paris, France
| | - Veronique Avettand-Fenoel
- Department of Virology, Hôpital Cochin, Paris, France
- Institut Cochin, CNRS 8104/INSERM U1016, Université Paris Cité, Paris, France
| | - Benjamin Terrier
- Department of Internal Medicine, National Referral Center for Rare Systemic Autoimmune Diseases, Université Paris Cité, Hôpital Cochin, Paris, France
| | - Jérome Hadjadj
- Department of Internal Medicine, Sorbonne Université, Hôpital Saint-Antoine, Paris, France
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Demuth S, Collongues N, Audoin B, Ayrignac X, Bourre B, Ciron J, Cohen M, Deschamps R, Durand-Dubief F, Maillart E, Papeix C, Ruet A, Zephir H, Marignier R, De Seze J. Rituximab De-escalation in Patients With Neuromyelitis Optica Spectrum Disorder. Neurology 2023; 101:e438-e450. [PMID: 37290967 PMCID: PMC10435052 DOI: 10.1212/wnl.0000000000207443] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2022] [Accepted: 04/07/2023] [Indexed: 06/10/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Exit strategies such as de-escalations have not been evaluated for rituximab in patients with neuromyelitis optica spectrum disorder (NMOSD). We hypothesized that they are associated with disease reactivations and aimed to estimate this risk. METHODS We describe a case series of real-world de-escalations from the French NMOSD registry (NOMADMUS). All patients met the 2015 International Panel for NMO Diagnosis (IPND) diagnostic criteria for NMOSD. A computerized screening of the registry extracted patients with rituximab de-escalations and at least 12 months of subsequent follow-up. We searched for 7 de-escalation regimens: scheduled discontinuations or switches to an oral treatment after single infusion cycles, scheduled discontinuations or switches to an oral treatment after periodic infusions, de-escalations before pregnancies, de-escalations after tolerance issues, and increased infusion intervals. Rituximab discontinuations motivated by inefficacy or for unknown purposes were excluded. The primary outcome was the absolute risk of NMOSD reactivation (one or more relapses) at 12 months. AQP4+ and AQP4- serotypes were analyzed separately. RESULTS We identified 137 rituximab de-escalations between 2006 and 2019 that corresponded to a predefined group: 13 discontinuations after a single infusion cycle, 6 switches to an oral treatment after a single infusion cycle, 9 discontinuations after periodic infusions, 5 switches to an oral treatment after periodic infusions, 4 de-escalations before pregnancies, 9 de-escalations after tolerance issues, and 91 increased infusion intervals. No group remained relapse-free over the whole de-escalation follow-up (mean: 3.2 years; range: 0.79-9.5), except pregnancies in AQP+ patients. In all groups combined and within 12 months, reactivations occurred after 11/119 de-escalations in patients with AQP4+ NMOSD (9.2%, 95% CI [4.7-15.9]), from 0.69 to 10.0 months, and in 5/18 de-escalations in patients with AQP4- NMOSD (27.8%, 95% CI [9.7-53.5]), from 1.1 to 9.9 months. DISCUSSION There is a risk of NMOSD reactivation whatever the rituximab de-escalation regimen. TRIAL REGISTRATION INFORMATION Registered on ClinicalTrials.gov: NCT02850705. CLASSIFICATION OF EVIDENCE This study provides Class IV evidence that de-escalation of rituximab increases the probability of disease reactivation.
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Affiliation(s)
- Stanislas Demuth
- From the Department of Neurology (S.D., N.C., J.D.S.); Clinical Investigation Center (N.C., J.D.S.), Strasbourg University Hospital; Department of Neurology (B.A.), APHM, Hôpital de la Timone, Pôle de Neurosciences Cliniques, Marseille; Department of Neurology (X.A.), Montpellier University Hospital; Department of Neurology (B.B.), Rouen University Hospital; Department of Neurology CRC-SEP (J.C.), CHU Toulouse; Department of Neurology, CHU Poitiers (J.C.); Department of Neurology (M.C.), CHU de Nice, UR2CA-URRIS, Nice Côte d'Azur University; Department of Neurology (R.D.), Hôpital Fondation Adolphe de Rothschild, Paris; Department of Neurology (F.D.U.R.A.N.D.-D.U.B.I.E.F.), Sclérose en Plaques, Pathologies de la Myéline et Neuro-inflammation, Hôpital Neurologique, Hospices Civils de Lyon; Department of Neurology (E.M., C.P.), AP-HP, Pitié-Salpêtrière Hospital, Paris; Department of Neurology (Groupe Hospitalier Pellegrin) (A.R.), Centre Hospitalier Universitaire de Bordeaux; Université de Bordeaux (A.R.), INSERM U1215, Neurocentre Magendie; Department of Neurology (H.Z.), University Hospital of Lille, UFR3S Univ-Lille, Inserm U 1172; Service de Neurologie, Sclérose en Plaques, Pathologies de la Myéline et Neuro Inflammation (R.M.), and Centre de Référence des Maladies Inflammatoires Rares du Cerveau et de la Moelle (MIRCEM), Hôpital Neurologique Pierre Wertheimer, Bron; Centre des Neurosciences de Lyon-FORGETTING Team (R.M.), INSERM 1028 and CNRS UMR5292; and Université Claude Bernard Lyon 1 (R.M.), France
| | - Nicolas Collongues
- From the Department of Neurology (S.D., N.C., J.D.S.); Clinical Investigation Center (N.C., J.D.S.), Strasbourg University Hospital; Department of Neurology (B.A.), APHM, Hôpital de la Timone, Pôle de Neurosciences Cliniques, Marseille; Department of Neurology (X.A.), Montpellier University Hospital; Department of Neurology (B.B.), Rouen University Hospital; Department of Neurology CRC-SEP (J.C.), CHU Toulouse; Department of Neurology, CHU Poitiers (J.C.); Department of Neurology (M.C.), CHU de Nice, UR2CA-URRIS, Nice Côte d'Azur University; Department of Neurology (R.D.), Hôpital Fondation Adolphe de Rothschild, Paris; Department of Neurology (F.D.U.R.A.N.D.-D.U.B.I.E.F.), Sclérose en Plaques, Pathologies de la Myéline et Neuro-inflammation, Hôpital Neurologique, Hospices Civils de Lyon; Department of Neurology (E.M., C.P.), AP-HP, Pitié-Salpêtrière Hospital, Paris; Department of Neurology (Groupe Hospitalier Pellegrin) (A.R.), Centre Hospitalier Universitaire de Bordeaux; Université de Bordeaux (A.R.), INSERM U1215, Neurocentre Magendie; Department of Neurology (H.Z.), University Hospital of Lille, UFR3S Univ-Lille, Inserm U 1172; Service de Neurologie, Sclérose en Plaques, Pathologies de la Myéline et Neuro Inflammation (R.M.), and Centre de Référence des Maladies Inflammatoires Rares du Cerveau et de la Moelle (MIRCEM), Hôpital Neurologique Pierre Wertheimer, Bron; Centre des Neurosciences de Lyon-FORGETTING Team (R.M.), INSERM 1028 and CNRS UMR5292; and Université Claude Bernard Lyon 1 (R.M.), France
| | - Bertrand Audoin
- From the Department of Neurology (S.D., N.C., J.D.S.); Clinical Investigation Center (N.C., J.D.S.), Strasbourg University Hospital; Department of Neurology (B.A.), APHM, Hôpital de la Timone, Pôle de Neurosciences Cliniques, Marseille; Department of Neurology (X.A.), Montpellier University Hospital; Department of Neurology (B.B.), Rouen University Hospital; Department of Neurology CRC-SEP (J.C.), CHU Toulouse; Department of Neurology, CHU Poitiers (J.C.); Department of Neurology (M.C.), CHU de Nice, UR2CA-URRIS, Nice Côte d'Azur University; Department of Neurology (R.D.), Hôpital Fondation Adolphe de Rothschild, Paris; Department of Neurology (F.D.U.R.A.N.D.-D.U.B.I.E.F.), Sclérose en Plaques, Pathologies de la Myéline et Neuro-inflammation, Hôpital Neurologique, Hospices Civils de Lyon; Department of Neurology (E.M., C.P.), AP-HP, Pitié-Salpêtrière Hospital, Paris; Department of Neurology (Groupe Hospitalier Pellegrin) (A.R.), Centre Hospitalier Universitaire de Bordeaux; Université de Bordeaux (A.R.), INSERM U1215, Neurocentre Magendie; Department of Neurology (H.Z.), University Hospital of Lille, UFR3S Univ-Lille, Inserm U 1172; Service de Neurologie, Sclérose en Plaques, Pathologies de la Myéline et Neuro Inflammation (R.M.), and Centre de Référence des Maladies Inflammatoires Rares du Cerveau et de la Moelle (MIRCEM), Hôpital Neurologique Pierre Wertheimer, Bron; Centre des Neurosciences de Lyon-FORGETTING Team (R.M.), INSERM 1028 and CNRS UMR5292; and Université Claude Bernard Lyon 1 (R.M.), France
| | - Xavier Ayrignac
- From the Department of Neurology (S.D., N.C., J.D.S.); Clinical Investigation Center (N.C., J.D.S.), Strasbourg University Hospital; Department of Neurology (B.A.), APHM, Hôpital de la Timone, Pôle de Neurosciences Cliniques, Marseille; Department of Neurology (X.A.), Montpellier University Hospital; Department of Neurology (B.B.), Rouen University Hospital; Department of Neurology CRC-SEP (J.C.), CHU Toulouse; Department of Neurology, CHU Poitiers (J.C.); Department of Neurology (M.C.), CHU de Nice, UR2CA-URRIS, Nice Côte d'Azur University; Department of Neurology (R.D.), Hôpital Fondation Adolphe de Rothschild, Paris; Department of Neurology (F.D.U.R.A.N.D.-D.U.B.I.E.F.), Sclérose en Plaques, Pathologies de la Myéline et Neuro-inflammation, Hôpital Neurologique, Hospices Civils de Lyon; Department of Neurology (E.M., C.P.), AP-HP, Pitié-Salpêtrière Hospital, Paris; Department of Neurology (Groupe Hospitalier Pellegrin) (A.R.), Centre Hospitalier Universitaire de Bordeaux; Université de Bordeaux (A.R.), INSERM U1215, Neurocentre Magendie; Department of Neurology (H.Z.), University Hospital of Lille, UFR3S Univ-Lille, Inserm U 1172; Service de Neurologie, Sclérose en Plaques, Pathologies de la Myéline et Neuro Inflammation (R.M.), and Centre de Référence des Maladies Inflammatoires Rares du Cerveau et de la Moelle (MIRCEM), Hôpital Neurologique Pierre Wertheimer, Bron; Centre des Neurosciences de Lyon-FORGETTING Team (R.M.), INSERM 1028 and CNRS UMR5292; and Université Claude Bernard Lyon 1 (R.M.), France
| | - Bertrand Bourre
- From the Department of Neurology (S.D., N.C., J.D.S.); Clinical Investigation Center (N.C., J.D.S.), Strasbourg University Hospital; Department of Neurology (B.A.), APHM, Hôpital de la Timone, Pôle de Neurosciences Cliniques, Marseille; Department of Neurology (X.A.), Montpellier University Hospital; Department of Neurology (B.B.), Rouen University Hospital; Department of Neurology CRC-SEP (J.C.), CHU Toulouse; Department of Neurology, CHU Poitiers (J.C.); Department of Neurology (M.C.), CHU de Nice, UR2CA-URRIS, Nice Côte d'Azur University; Department of Neurology (R.D.), Hôpital Fondation Adolphe de Rothschild, Paris; Department of Neurology (F.D.U.R.A.N.D.-D.U.B.I.E.F.), Sclérose en Plaques, Pathologies de la Myéline et Neuro-inflammation, Hôpital Neurologique, Hospices Civils de Lyon; Department of Neurology (E.M., C.P.), AP-HP, Pitié-Salpêtrière Hospital, Paris; Department of Neurology (Groupe Hospitalier Pellegrin) (A.R.), Centre Hospitalier Universitaire de Bordeaux; Université de Bordeaux (A.R.), INSERM U1215, Neurocentre Magendie; Department of Neurology (H.Z.), University Hospital of Lille, UFR3S Univ-Lille, Inserm U 1172; Service de Neurologie, Sclérose en Plaques, Pathologies de la Myéline et Neuro Inflammation (R.M.), and Centre de Référence des Maladies Inflammatoires Rares du Cerveau et de la Moelle (MIRCEM), Hôpital Neurologique Pierre Wertheimer, Bron; Centre des Neurosciences de Lyon-FORGETTING Team (R.M.), INSERM 1028 and CNRS UMR5292; and Université Claude Bernard Lyon 1 (R.M.), France
| | - Jonathan Ciron
- From the Department of Neurology (S.D., N.C., J.D.S.); Clinical Investigation Center (N.C., J.D.S.), Strasbourg University Hospital; Department of Neurology (B.A.), APHM, Hôpital de la Timone, Pôle de Neurosciences Cliniques, Marseille; Department of Neurology (X.A.), Montpellier University Hospital; Department of Neurology (B.B.), Rouen University Hospital; Department of Neurology CRC-SEP (J.C.), CHU Toulouse; Department of Neurology, CHU Poitiers (J.C.); Department of Neurology (M.C.), CHU de Nice, UR2CA-URRIS, Nice Côte d'Azur University; Department of Neurology (R.D.), Hôpital Fondation Adolphe de Rothschild, Paris; Department of Neurology (F.D.U.R.A.N.D.-D.U.B.I.E.F.), Sclérose en Plaques, Pathologies de la Myéline et Neuro-inflammation, Hôpital Neurologique, Hospices Civils de Lyon; Department of Neurology (E.M., C.P.), AP-HP, Pitié-Salpêtrière Hospital, Paris; Department of Neurology (Groupe Hospitalier Pellegrin) (A.R.), Centre Hospitalier Universitaire de Bordeaux; Université de Bordeaux (A.R.), INSERM U1215, Neurocentre Magendie; Department of Neurology (H.Z.), University Hospital of Lille, UFR3S Univ-Lille, Inserm U 1172; Service de Neurologie, Sclérose en Plaques, Pathologies de la Myéline et Neuro Inflammation (R.M.), and Centre de Référence des Maladies Inflammatoires Rares du Cerveau et de la Moelle (MIRCEM), Hôpital Neurologique Pierre Wertheimer, Bron; Centre des Neurosciences de Lyon-FORGETTING Team (R.M.), INSERM 1028 and CNRS UMR5292; and Université Claude Bernard Lyon 1 (R.M.), France
| | - Mikael Cohen
- From the Department of Neurology (S.D., N.C., J.D.S.); Clinical Investigation Center (N.C., J.D.S.), Strasbourg University Hospital; Department of Neurology (B.A.), APHM, Hôpital de la Timone, Pôle de Neurosciences Cliniques, Marseille; Department of Neurology (X.A.), Montpellier University Hospital; Department of Neurology (B.B.), Rouen University Hospital; Department of Neurology CRC-SEP (J.C.), CHU Toulouse; Department of Neurology, CHU Poitiers (J.C.); Department of Neurology (M.C.), CHU de Nice, UR2CA-URRIS, Nice Côte d'Azur University; Department of Neurology (R.D.), Hôpital Fondation Adolphe de Rothschild, Paris; Department of Neurology (F.D.U.R.A.N.D.-D.U.B.I.E.F.), Sclérose en Plaques, Pathologies de la Myéline et Neuro-inflammation, Hôpital Neurologique, Hospices Civils de Lyon; Department of Neurology (E.M., C.P.), AP-HP, Pitié-Salpêtrière Hospital, Paris; Department of Neurology (Groupe Hospitalier Pellegrin) (A.R.), Centre Hospitalier Universitaire de Bordeaux; Université de Bordeaux (A.R.), INSERM U1215, Neurocentre Magendie; Department of Neurology (H.Z.), University Hospital of Lille, UFR3S Univ-Lille, Inserm U 1172; Service de Neurologie, Sclérose en Plaques, Pathologies de la Myéline et Neuro Inflammation (R.M.), and Centre de Référence des Maladies Inflammatoires Rares du Cerveau et de la Moelle (MIRCEM), Hôpital Neurologique Pierre Wertheimer, Bron; Centre des Neurosciences de Lyon-FORGETTING Team (R.M.), INSERM 1028 and CNRS UMR5292; and Université Claude Bernard Lyon 1 (R.M.), France
| | - Romain Deschamps
- From the Department of Neurology (S.D., N.C., J.D.S.); Clinical Investigation Center (N.C., J.D.S.), Strasbourg University Hospital; Department of Neurology (B.A.), APHM, Hôpital de la Timone, Pôle de Neurosciences Cliniques, Marseille; Department of Neurology (X.A.), Montpellier University Hospital; Department of Neurology (B.B.), Rouen University Hospital; Department of Neurology CRC-SEP (J.C.), CHU Toulouse; Department of Neurology, CHU Poitiers (J.C.); Department of Neurology (M.C.), CHU de Nice, UR2CA-URRIS, Nice Côte d'Azur University; Department of Neurology (R.D.), Hôpital Fondation Adolphe de Rothschild, Paris; Department of Neurology (F.D.U.R.A.N.D.-D.U.B.I.E.F.), Sclérose en Plaques, Pathologies de la Myéline et Neuro-inflammation, Hôpital Neurologique, Hospices Civils de Lyon; Department of Neurology (E.M., C.P.), AP-HP, Pitié-Salpêtrière Hospital, Paris; Department of Neurology (Groupe Hospitalier Pellegrin) (A.R.), Centre Hospitalier Universitaire de Bordeaux; Université de Bordeaux (A.R.), INSERM U1215, Neurocentre Magendie; Department of Neurology (H.Z.), University Hospital of Lille, UFR3S Univ-Lille, Inserm U 1172; Service de Neurologie, Sclérose en Plaques, Pathologies de la Myéline et Neuro Inflammation (R.M.), and Centre de Référence des Maladies Inflammatoires Rares du Cerveau et de la Moelle (MIRCEM), Hôpital Neurologique Pierre Wertheimer, Bron; Centre des Neurosciences de Lyon-FORGETTING Team (R.M.), INSERM 1028 and CNRS UMR5292; and Université Claude Bernard Lyon 1 (R.M.), France
| | - Françoise Durand-Dubief
- From the Department of Neurology (S.D., N.C., J.D.S.); Clinical Investigation Center (N.C., J.D.S.), Strasbourg University Hospital; Department of Neurology (B.A.), APHM, Hôpital de la Timone, Pôle de Neurosciences Cliniques, Marseille; Department of Neurology (X.A.), Montpellier University Hospital; Department of Neurology (B.B.), Rouen University Hospital; Department of Neurology CRC-SEP (J.C.), CHU Toulouse; Department of Neurology, CHU Poitiers (J.C.); Department of Neurology (M.C.), CHU de Nice, UR2CA-URRIS, Nice Côte d'Azur University; Department of Neurology (R.D.), Hôpital Fondation Adolphe de Rothschild, Paris; Department of Neurology (F.D.U.R.A.N.D.-D.U.B.I.E.F.), Sclérose en Plaques, Pathologies de la Myéline et Neuro-inflammation, Hôpital Neurologique, Hospices Civils de Lyon; Department of Neurology (E.M., C.P.), AP-HP, Pitié-Salpêtrière Hospital, Paris; Department of Neurology (Groupe Hospitalier Pellegrin) (A.R.), Centre Hospitalier Universitaire de Bordeaux; Université de Bordeaux (A.R.), INSERM U1215, Neurocentre Magendie; Department of Neurology (H.Z.), University Hospital of Lille, UFR3S Univ-Lille, Inserm U 1172; Service de Neurologie, Sclérose en Plaques, Pathologies de la Myéline et Neuro Inflammation (R.M.), and Centre de Référence des Maladies Inflammatoires Rares du Cerveau et de la Moelle (MIRCEM), Hôpital Neurologique Pierre Wertheimer, Bron; Centre des Neurosciences de Lyon-FORGETTING Team (R.M.), INSERM 1028 and CNRS UMR5292; and Université Claude Bernard Lyon 1 (R.M.), France
| | - Elisabeth Maillart
- From the Department of Neurology (S.D., N.C., J.D.S.); Clinical Investigation Center (N.C., J.D.S.), Strasbourg University Hospital; Department of Neurology (B.A.), APHM, Hôpital de la Timone, Pôle de Neurosciences Cliniques, Marseille; Department of Neurology (X.A.), Montpellier University Hospital; Department of Neurology (B.B.), Rouen University Hospital; Department of Neurology CRC-SEP (J.C.), CHU Toulouse; Department of Neurology, CHU Poitiers (J.C.); Department of Neurology (M.C.), CHU de Nice, UR2CA-URRIS, Nice Côte d'Azur University; Department of Neurology (R.D.), Hôpital Fondation Adolphe de Rothschild, Paris; Department of Neurology (F.D.U.R.A.N.D.-D.U.B.I.E.F.), Sclérose en Plaques, Pathologies de la Myéline et Neuro-inflammation, Hôpital Neurologique, Hospices Civils de Lyon; Department of Neurology (E.M., C.P.), AP-HP, Pitié-Salpêtrière Hospital, Paris; Department of Neurology (Groupe Hospitalier Pellegrin) (A.R.), Centre Hospitalier Universitaire de Bordeaux; Université de Bordeaux (A.R.), INSERM U1215, Neurocentre Magendie; Department of Neurology (H.Z.), University Hospital of Lille, UFR3S Univ-Lille, Inserm U 1172; Service de Neurologie, Sclérose en Plaques, Pathologies de la Myéline et Neuro Inflammation (R.M.), and Centre de Référence des Maladies Inflammatoires Rares du Cerveau et de la Moelle (MIRCEM), Hôpital Neurologique Pierre Wertheimer, Bron; Centre des Neurosciences de Lyon-FORGETTING Team (R.M.), INSERM 1028 and CNRS UMR5292; and Université Claude Bernard Lyon 1 (R.M.), France
| | - Caroline Papeix
- From the Department of Neurology (S.D., N.C., J.D.S.); Clinical Investigation Center (N.C., J.D.S.), Strasbourg University Hospital; Department of Neurology (B.A.), APHM, Hôpital de la Timone, Pôle de Neurosciences Cliniques, Marseille; Department of Neurology (X.A.), Montpellier University Hospital; Department of Neurology (B.B.), Rouen University Hospital; Department of Neurology CRC-SEP (J.C.), CHU Toulouse; Department of Neurology, CHU Poitiers (J.C.); Department of Neurology (M.C.), CHU de Nice, UR2CA-URRIS, Nice Côte d'Azur University; Department of Neurology (R.D.), Hôpital Fondation Adolphe de Rothschild, Paris; Department of Neurology (F.D.U.R.A.N.D.-D.U.B.I.E.F.), Sclérose en Plaques, Pathologies de la Myéline et Neuro-inflammation, Hôpital Neurologique, Hospices Civils de Lyon; Department of Neurology (E.M., C.P.), AP-HP, Pitié-Salpêtrière Hospital, Paris; Department of Neurology (Groupe Hospitalier Pellegrin) (A.R.), Centre Hospitalier Universitaire de Bordeaux; Université de Bordeaux (A.R.), INSERM U1215, Neurocentre Magendie; Department of Neurology (H.Z.), University Hospital of Lille, UFR3S Univ-Lille, Inserm U 1172; Service de Neurologie, Sclérose en Plaques, Pathologies de la Myéline et Neuro Inflammation (R.M.), and Centre de Référence des Maladies Inflammatoires Rares du Cerveau et de la Moelle (MIRCEM), Hôpital Neurologique Pierre Wertheimer, Bron; Centre des Neurosciences de Lyon-FORGETTING Team (R.M.), INSERM 1028 and CNRS UMR5292; and Université Claude Bernard Lyon 1 (R.M.), France
| | - Aurélie Ruet
- From the Department of Neurology (S.D., N.C., J.D.S.); Clinical Investigation Center (N.C., J.D.S.), Strasbourg University Hospital; Department of Neurology (B.A.), APHM, Hôpital de la Timone, Pôle de Neurosciences Cliniques, Marseille; Department of Neurology (X.A.), Montpellier University Hospital; Department of Neurology (B.B.), Rouen University Hospital; Department of Neurology CRC-SEP (J.C.), CHU Toulouse; Department of Neurology, CHU Poitiers (J.C.); Department of Neurology (M.C.), CHU de Nice, UR2CA-URRIS, Nice Côte d'Azur University; Department of Neurology (R.D.), Hôpital Fondation Adolphe de Rothschild, Paris; Department of Neurology (F.D.U.R.A.N.D.-D.U.B.I.E.F.), Sclérose en Plaques, Pathologies de la Myéline et Neuro-inflammation, Hôpital Neurologique, Hospices Civils de Lyon; Department of Neurology (E.M., C.P.), AP-HP, Pitié-Salpêtrière Hospital, Paris; Department of Neurology (Groupe Hospitalier Pellegrin) (A.R.), Centre Hospitalier Universitaire de Bordeaux; Université de Bordeaux (A.R.), INSERM U1215, Neurocentre Magendie; Department of Neurology (H.Z.), University Hospital of Lille, UFR3S Univ-Lille, Inserm U 1172; Service de Neurologie, Sclérose en Plaques, Pathologies de la Myéline et Neuro Inflammation (R.M.), and Centre de Référence des Maladies Inflammatoires Rares du Cerveau et de la Moelle (MIRCEM), Hôpital Neurologique Pierre Wertheimer, Bron; Centre des Neurosciences de Lyon-FORGETTING Team (R.M.), INSERM 1028 and CNRS UMR5292; and Université Claude Bernard Lyon 1 (R.M.), France
| | - Helene Zephir
- From the Department of Neurology (S.D., N.C., J.D.S.); Clinical Investigation Center (N.C., J.D.S.), Strasbourg University Hospital; Department of Neurology (B.A.), APHM, Hôpital de la Timone, Pôle de Neurosciences Cliniques, Marseille; Department of Neurology (X.A.), Montpellier University Hospital; Department of Neurology (B.B.), Rouen University Hospital; Department of Neurology CRC-SEP (J.C.), CHU Toulouse; Department of Neurology, CHU Poitiers (J.C.); Department of Neurology (M.C.), CHU de Nice, UR2CA-URRIS, Nice Côte d'Azur University; Department of Neurology (R.D.), Hôpital Fondation Adolphe de Rothschild, Paris; Department of Neurology (F.D.U.R.A.N.D.-D.U.B.I.E.F.), Sclérose en Plaques, Pathologies de la Myéline et Neuro-inflammation, Hôpital Neurologique, Hospices Civils de Lyon; Department of Neurology (E.M., C.P.), AP-HP, Pitié-Salpêtrière Hospital, Paris; Department of Neurology (Groupe Hospitalier Pellegrin) (A.R.), Centre Hospitalier Universitaire de Bordeaux; Université de Bordeaux (A.R.), INSERM U1215, Neurocentre Magendie; Department of Neurology (H.Z.), University Hospital of Lille, UFR3S Univ-Lille, Inserm U 1172; Service de Neurologie, Sclérose en Plaques, Pathologies de la Myéline et Neuro Inflammation (R.M.), and Centre de Référence des Maladies Inflammatoires Rares du Cerveau et de la Moelle (MIRCEM), Hôpital Neurologique Pierre Wertheimer, Bron; Centre des Neurosciences de Lyon-FORGETTING Team (R.M.), INSERM 1028 and CNRS UMR5292; and Université Claude Bernard Lyon 1 (R.M.), France
| | - Romain Marignier
- From the Department of Neurology (S.D., N.C., J.D.S.); Clinical Investigation Center (N.C., J.D.S.), Strasbourg University Hospital; Department of Neurology (B.A.), APHM, Hôpital de la Timone, Pôle de Neurosciences Cliniques, Marseille; Department of Neurology (X.A.), Montpellier University Hospital; Department of Neurology (B.B.), Rouen University Hospital; Department of Neurology CRC-SEP (J.C.), CHU Toulouse; Department of Neurology, CHU Poitiers (J.C.); Department of Neurology (M.C.), CHU de Nice, UR2CA-URRIS, Nice Côte d'Azur University; Department of Neurology (R.D.), Hôpital Fondation Adolphe de Rothschild, Paris; Department of Neurology (F.D.U.R.A.N.D.-D.U.B.I.E.F.), Sclérose en Plaques, Pathologies de la Myéline et Neuro-inflammation, Hôpital Neurologique, Hospices Civils de Lyon; Department of Neurology (E.M., C.P.), AP-HP, Pitié-Salpêtrière Hospital, Paris; Department of Neurology (Groupe Hospitalier Pellegrin) (A.R.), Centre Hospitalier Universitaire de Bordeaux; Université de Bordeaux (A.R.), INSERM U1215, Neurocentre Magendie; Department of Neurology (H.Z.), University Hospital of Lille, UFR3S Univ-Lille, Inserm U 1172; Service de Neurologie, Sclérose en Plaques, Pathologies de la Myéline et Neuro Inflammation (R.M.), and Centre de Référence des Maladies Inflammatoires Rares du Cerveau et de la Moelle (MIRCEM), Hôpital Neurologique Pierre Wertheimer, Bron; Centre des Neurosciences de Lyon-FORGETTING Team (R.M.), INSERM 1028 and CNRS UMR5292; and Université Claude Bernard Lyon 1 (R.M.), France
| | - Jerome De Seze
- From the Department of Neurology (S.D., N.C., J.D.S.); Clinical Investigation Center (N.C., J.D.S.), Strasbourg University Hospital; Department of Neurology (B.A.), APHM, Hôpital de la Timone, Pôle de Neurosciences Cliniques, Marseille; Department of Neurology (X.A.), Montpellier University Hospital; Department of Neurology (B.B.), Rouen University Hospital; Department of Neurology CRC-SEP (J.C.), CHU Toulouse; Department of Neurology, CHU Poitiers (J.C.); Department of Neurology (M.C.), CHU de Nice, UR2CA-URRIS, Nice Côte d'Azur University; Department of Neurology (R.D.), Hôpital Fondation Adolphe de Rothschild, Paris; Department of Neurology (F.D.U.R.A.N.D.-D.U.B.I.E.F.), Sclérose en Plaques, Pathologies de la Myéline et Neuro-inflammation, Hôpital Neurologique, Hospices Civils de Lyon; Department of Neurology (E.M., C.P.), AP-HP, Pitié-Salpêtrière Hospital, Paris; Department of Neurology (Groupe Hospitalier Pellegrin) (A.R.), Centre Hospitalier Universitaire de Bordeaux; Université de Bordeaux (A.R.), INSERM U1215, Neurocentre Magendie; Department of Neurology (H.Z.), University Hospital of Lille, UFR3S Univ-Lille, Inserm U 1172; Service de Neurologie, Sclérose en Plaques, Pathologies de la Myéline et Neuro Inflammation (R.M.), and Centre de Référence des Maladies Inflammatoires Rares du Cerveau et de la Moelle (MIRCEM), Hôpital Neurologique Pierre Wertheimer, Bron; Centre des Neurosciences de Lyon-FORGETTING Team (R.M.), INSERM 1028 and CNRS UMR5292; and Université Claude Bernard Lyon 1 (R.M.), France.
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3
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Athni TS, Barmettler S. Hypogammaglobulinemia, late-onset neutropenia, and infections following rituximab. Ann Allergy Asthma Immunol 2023; 130:699-712. [PMID: 36706910 PMCID: PMC10247428 DOI: 10.1016/j.anai.2023.01.018] [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: 12/01/2022] [Revised: 12/23/2022] [Accepted: 01/16/2023] [Indexed: 01/26/2023]
Abstract
Rituximab is a chimeric anti-CD20 monoclonal antibody that targets CD20-expressing B lymphocytes, has a well-defined efficacy and safety profile, and is broadly used to treat a wide array of diseases. In this review, we cover the mechanism of action of rituximab and focus on hypogammaglobulinemia and late-onset neutropenia-2 immune effects secondary to rituximab-and subsequent infection. We review risk factors and highlight key considerations for immunologic monitoring and clinical management of rituximab-induced secondary immune deficiencies. In patients treated with rituximab, monitoring for hypogammaglobulinemia and infections may help to identify the subset of patients at high risk for developing poor B cell reconstitution, subsequent infections, and adverse complications. These patients may benefit from early interventions such as vaccination, antibacterial prophylaxis, and immunoglobulin replacement therapy. Systematic evaluation of immunoglobulin levels and peripheral B cell counts by flow cytometry, both at baseline and periodically after therapy, is recommended for monitoring. In addition, in those patients with prolonged hypogammaglobulinemia and increased infections after rituximab use, immunologic evaluation for inborn errors of immunity may be warranted to further risk stratification, increase monitoring, and assist in therapeutic decision-making. As the immunologic effects of rituximab are further elucidated, personalized approaches to minimize the risk of adverse reactions while maximizing benefit will allow for improved care of patients with decreased morbidity and mortality.
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Affiliation(s)
| | - Sara Barmettler
- Allergy and Clinical Immunology Unit, Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Boston, Massachusetts.
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4
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Viallard JF. [Management of hypogammaglobulinemia]. Rev Med Interne 2023; 44:133-138. [PMID: 36725480 DOI: 10.1016/j.revmed.2023.01.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 12/28/2022] [Accepted: 01/15/2023] [Indexed: 02/01/2023]
Abstract
Hypogammaglobulinemia (hypoγ) is defined as a serum IgG level < 7 g/L. It is most often detected on serum protein electrophoresis. Given the existence of transient hypoγ, its persistence should be checked at distance, preferably by requesting a blood test for IgG, IgA and IgM, which will be needed to characterize a possible primary immune deficiency (PID). In the case of association with a monoclonal component, the first step is to look for a cryoglobulin causing a false hypoγ. Otherwise, the etiological investigation is dictated by the clinical examination. For example, the notion of chronic diarrhea should lead to a search for an enteropathy causing a digestive loss of gammaglobulins (an ambiguous situation because some DIP can be complicated by an enteropathy). In the absence of an obvious explanation, a secondary cause must first be ruled out (secondary immune deficiencies are 30 times more common than PID). The first simple test to perform is 24-hour proteinuria, coupled with urinary protein electrophoresis, to rule out 2 diagnoses: nephrotic syndrome and light chain myeloma. Subsequently, blood immunophenotyping looking for a circulating B clone is recommended, allowing the investigations to be directed towards a lymphoid hemopathy. Drug-induced hypoγ may also be suspected if certain drugs such as corticosteroids, anti-epileptics or immunosuppressive agents (especially anti-CD20) are taken. The profile of a drug-induced hypoγ is different from that of a DIP: it is rarely profound, the IgA level is preserved and there is no deficit in switched memory B lymphocytes. Finally, a thoracoabdominal CT-scan will help to rule out a thymoma and identify a deep tumor syndrome. If all these tests are normal, a PID is suspected, the leader of which in adults remains the common variable immunodeficiency, which is the most frequent symptomatic PID in adults.
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Affiliation(s)
- J-F Viallard
- Service de médecine interne et maladies infectieuses, université de Bordeaux, hôpital Haut-Lévêque, CHU de Bordeaux, 5, avenue de Magellan, 33604 Pessac.
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5
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Allain V, Grandin V, Meignin V, Bertinchamp R, Boutboul D, Fieschi C, Galicier L, Gérard L, Malphettes M, Bustamante J, Fusaro M, Lambert N, Rosain J, Lenoir C, Kracker S, Rieux-Laucat F, Latour S, de Villartay JP, Picard C, Oksenhendler E. Lymphoma as an Exclusion Criteria for CVID Diagnosis Revisited. J Clin Immunol 2023; 43:181-191. [PMID: 36155879 DOI: 10.1007/s10875-022-01368-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Accepted: 09/14/2022] [Indexed: 01/18/2023]
Abstract
PURPOSE Hypogammaglobulinemia in a context of lymphoma is usually considered as secondary and prior lymphoma remains an exclusion criterion for a common variable immunodeficiency (CVID) diagnosis. We hypothesized that lymphoma could be the revealing symptom of an underlying primary immunodeficiency (PID), challenging the distinction between primary and secondary hypogammaglobulinemia. METHODS Within a French cohort of adult patients with hypogammaglobulinemia, patients who developed a lymphoma either during follow-up or before the diagnosis of hypogammaglobulinemia were identified. These two chronology groups were then compared. For patients without previous genetic diagnosis, a targeted next-generation sequencing of 300 PID-associated genes was performed. RESULTS A total of forty-seven patients had developed 54 distinct lymphomas: non-Hodgkin B cell lymphoma (67%), Hodgkin lymphoma (26%), and T cell lymphoma (7%). In 25 patients, lymphoma developed prior to the diagnosis of hypogammaglobulinemia. In this group of patients, Hodgkin lymphoma was overrepresented compared to the group of patients in whom lymphoma occurred during follow-up (48% versus 9%), whereas MALT lymphoma was absent (0 versus 32%). Despite the histopathological differences, both groups presented with similar characteristics in terms of age at hypogammaglobulinemia diagnosis, consanguinity rate, or severe T cell defect. Overall, genetic analyses identified a molecular diagnosis in 10/47 patients (21%), distributed in both groups and without peculiar gene recurrence. Most of these patients presented with a late onset combined immunodeficiency (LOCID) phenotype. CONCLUSION Prior or concomitant lymphoma should not be used as an exclusion criteria for CVID diagnosis, and these patients should be investigated accordingly.
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Affiliation(s)
- Vincent Allain
- University of Paris, Paris, France.,Department of Clinical Immunology, Saint-Louis Hospital, AP-HP, 1 avenue Claude Vellefaux, 75010, Paris, France
| | - Virginie Grandin
- Study Center for Primary Immunodeficiencies, Necker Hospital for Sick Children, AP-HP, Paris, France
| | | | - Rémi Bertinchamp
- Department of Clinical Immunology, Saint-Louis Hospital, AP-HP, 1 avenue Claude Vellefaux, 75010, Paris, France
| | - David Boutboul
- University of Paris, Paris, France.,Department of Clinical Immunology, Saint-Louis Hospital, AP-HP, 1 avenue Claude Vellefaux, 75010, Paris, France.,Centre de Référence Des Déficits Immunitaires Héréditaires (CEREDIH), Paris, France
| | - Claire Fieschi
- University of Paris, Paris, France.,Department of Clinical Immunology, Saint-Louis Hospital, AP-HP, 1 avenue Claude Vellefaux, 75010, Paris, France.,Centre de Référence Des Déficits Immunitaires Héréditaires (CEREDIH), Paris, France
| | - Lionel Galicier
- Department of Clinical Immunology, Saint-Louis Hospital, AP-HP, 1 avenue Claude Vellefaux, 75010, Paris, France.,Centre de Référence Des Déficits Immunitaires Héréditaires (CEREDIH), Paris, France
| | - Laurence Gérard
- Department of Clinical Immunology, Saint-Louis Hospital, AP-HP, 1 avenue Claude Vellefaux, 75010, Paris, France.,Centre de Référence Des Déficits Immunitaires Héréditaires (CEREDIH), Paris, France
| | - Marion Malphettes
- Department of Clinical Immunology, Saint-Louis Hospital, AP-HP, 1 avenue Claude Vellefaux, 75010, Paris, France.,Centre de Référence Des Déficits Immunitaires Héréditaires (CEREDIH), Paris, France
| | - Jacinta Bustamante
- University of Paris, Paris, France.,Study Center for Primary Immunodeficiencies, Necker Hospital for Sick Children, AP-HP, Paris, France.,Centre de Référence Des Déficits Immunitaires Héréditaires (CEREDIH), Paris, France.,Laboratory of Human Genetics of Infectious Diseases, Necker Branch, INSERM U1163, Imagine Institute, Necker Hospital for Sick Children, Paris, France.,St Giles Laboratory of Human Genetics of Infectious Diseases, Rockefeller Branch, Rockefeller University, New York, NY, USA
| | - Mathieu Fusaro
- University of Paris, Paris, France.,Study Center for Primary Immunodeficiencies, Necker Hospital for Sick Children, AP-HP, Paris, France
| | - Nathalie Lambert
- Study Center for Primary Immunodeficiencies, Necker Hospital for Sick Children, AP-HP, Paris, France
| | - Jérémie Rosain
- University of Paris, Paris, France.,Study Center for Primary Immunodeficiencies, Necker Hospital for Sick Children, AP-HP, Paris, France
| | - Christelle Lenoir
- University of Paris, Paris, France.,Laboratory of Lymphocyte Activation and Susceptibility to EBV, INSERM UMR 1163, Imagine Institute, Paris, France
| | - Sven Kracker
- University of Paris, Paris, France.,Laboratory of Human Lymphohematopoiesis, INSERM UMR 1163, Imagine Institute, Paris, France
| | - Frédéric Rieux-Laucat
- University of Paris, Paris, France.,Imagine Institute, INSERM UMR 1163, Paris, France
| | - Sylvain Latour
- University of Paris, Paris, France.,Laboratory of Lymphocyte Activation and Susceptibility to EBV, INSERM UMR 1163, Imagine Institute, Paris, France
| | - Jean-Pierre de Villartay
- University of Paris, Paris, France.,Laboratory "Genome Dynamics in the Immune System," INSERM UMR 1163, Imagine Institute, Paris, France
| | - Capucine Picard
- University of Paris, Paris, France.,Study Center for Primary Immunodeficiencies, Necker Hospital for Sick Children, AP-HP, Paris, France.,Centre de Référence Des Déficits Immunitaires Héréditaires (CEREDIH), Paris, France.,Laboratory of Lymphocyte Activation and Susceptibility to EBV, INSERM UMR 1163, Imagine Institute, Paris, France.,Immuno-Hematology Unit, Necker Hospital for Sick Children, AP-HP, Paris, France
| | - Eric Oksenhendler
- University of Paris, Paris, France. .,Department of Clinical Immunology, Saint-Louis Hospital, AP-HP, 1 avenue Claude Vellefaux, 75010, Paris, France. .,Centre de Référence Des Déficits Immunitaires Héréditaires (CEREDIH), Paris, France.
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6
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Ottaviano G, Sgrulletti M, Moschese V. Secondary rituximab-associated versus primary immunodeficiencies: The enigmatic border. Eur J Immunol 2022; 52:1572-1580. [PMID: 35892275 DOI: 10.1002/eji.202149667] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 05/22/2022] [Accepted: 07/26/2022] [Indexed: 12/14/2022]
Abstract
Rituximab (RTX), a chimeric monoclonal antibody targeting CD20-positive cells, is a valuable treatment option for malignant and benign immune-related disorders. The rationale of targeting the CD20 antigen relies on depletion of both healthy and autoreactive/malignant CD20-espressing cells, but normal B-cell reconstitution is expected within months after treatment. Nevertheless, a number of recent studies have documented prolonged B-cell deficiency associated with new-onset hypogammaglobulinemia in patients receiving RTX. Awareness of post-RTX hypogammaglobulinemia has become wider among clinicians, with a growing number of reports about the increased incidence, especially in children. Although these patients were previously regarded as affected by secondary/iatrogenic immunodeficiency, atypical clinical and immunological manifestations (e.g., severe or opportunistic infections; prolonged B-cell aplasia) raise concerns of delayed manifestations of genetic immunological disorders that have been unveiled by B-cell perturbation. As more patients with undiagnosed primary immune deficiency receiving RTX have been identified, it remains the challenge in discerning those that might display a higher risk of persistent RTX-associated hypogammaglobulinemia and need a tailored immunology follow-up. In this review, we summarize the principal evidence regarding post-RTX hypogammaglobulinemia and provide a guideline for identifying patients at higher risk of RTX-associated hypogammaglobulinemia that could harbor an inborn error of immunity.
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Affiliation(s)
- Giorgio Ottaviano
- Molecular and Cellular Immunology Unit, UCL Institute of Child Health, London, UK
| | - Mayla Sgrulletti
- Pediatric Immunopathology and Allergology Unit, Policlinico Tor Vergata, University of Rome Tor Vergata, Rome, Italy.,PhD. Program in Immunology, Molecular Medicine and Applied Biotechnology, University of Rome Tor Vergata, Rome, Italy
| | - Viviana Moschese
- Pediatric Immunopathology and Allergology Unit, Policlinico Tor Vergata, University of Rome Tor Vergata, Rome, Italy
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7
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Otani IM, Lehman HK, Jongco AM, Tsao LR, Azar AE, Tarrant TK, Engel E, Walter JE, Truong TQ, Khan DA, Ballow M, Cunningham-Rundles C, Lu H, Kwan M, Barmettler S. Practical guidance for the diagnosis and management of secondary hypogammaglobulinemia: A Work Group Report of the AAAAI Primary Immunodeficiency and Altered Immune Response Committees. J Allergy Clin Immunol 2022; 149:1525-1560. [PMID: 35176351 DOI: 10.1016/j.jaci.2022.01.025] [Citation(s) in RCA: 43] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Revised: 12/31/2021] [Accepted: 01/21/2022] [Indexed: 11/17/2022]
Abstract
Secondary hypogammaglobulinemia (SHG) is characterized by reduced immunoglobulin levels due to acquired causes of decreased antibody production or increased antibody loss. Clarification regarding whether the hypogammaglobulinemia is secondary or primary is important because this has implications for evaluation and management. Prior receipt of immunosuppressive medications and/or presence of conditions associated with SHG development, including protein loss syndromes, are histories that raise suspicion for SHG. In patients with these histories, a thorough investigation of potential etiologies of SHG reviewed in this report is needed to devise an effective treatment plan focused on removal of iatrogenic causes (eg, discontinuation of an offending drug) or treatment of the underlying condition (eg, management of nephrotic syndrome). When iatrogenic causes cannot be removed or underlying conditions cannot be reversed, therapeutic options are not clearly delineated but include heightened monitoring for clinical infections, supportive antimicrobials, and in some cases, immunoglobulin replacement therapy. This report serves to summarize the existing literature regarding immunosuppressive medications and populations (autoimmune, neurologic, hematologic/oncologic, pulmonary, posttransplant, protein-losing) associated with SHG and highlights key areas for future investigation.
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Affiliation(s)
- Iris M Otani
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, UCSF Medical Center, San Francisco, Calif.
| | - Heather K Lehman
- Division of Allergy, Immunology, and Rheumatology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY
| | - Artemio M Jongco
- Division of Allergy and Immunology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Great Neck, NY
| | - Lulu R Tsao
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, UCSF Medical Center, San Francisco, Calif
| | - Antoine E Azar
- Division of Allergy and Clinical Immunology, Johns Hopkins University School of Medicine, Baltimore
| | - Teresa K Tarrant
- Division of Rheumatology and Immunology, Duke University, Durham, NC
| | - Elissa Engel
- Division of Hematology and Oncology, Cincinnati Children's Hospital, Cincinnati, Ohio
| | - Jolan E Walter
- Division of Allergy and Immunology, Johns Hopkins All Children's Hospital, St Petersburg, Fla; Division of Allergy and Immunology, Morsani College of Medicine, University of South Florida, Tampa; Division of Allergy and Immunology, Massachusetts General Hospital for Children, Boston
| | - Tho Q Truong
- Divisions of Rheumatology, Allergy and Clinical Immunology, National Jewish Health, Denver
| | - David A Khan
- Division of Allergy and Immunology, University of Texas Southwestern Medical Center, Dallas
| | - Mark Ballow
- Division of Allergy and Immunology, Morsani College of Medicine, Johns Hopkins All Children's Hospital, St Petersburg
| | | | - Huifang Lu
- Department of General Internal Medicine, Section of Rheumatology and Clinical Immunology, The University of Texas MD Anderson Cancer Center, Houston
| | - Mildred Kwan
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill
| | - Sara Barmettler
- Allergy and Immunology, Massachusetts General Hospital, Boston.
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8
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Sgrulletti M, Cifaldi C, Di Cesare S, Kroegler B, Del Duca E, Ferradini V, Graziani S, Bengala M, Di Matteo G, Moschese V. Case Report: Crossing a rugged road in a primary immune regulatory disorder. Front Pediatr 2022; 10:1055091. [PMID: 36699297 PMCID: PMC9869371 DOI: 10.3389/fped.2022.1055091] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 12/19/2022] [Indexed: 01/11/2023] Open
Abstract
Over the last decades, Inborn Errors of Immunity (IEI) characterized by an immune dysregulatory picture, isolated or combined with infections, have been increasingly identified and referred as Primary Immune Regulatory Disorders (PIRD). PIRD diagnosis may be difficult due to heterogeneity of time onset, sequence of clinical manifestations and laboratory abnormalities. Moreover, the dissection of a PIRD vs. a secondary immunodeficiency (SID) might be a real challenge since the same indications for immunosuppressant treatments might represent per se a PIRD clinical expression. Here we report a female patient with a history of recurrent respiratory and urinary tract infections since early infancy and a diagnosis of Rheumatoid Arthritis in adulthood. After poor response to several biologicals she was treated with Rituximab and sent to immunology referral for a severe hypogammaglobulinemia. Clinical and immunological features matched a diagnosis of common variable immunodeficiency and when IgG replacement therapy and antibiotic prophylaxis were added a good infectious control was obtained. Next generation sequencing analysis has revealed a novel heterozygous VUS in the IKBKB gene (c.1465A > G; p.Ser489Gly). Functional analysis has shown a reduced capacity of B lymphocytes and CD4 positive T cells in inducing IκBα degradation, with negative impact on NF-kB pathway. Due to recurrent infections attributed to a common condition in childhood and to an exclusive autoimmunity-centered approach in adulthood, both diagnosis and suitable treatment strategies have suffered a significant delay. To reduce the diagnostic delay, pediatricians, general practitioners and specialists should be aware of IEI and the challenges to differentiate them from SID. Furthermore, genetic characterization and functional analysis may contribute to a personalized approach, in a perspective of targeted or semi-targeted therapy.
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Affiliation(s)
- Mayla Sgrulletti
- Pediatric Immunopathology and Allergology Unit, Policlinico Tor Vergata, University of Tor Vergata, Rome, Italy.,PhD Program in Immunology, Molecular Medicine and Applied Biotechnology, University of Rome Tor Vergata, Rome, Italy
| | - Cristina Cifaldi
- Academic Department of Pediatrics, Immune and Infectious Diseases Division, Research Unit of Primary Immunodeficiencies, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Silvia Di Cesare
- Department of Systems Medicine, University of Tor Vergata, Rome, Italy
| | - Barbara Kroegler
- Rheumatology Allergology and Clinical Immunology, Department "Medicina dei Sistemi", University of Rome Tor Vergata, Rome, Italy
| | - Elisabetta Del Duca
- Pediatric Immunopathology and Allergology Unit, Policlinico Tor Vergata, University of Tor Vergata, Rome, Italy
| | - Valentina Ferradini
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | - Simona Graziani
- Pediatric Immunopathology and Allergology Unit, Policlinico Tor Vergata, University of Tor Vergata, Rome, Italy
| | - Mario Bengala
- Laboratory of Medical Genetics, Tor Vergata Hospital, Rome, Italy
| | | | - Viviana Moschese
- Pediatric Immunopathology and Allergology Unit, Policlinico Tor Vergata, University of Tor Vergata, Rome, Italy
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9
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Luterbacher F, Bernard F, Baleydier F, Ranza E, Jandus P, Blanchard-Rohner G. Case Report: Persistent Hypogammaglobulinemia More Than 10 Years After Rituximab Given Post-HSCT. Front Immunol 2021; 12:773853. [PMID: 35003091 PMCID: PMC8727997 DOI: 10.3389/fimmu.2021.773853] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 11/26/2021] [Indexed: 12/14/2022] Open
Abstract
Rituximab (RTX) is an anti-CD20 monoclonal antibody that targets B cells-from the immature pre-B-cell stage in the bone marrow to mature circulating B cells-while preserving stem cells and plasma cells. It is used to treat autoimmune diseases, hematological malignancies, or complications after hematopoietic stem cell transplantation (HSCT). Its safety profile is acceptable; however, a subset of patients can develop persistent hypogammaglobulinemia and associated severe complications, especially in pediatric populations. We report the unrelated cases of two young men aged 17 and 22, presenting with persistent hypogammaglobulinemia more than 7 and 10 years after treatment with RTX, respectively, and administered after HSCT for hemolytic anemia and Epstein-Barr virus reactivation, respectively. Both patients' immunological workups showed low levels of total immunoglobulin, vaccine antibodies, and class switched-memory B cells but an increase in naive B cells, which can also be observed in primary immunodeficiencies such as those making up common variable immunodeficiency. Whole exome sequencing for one of the patients failed to detect a pathogenic variant causing a Mendelian immunological disorder. Annual assessments involving interruption of immunoglobulin replacement therapy each summer failed to demonstrate the recovery of endogenous immunoglobulin production or normal numbers of class switched-memory B cells 7 and 10 years after the patients' respective treatments with RTX. Although the factors that may lead to prolonged hypogammaglobulinemia after rituximab treatment (if necessary) remain unclear, a comprehensive immunological workup before treatment and long-term follow-up are mandatory to assess long-term complications, especially in children.
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Affiliation(s)
- Fanny Luterbacher
- The Children’s Hospital, Faculty of Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Fanette Bernard
- Pediatric Hematology/Oncology Unit, Faculty of Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Frédéric Baleydier
- Pediatric Hematology/Oncology Unit, Faculty of Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Emmanuelle Ranza
- Genetic Medicine Division, Geneva University Hospitals, Geneva, Switzerland
- Medigenome, Swiss Institute of Genomic Medicine, Geneva, Switzerland
| | - Peter Jandus
- Immunology and Allergology Division, Faculty of Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Geraldine Blanchard-Rohner
- Pediatric Immunology and Vaccinology Unit, General Pediatrics Division, Department for Women, Children, and Teenagers, Geneva University Hospitals and University of Geneva, Geneva, Switzerland
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10
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Lanaret C, Anglicheau D, Audard V, Büchler M, Caillard S, Couzi L, Malvezzi P, Mesnard L, Bertrand D, Martinez F, Pernin V, Ducloux D, Poulain C, Thierry A, Del Bello A, Rerolle JP, Greze C, Uro-Coste C, Aniort J, Lambert C, Bouvier N, Schvartz B, Maillard N, Sayegh J, Oniszczuk J, Morin MP, Legendre C, Kamar N, Heng AE, Garrouste C. Rituximab for recurrence of primary focal segmental glomerulosclerosis after kidney transplantation: Results of a nationwide study. Am J Transplant 2021; 21:3021-3033. [PMID: 33512779 DOI: 10.1111/ajt.16504] [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: 06/23/2020] [Revised: 01/15/2021] [Accepted: 01/15/2021] [Indexed: 01/25/2023]
Abstract
Rituximab (RTX) therapy for primary focal segmental glomerulosclerosis recurrence after kidney transplantation (KT) has been extensively debated. We aimed to assess the benefit of adding RTX to plasmapheresis (PP), corticosteroids, and calcineurin inhibitors (standard of care, SOC). We identified 148 adult patients who received KT in 12/2004-12/2018 at 21 French centers: 109 received SOC (Group 1, G1), and 39 received immediate RTX along with SOC (Group 2, G2). In G1, RTX was introduced after 28 days of SOC in the event of failure (G1a, n = 19) or PP withdrawal (G1b, n = 12). Complete remission (CR) was achieved in 46.6% of patients, and partial remission (PR) was achieved in 33.1%. The 10-year graft survival rates were 64.7% and 17.9% in responders and nonresponders, respectively. Propensity score analysis showed no difference in CR+PR rates between G1 (82.6%) and G2 (71.8%) (p = .08). Following the addition of RTX (G1a), 26.3% of patients had CR, and 31.6% had PR. The incidence of severe infections was similar between patients treated with and without RTX. In multivariable analysis, infection episodes were associated with hypogammaglobulinemia <5 g/L. RTX could be used in cases of SOC failure or remission for early discontinuation of PP without increasing the risk of infection.
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Affiliation(s)
- Camille Lanaret
- Department of Nephrology, Clermont-Ferrand University Hospital, Clermont-Ferrand, France
| | - Dany Anglicheau
- Assistance Publique des Hôpitaux de Paris, Service de Néphrologie et Transplantation, Hôpital Universitaire Necker-Enfants Malades, Université de Paris, Paris, France
| | - Vincent Audard
- Assistance Publique des Hôpitaux de Paris (AP-HP, Service de Néphrologie et Transplantation Centre de Référence Maladie Rare «Syndrome Néphrotique Idiopathique», Hôpitaux Universitaires Henri-Mondor, Univ Paris Est Créteil, INSERM, IMRB, Créteil, France
| | - Mathias Büchler
- Service de Néphrologie et Immunologie Clinique, CHRU de Tours, Tours, France
| | - Sophie Caillard
- Service de Néphrologie, University Hospital, Strasbourg, France
| | - Lionel Couzi
- Service de Néphrologie, Transplantation, Dialyse et Aphérèses, CHU de Bordeaux, Bordeaux, France
| | - Paolo Malvezzi
- Service de Néphrologie, Hémodialyse, Aphérèses et Transplantation Rénale, CHU Grenoble-Alpes, Grenoble, France
| | - Laurent Mesnard
- Assistance Publique des Hôpitaux de Paris, Hôpital Universitaire Tenon, Urgences Néphrologiques et Transplantation Rénale, Université de Paris, Paris, France
| | | | - Franck Martinez
- Assistance Publique des Hôpitaux de Paris, Service de Néphrologie et Transplantation, Hôpital Universitaire Necker-Enfants Malades, Université de Paris, Paris, France
| | - Vincent Pernin
- Service de Néphrologie, Dialyse et Transplantation, Hôpital Lapeyronie, CHU Montpellier, Montpellier, France
| | - Didier Ducloux
- Service de Néphrologie, Dialyse et Transplantation, CHU Besançon, Besançon, France
| | - Coralie Poulain
- Service de Néphrologie-Médecine Interne-Dialyse-Transplantation, CHU d'Amiens, Amiens, France
| | - Antoine Thierry
- Service de Néphrologie-Hémodialyse-Transplantation Rénale, CHU de Poitiers, Poitiers, France
| | - Arnaud Del Bello
- Département de Néphrologie et Transplantation d'Organes, CHU Toulouse, INSERM U1043, IFR-BMT, Université Paul Sabatier, Toulouse, France
| | - Jean P Rerolle
- Service de Néphrologie, Dialyse et Transplantation, CHU Limoges, Limoges, France
| | - Clarisse Greze
- Assistance Publique des Hôpitaux de Paris, Service de Néphrologie, Hôpital Universitaire Bichat-Claude-Bernard, Université de Paris, Paris, France
| | - Charlotte Uro-Coste
- Department of Nephrology, Clermont-Ferrand University Hospital, Clermont-Ferrand, France
| | - Julien Aniort
- Department of Nephrology, Clermont-Ferrand University Hospital, Clermont-Ferrand, France
| | - Céline Lambert
- Unité de Biostatistiques (DRCI, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Nicolas Bouvier
- Service de Néphrologie et Transplantation, CHU Caen, Caen, France
| | | | - Nicolas Maillard
- Service de Néphrologie et Transplantation, CHU Saint-Etienne, Saint-Etienne, France
| | - Johnny Sayegh
- Service de Néphrologie-Dialyse-Transplantation, CHU Angers, Angers, France
| | - Julie Oniszczuk
- Assistance Publique des Hôpitaux de Paris (AP-HP, Service de Néphrologie et Transplantation Centre de Référence Maladie Rare «Syndrome Néphrotique Idiopathique», Hôpitaux Universitaires Henri-Mondor, Univ Paris Est Créteil, INSERM, IMRB, Créteil, France
| | | | - Christophe Legendre
- Assistance Publique des Hôpitaux de Paris, Service de Néphrologie et Transplantation, Hôpital Universitaire Necker-Enfants Malades, Université de Paris, Paris, France
| | - Nassim Kamar
- Département de Néphrologie et Transplantation d'Organes, CHU Toulouse, INSERM U1043, IFR-BMT, Université Paul Sabatier, Toulouse, France
| | - Anne E Heng
- Department of Nephrology, Clermont-Ferrand University Hospital, Clermont-Ferrand, France
| | - Cyril Garrouste
- Department of Nephrology, Clermont-Ferrand University Hospital, Clermont-Ferrand, France
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11
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Dysfunctional Immune System Reconstitution After Rituximab Exposure In Utero. J Pediatr Hematol Oncol 2021; 43:e601-e604. [PMID: 32590421 DOI: 10.1097/mph.0000000000001871] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Accepted: 05/27/2020] [Indexed: 11/26/2022]
Abstract
Rituximab is an antibody that binds to B-lymphocytes and is increasingly used during pregnancy. As an immunoglobulin G, it will transfer across the placenta. Previous case reports describe a diversity of clinical presentations in neonates born following rituximab exposure in utero. Our case is the first to offer the long-term experience in the care of an infant with severe neutropenia and prolonged profound hypogammaglobulinemia and class-switching B cell defect after in utero rituximab exposure.
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12
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Fieschi C, Viallard JF. [Common variable immunodeficiency disorders: Updated diagnostic criteria and genetics]. Rev Med Interne 2021; 42:465-472. [PMID: 33875312 DOI: 10.1016/j.revmed.2021.03.328] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 02/26/2021] [Accepted: 03/21/2021] [Indexed: 12/24/2022]
Abstract
Common variable immunodeficiency disorders (CVID) are a heterogeneous group of conditions with hypogammaglobulinemia as the common denominator. These are the most common symptomatic primary immunodeficiency disorder in adults. Two different clinical forms are described: one group only develops infections, while a second includes (sometimes without infections, at least at the onset of disease course) a variety of non-infectious autoimmune, inflammatory, granulomatous and/or lymphoproliferative manifestations, sometimes revealing the disease and often observed in Internal Medicine. The international diagnostic criteria for CVID were updated in 2016 and are the subject of several comments in this general review. The recent use of new sequencing techniques makes it possible to better genetically define CVID. The identification of such a genetic disease makes it possible to treat pathophysiologically, in particular autoimmune and lymphoproliferative complications, with targeted treatments, sometimes used in other diseases. Determining a genetic disease in these patients also makes it possible to provide appropriate genetic counseling, and therefore to monitor mutated individuals, symptomatic or not.
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Affiliation(s)
- C Fieschi
- Département d'immunologie, Assistance Publique hôpitaux de Paris (AP-HP), Université de Paris, Paris, France; Inserm U976, institut de recherche Saint-Louis, hôpital Saint-Louis, centre constitutif déficit immunitaire chez l'adulte, CEREDIH, Paris, France
| | - J-F Viallard
- Service de médecine interne et maladies infectieuses, hôpital Haut-Lévêque, CHU de Bordeaux, 5, avenue de Magellan, 33604 Pessac, France; Université de Bordeaux, Bordeaux, France.
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13
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Morishita KA, Wagner-Weiner L, Yen EY, Sivaraman V, James KE, Gerstbacher D, Szymanski AM, O'Neil KM, Cabral DA. Consensus Treatment Plans for Severe Pediatric Antineutrophil Cytoplasmic Antibody-Associated Vasculitis. Arthritis Care Res (Hoboken) 2021; 74:1550-1558. [PMID: 33675161 DOI: 10.1002/acr.24590] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 02/17/2021] [Accepted: 03/02/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVE There is no standardized approach to the treatment of pediatric antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (ped-AAV). Because of the rarity of ped-AAV, randomized trials have not been feasible. The Childhood Arthritis and Rheumatology Research Alliance (CARRA) developed consensus treatment plans (CTPs) for severe ped-AAV to enable the future study of comparative effectiveness and safety. METHODS A workgroup of CARRA members (rheumatologists and nephrologists) formed the AAV working group. This group performed a literature review on existing evidence-based treatments and guidelines for the management of AAV. They determined that the target population for CTP development was patients <18 years with new-onset granulomatosis with polyangiitis (GPA), microscopic polyangiitis, or renal-limited AAV (eosinophilic-GPA was excluded) with presentation confined to those with severe disease i.e. organ- or life-threatening. Face-to-face consensus conferences employed nominal group techniques to identify treatment strategies for remission-induction and remission-maintenance, data elements to be systematically collected, and outcomes to be measured over time. RESULTS The ped-AAV workgroup developed two CTPs for each of the remission-induction and remission-maintenance of severe AAV. A corticosteroid-weaning regimen for induction and maintenance, a core dataset, and outcome measures were also defined. A random sample of CARRA membership voted acceptance of the CTPs for remission-induction and remission-maintenance with a 94% (75/80) and 98% (78/80) approval rate respectively. CONCLUSION Consensus methodology established standardized CTPs for treating severe ped-AAV. These CTPs were in principle accepted by CARRA-wide membership for pragmatic comparative effectiveness evaluation in a long-term registry.
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Affiliation(s)
| | | | | | | | | | | | | | | | - David A Cabral
- British Columbia's Children's Hospital, University of British Columbia
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14
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Bohelay G, Caux F, Musette P. Clinical and biological activity of rituximab in the treatment of pemphigus. Immunotherapy 2021; 13:35-53. [PMID: 33045883 DOI: 10.2217/imt-2020-0189] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
B-cells are major effector cells in autoimmunity since they differentiate into plasmocytes that produce pathogenic auto-antibody such as anti-desmoglein antibodies in pemphigus patients. Major advances were obtained using whole B-cell depleting therapies including anti-CD20 antibodies in refractory pemphigus patients that lead to rituximab approval in pemphigus patients in EU and USA. This review summarizes the data supporting the efficacy of rituximab in pemphigus and provides an overview of the reported immunological changes underlying its therapeutic action. Short and long-term remission in pemphigus is explained by the removal of autoreactive B-cells involved in the production of pathogenic IgG auto-antibodies and by enhancement of the appearance of regulatory B-cells that could maintain long term immune tolerance.
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Affiliation(s)
- Gérôme Bohelay
- Department of Dermatology, Groupe Hospitalier Paris Seine-Saint-Denis, AP-HP & INSERM UMR1125, Bobigny, France
| | - Frédéric Caux
- Department of Dermatology, Groupe Hospitalier Paris Seine-Saint-Denis, AP-HP & INSERM UMR1125, Bobigny, France
| | - Philippe Musette
- Department of Dermatology, Groupe Hospitalier Paris Seine-Saint-Denis, AP-HP & INSERM UMR1125, Bobigny, France
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15
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Engel ER, Walter JE. Rituximab and eculizumab when treating nonmalignant hematologic disorders: infection risk, immunization recommendations, and antimicrobial prophylaxis needs. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2020; 2020:312-318. [PMID: 33275746 PMCID: PMC7727502 DOI: 10.1182/hematology.2020000171] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/08/2023]
Abstract
Rituximab and eculizumab, monoclonal antibodies that deplete most B cells and activate the terminal complement, respectively, are used to treat nonmalignant hematologic disorders (NMHDs), sometimes with unfavorable effects on the immune system. Hypogammaglobulinemia and neutropenia have been reported with variable prevalence in patients treated with rituximab. Neutropenia is mild and transient, and serious infectious complications are uncommon, so treatment is not indicated. Hypogammaglobulinemia is of greater concern. There is a lack of agreement on a standardized definition, and pre- and posttreatment immunoglobulin (Ig) levels are not routinely obtained. The association among low Ig levels, infectious risk, and mortality and morbidity in this population is unclear. There are also no formal guidelines on indication, risk factors, and threshold level of IgG to prompt Ig replacement therapy (IgRT). Among patients with NMHD, preexisting or persistent hypogammaglobulinemia (PH) after treatment with rituximab has been linked to underlying primary immunodeficiency disorders; therefore, a high index of suspicion should be maintained, and immunologic and genetic evaluation should be considered. Overall, important strategies in managing patients who are receiving rituximab include routine monitoring of pre- and posttreatment IgG levels, immune reconstitution (eg, B-cell subsets), assessment of vaccination status and optimization before treatment, and individualized consideration for IgRT. Accordingly, we discuss immunizations. Eculizumab, most commonly used in the treatment of paroxysmal nocturnal hemoglobinuria and atypical hemolytic uremic syndrome, poses increased risk of meningococcal infections. To decrease the risk of infection, a meningococcal vaccination series is recommended before initiating therapy, and prophylactic antibiotics are preferred during the course of treatment.
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Affiliation(s)
- Elissa R. Engel
- Department of Pediatrics, University of South Florida, Tampa, FL
| | - Jolan E. Walter
- Department of Pediatrics, University of South Florida, Tampa, FL
- Division of Allergy and Immunology, Department of Pediatrics, Johns Hopkins All Children’s Hospital, St. Petersburg, FL; and
- Massachusetts General Hospital for Children, Boston, MA
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16
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Michel M, Lega JC, Terriou L. [Secondary ITP in adults]. Rev Med Interne 2020; 42:50-57. [PMID: 33139079 DOI: 10.1016/j.revmed.2020.08.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Accepted: 08/07/2020] [Indexed: 12/13/2022]
Abstract
Secondary forms of immune thrombocytopenia (ITP) represent approximately 20% of all ITP cases in adulthood and this rate increases with age. Since some causes may influence both the prognosis and outcome but also the management of ITP, a minimal workup must be performed at ITP diagnosis to look for an associated or underlying cause. Among adults, B-cell lymphomas and mainly chronic lymphocytic leukemia, systemic auto-immune diseases such as systemic lupus or primary immunodeficiencies mainly represented by common variable immunodeficiency are the most frequent causes of secondary ITP. Whereas first-line therapy used for secondary ITP is usually similar to the one commonly used in primary ITP and relies mostly on corticosteroids±intravenous immunoglobulin according to the severity of bleeding, second and third-line treatments must take into account the type and degree of activity of the underlying disease.
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Affiliation(s)
- M Michel
- Service de médecine interne, centre de référence pour les cytopénies auto-immunes de l'adulte, CHU Henri-Mondor, université Paris Est Créteil, Assistance publique-Hôpitaux de Paris, Créteil, France.
| | - J-C Lega
- Service de médecine interne et vasculaire, centre de compétences cytopénies auto-immunes, hôpital Lyon Sud, Lyon, France
| | - L Terriou
- Département de médecine interne et immunologie clinique, CHU de Lille, Lille, France
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17
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Rituximab and immune thrombocytopenia in adults: The state of knowledge 20 years later. Rev Med Interne 2020; 42:32-37. [PMID: 32680716 DOI: 10.1016/j.revmed.2020.05.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Accepted: 05/23/2020] [Indexed: 01/19/2023]
Abstract
Rituximab has been used for immune thrombocytopenia (ITP) for almost 20 years and is now considered a valid off-label second-line treatment. About 60% to 70% of patients with ITP show initial response to rituximab, but in half of these patients, the disease will eventually relapse. Therefore, in 30% of patients with persistent or chronic ITP, one course of rituximab at 375 mg/m2/week for 4 weeks or 2 fixed 1000-mg rituximab infusions allows for a sustained response rate at 5 years. Unfortunately, to date, no robust predictor of long-term sustained response has been found to assist the physician in deciding to treat with rituximab on an individual basis, and the choice of rituximab or another second-line treatment must be individualized and shared with the patient. Retreatment with rituximab has been found efficient, with a similar or higher magnitude and duration of response in most patients. Rituximab is usually well tolerated, with mainly mild and easily manageable infusion-related adverse events. Severe infections are uncommon, including in the long-term, and occur in patients with at least another contributing factor in more than two thirds. Several issues remain to be resolved. Indeed, head-to-head comparisons with other and new treatments in ITP and robust predictors of long-term response are urgently needed to better determine the position of rituximab in the therapeutic armamentarium for adult ITP. Additionally, the place of combination therapies, maintenance therapy with rituximab and rituximab in newly-diagnosed ITP deserve additional studies.
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18
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Shree T, Li Q, Glaser SL, Brunson A, Maecker HT, Haile RW, Levy R, Keegan THM. Impaired Immune Health in Survivors of Diffuse Large B-Cell Lymphoma. J Clin Oncol 2020; 38:1664-1675. [PMID: 32083991 PMCID: PMC7238489 DOI: 10.1200/jco.19.01937] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/27/2019] [Indexed: 01/07/2023] Open
Abstract
PURPOSE Therapeutic advances for diffuse large B-cell lymphoma (DLBCL) have led to an increasing number of survivors. Both DLBCL and its treatments perturb the immune system, yet little is known about immune health during extended survivorship. METHODS In this retrospective cohort study, we compared 21,690 survivors of DLBCL from the California Cancer Registry (CCR) to survivors of breast, prostate, head and neck, and melanoma cancers. We linked their CCR records to a statewide database documenting hospital, emergency room, and ambulatory surgery visits and investigated the incidence of autoimmune conditions, immune deficiencies, and infections 1-10 years after cancer diagnosis. RESULTS We found elevated incidence rate ratios (IRRs) for many immune-related conditions in survivors of DLBCL compared with other cancer survivors, including significantly and consistently elevated IRRs for viral and fungal pneumonias (up to 10.8-fold), meningitis (up to 5.3-fold), as well as humoral deficiency (up to 17.6-fold) and autoimmune cytopenias (up to 12-fold). IRRs for most conditions remained high even in the late survivorship period (5-10 years after cancer diagnosis). The elevated risks could not be explained by exposure to chemotherapy, stem-cell transplantation, or rituximab, except for IRRs for humoral deficiency, which were consistently higher after the incorporation of rituximab into DLBCL treatments. CONCLUSION To our knowledge, this is the largest cohort study with extended follow-up to demonstrate impaired immune health in survivors of DLBCL. The observed persistent, elevated risks for autoimmune diseases, immune deficiencies, and infectious conditions may reflect persistent immune dysregulation caused by lymphoma or treatment and may lead to excess morbidity and mortality during survivorship. Improved understanding of these risks could meaningfully improve long-term care of patients with DLBCL.
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Affiliation(s)
- Tanaya Shree
- Division of Oncology, Department of Medicine, Stanford University School of Medicine, Stanford, CA
| | - Qian Li
- Center for Oncology Hematology Outcomes Research and Training (COHORT) and Division of Hematology and Oncology, University of California Davis School of Medicine, Sacramento, CA
| | | | - Ann Brunson
- Center for Oncology Hematology Outcomes Research and Training (COHORT) and Division of Hematology and Oncology, University of California Davis School of Medicine, Sacramento, CA
| | - Holden T. Maecker
- Department of Microbiology and Immunology, Stanford University School of Medicine, Stanford, CA
| | - Robert W. Haile
- Center for Translational Population Sciences, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Ronald Levy
- Division of Oncology, Department of Medicine, Stanford University School of Medicine, Stanford, CA
| | - Theresa H. M. Keegan
- Center for Oncology Hematology Outcomes Research and Training (COHORT) and Division of Hematology and Oncology, University of California Davis School of Medicine, Sacramento, CA
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19
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Ducassou S, Gourdonneau A, Fernandes H, Leverger G, Pasquet M, Fouyssac F, Bayart S, Bertrand Y, Michel G, Jeziorski E, Thomas C, Abouchallah W, Viard F, Guitton C, Cheikh N, Pellier I, Carausu L, Droz C, Leblanc T, Aladjidi N. Second-line treatment trends and long-term outcomes of 392 children with chronic immune thrombocytopenic purpura: the French experience over the past 25 years. Br J Haematol 2020; 189:931-942. [PMID: 32130726 DOI: 10.1111/bjh.16448] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Accepted: 10/22/2019] [Indexed: 01/19/2023]
Abstract
Childhood chronic immune thrombocytopenic purpura (cITP) is a rare disease. In severe cases, there is no evidence for the optimal therapeutic strategy. Our aim was to describe the real-life management of non-selected children with cITP at diagnosis. Since 2004, patients less than 18 years old with cITP have been enrolled in the national prospective cohort, OBS'CEREVANCE. From 1990 to 2014, in 29 centres, 392 children were diagnosed with cITP. With a median follow-up of six years (2·0-25), 45% did not need second-line therapy, and 55% (n = 217) received one or more second lines, mainly splenectomy (n = 108), hydroxychloroquine (n = 61), rituximab (n = 61) or azathioprine (n = 40). The overall five-year further second-line treatment-free survival was 56% [95% CI 49·5-64.1]. The use of splenectomy significantly decreased over time. Hydroxychloroquine was administered to children with positive antinuclear antibodies, more frequently older and girls, and reached 55% efficacy. None of the patients died. Ten years after the initial diagnosis, 55% of the 56 followed children had achieved complete remission. Children with cITP do not need second-line treatments in 45% of cases. Basing the treatment decision on the pathophysiological pathways is challenging, as illustrated by ITP patients with positive antinuclear antibodies treated with hydroxychloroquine.
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Affiliation(s)
- Stéphane Ducassou
- Pediatric Hematology Unit, CIC1401, INSERM CICP, University Hospital of Bordeaux, Bordeaux, France.,Centre de Référence National des Cytopénies Autoimmunes de l'enfant (CEREVANCE), University Hospital of Bordeaux, Bordeaux, France.,University of Bordeaux, INSERM U1218, Bordeaux, France
| | - Anne Gourdonneau
- Pediatric Hematology Unit, CIC1401, INSERM CICP, University Hospital of Bordeaux, Bordeaux, France
| | - Helder Fernandes
- Centre de Référence National des Cytopénies Autoimmunes de l'enfant (CEREVANCE), University Hospital of Bordeaux, Bordeaux, France
| | - Guy Leverger
- Centre de Recherche Saint Antoine UMR_S 938, Service d'Hématologie Oncologie Pédiatrique, Centre de Référence National des Cytopénies Auto-immunes de l'enfant (CEREVANCE), AP-HP, Hôpital Armand Trousseau, Sorbonne Université, Paris, France
| | - Marlène Pasquet
- Pediatric Hematology Unit, University Hospital of Toulouse, Toulouse, France
| | - Fanny Fouyssac
- Pediatric Hematology Unit, University Hospital of Nancy, Nancy, France
| | - Sophie Bayart
- Pediatric Hematology Unit, University Hospital of Rennes, Rennes, France
| | - Yves Bertrand
- Pediatric Hematology Unit, Institute of Pediatric Hematology and Oncology, Claude Bernard University Lyon, Lyon, France
| | - Gérard Michel
- Pediatric Hematology Unit, University Hospital Timone Enfants, Marseille, France
| | - Eric Jeziorski
- Department of Pediatrics, Hôpital Arnaud de Villeneuve, University Hospital of Montpellier, Montpellier, France
| | - Caroline Thomas
- Pediatric Hematology Unit, University Hospital of Nantes, Nantes, France
| | - Wadih Abouchallah
- Pediatric Hematology Unit, University Hospital of Lille, Lille, France
| | - Florence Viard
- Centre de Référence National des Cytopénies Autoimmunes de l'enfant (CEREVANCE), University Hospital of Bordeaux, Bordeaux, France
| | - Corinne Guitton
- Department of Pediatrics, University Hospital of Bicêtre, Le Kremlin-Bicêtre, France
| | - Nathalie Cheikh
- Pediatric Hematology Unit, University Hospital of Besançon, Besançon, France
| | - Isabelle Pellier
- Pediatric Hematology Unit, University Hospital of Angers, Angers, France
| | - Liana Carausu
- Pediatric Hematology Unit, University Hospital of Brest, Brest, France
| | - Cécile Droz
- Inserm CIC1401, Bordeaux PharmacoEpi, University of Bordeaux, Bordeaux, France
| | - Thierry Leblanc
- Hematology Unit, Centre de référeNce National des Cytopénies Auto-Immunes de l'enfant (CEREVANCE), APHP - Hôpital Robert Debré, Paris, France
| | - Nathalie Aladjidi
- Pediatric Hematology Unit, CIC1401, INSERM CICP, University Hospital of Bordeaux, Bordeaux, France.,Centre de Référence National des Cytopénies Autoimmunes de l'enfant (CEREVANCE), University Hospital of Bordeaux, Bordeaux, France
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20
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Fatal Hypogammaglobulinemia 3 Years after Rituximab in a Patient with Immune Thrombocytopenia: An Underlying Genetic Predisposition? Case Reports Immunol 2019; 2019:2543038. [PMID: 31956452 PMCID: PMC6949674 DOI: 10.1155/2019/2543038] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Accepted: 11/07/2019] [Indexed: 12/04/2022] Open
Abstract
We report the case of a young woman who developed, 3 years after stopping Rituximab (RTX) prescribed for immune thrombocytopenia (ITP), a severe immunodeficiency leading to fatal pulmonary Epstein–Barr virus-positive diffuse large B-cell lymphoma. Genetic analysis led us to identify four missense mutations known to affect immune-deficiency–associated genes (FAS-ligand (FASL) gene (p.G167R); perforin-1 (PRF1 (p.R55C) gene; the Bloom syndrome RecQ-Like helicase (BLM) gene and the Moesin (MSN) (p.A122T) gene). The heterozygous mutation in the FASL gene, not present in the Genome Aggregation Database or ClinVar database, could suggest atypical Autoimmune LymphoProliferative Syndrome and its role in this patient's immunodepression is discussed. This observation strengthens the role of FASL gene mutation in severe clinical phenotypes of primary immune deficiency and raises new questions about the genetic background of ITP occurring in young people in a context of immunodeficiency.
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21
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Deshayes S, Khellaf M, Zarour A, Layese R, Fain O, Terriou L, Viallard J, Cheze S, Graveleau J, Slama B, Audia S, Cliquennois M, Ebbo M, Le Guenno G, Salles G, Bonmati C, Teillet F, Galicier L, Lambotte O, Hot A, Lefrère F, Mahévas M, Canoui‐Poitrine F, Michel M, Godeau B. Long-term safety and efficacy of rituximab in 248 adults with immune thrombocytopenia: Results at 5 years from the French prospective registry ITP-ritux. Am J Hematol 2019; 94:1314-1324. [PMID: 31489694 DOI: 10.1002/ajh.25632] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Revised: 08/29/2019] [Accepted: 09/03/2019] [Indexed: 01/19/2023]
Abstract
Rituximab is a second-line option in adults with immune thrombocytopenia (ITP), but the estimated 5-year response rate, only based on pooled retrospective data, is about 20%, and no studies have focused on long-term safety. We conducted a prospective multicenter registry of 248 adults with ITP treated with rituximab with 5 years of follow-up to assess its long-term safety and efficacy. The median follow-up was 68.4 [53.7-78.5] months. The incidence of severe infections was only 2/100 patient-years. Profound hypogammaglobulinemia (<5 g/L) developed in five patients at 15 to 31 months after the last rituximab infusion. In total, 25 patients died at a median age of 80 [69.5-83.9] years, corresponding to a mortality rate of 2.3/100 patient-years. Only three deaths related to infection that occurred 12 to 14 months after rituximab infusions could be due in part to rituximab. At 60 months of follow-up, 73 (29.4%) patients had a sustained response. On univariate and multivariate analysis, the only factor significantly associated with sustained response was a previous transient response to corticosteroids (P = .022). Overall, 24 patients with an initial response and then relapse received retreatment with rituximab, which gave a response in 92%, with a higher duration of response in 54%. As a result of its safety profile and its sustained response rate, rituximab remains an important option in the current therapeutic armamentarium for adult ITP. Retreatment could be an effective and safe option.
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Affiliation(s)
- Samuel Deshayes
- Service de Médecine Interne, Centre National de Référence des Cytopénies Auto‐Immunes de l'Adulte, Centre Hospitalier Universitaire Henri‐Mondor, Assistance Publique‐Hôpitaux de Paris Université Paris Est Créteil Créteil France
- Service de Médecine Interne Normandie Univ, UNICAEN, CHU de Caen Normandie Caen France
| | - Mehdi Khellaf
- Service de Médecine Interne, Centre National de Référence des Cytopénies Auto‐Immunes de l'Adulte, Centre Hospitalier Universitaire Henri‐Mondor, Assistance Publique‐Hôpitaux de Paris Université Paris Est Créteil Créteil France
| | - Anissa Zarour
- Unité de Recherche Clinique, Centre Hospitalier Universitaire Henri‐Mondor, Assistance Publique‐Hôpitaux de Paris Université Paris Est Créteil Créteil France
| | - Richard Layese
- Unité de Recherche Clinique, Centre Hospitalier Universitaire Henri‐Mondor, Assistance Publique‐Hôpitaux de Paris Université Paris Est Créteil Créteil France
- Service de Santé Publique CHU Henri‐Mondor, EA 7376 CEpiA, UPEC Créteil France
| | - Olivier Fain
- Service de Médecine Interne, Hôpital Saint‐Antoine, Assistance Publique‐Hôpitaux de Paris Sorbonne Université Paris France
| | - Louis Terriou
- Service de Médecine Interne Centre Hospitalier Régional Universitaire de Lille Lille France
| | - Jean‐François Viallard
- Département de Médecine Interne et Maladies Infectieuses Centre Hospitalier Universitaire Haut Lévêque, Université de Bordeaux Pessac France
| | - Stéphane Cheze
- Service d'Hématologie Clinique Normandie Univ, UNICAEN, CHU de Caen Normandie Caen France
| | - Julie Graveleau
- Service de Médecine Interne Centre Hospitalier Universitaire de Nantes Nantes France
| | - Borhane Slama
- Service d'Hématologie Centre Hospitalier d'Avignon Avignon France
| | | | - Manuel Cliquennois
- Département d'Hématologie Groupe Hospitalier de l'Institut Catholique de Lille Lille France
| | - Mikael Ebbo
- Service de Médecine Interne Hôpital de la Timone, Assistance Publique‐Hôpitaux de Marseille, Université Aix‐Marseille Marseille France
| | - Guillaume Le Guenno
- Service de Médecine Interne Centre Hospitalier Universitaire Estaing Clermont Ferrand France
| | - Gilles Salles
- Service d'Hématologie Hospices Civils de Lyon, Centre Hospitalier Lyon Sud, Pierre‐Bénite, University Claude Bernard Lyon 1 Lyon France
| | - Caroline Bonmati
- Service d'Hématologie Centre Hospitalier Universitaire de Nancy Nancy France
| | - France Teillet
- Département d'Immuno‐Hématologie Centre Hospitalier Universitaire Louis Mourier, Assistance Publique‐Hôpitaux de Paris Colombes France
| | - Lionel Galicier
- Service d'Immuno‐Pathologie Centre Hospitalier Universitaire Saint‐Louis, Assistance Publique‐Hôpitaux de Paris Paris France
| | - Olivier Lambotte
- Service de Médecine Interne Centre Hospitalier Universitaire Bicêtre, Assistance Publique‐Hôpitaux de Paris Paris France
| | - Arnaud Hot
- Service de Médecine Interne Groupement Hospitalier Edouard Herriot Lyon France
| | - François Lefrère
- Service d'Hématologie Centre Hospitalier Universitaire Necker, Assistance Publique‐ Hôpitaux de Paris Paris France
| | - Matthieu Mahévas
- Service de Médecine Interne, Centre National de Référence des Cytopénies Auto‐Immunes de l'Adulte, Centre Hospitalier Universitaire Henri‐Mondor, Assistance Publique‐Hôpitaux de Paris Université Paris Est Créteil Créteil France
| | - Florence Canoui‐Poitrine
- Unité de Recherche Clinique, Centre Hospitalier Universitaire Henri‐Mondor, Assistance Publique‐Hôpitaux de Paris Université Paris Est Créteil Créteil France
- Service de Santé Publique CHU Henri‐Mondor, EA 7376 CEpiA, UPEC Créteil France
| | - Marc Michel
- Service de Médecine Interne, Centre National de Référence des Cytopénies Auto‐Immunes de l'Adulte, Centre Hospitalier Universitaire Henri‐Mondor, Assistance Publique‐Hôpitaux de Paris Université Paris Est Créteil Créteil France
| | - Bertrand Godeau
- Service de Médecine Interne, Centre National de Référence des Cytopénies Auto‐Immunes de l'Adulte, Centre Hospitalier Universitaire Henri‐Mondor, Assistance Publique‐Hôpitaux de Paris Université Paris Est Créteil Créteil France
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22
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Ottaviano G, Marinoni M, Graziani S, Sibson K, Barzaghi F, Bertolini P, Chini L, Corti P, Cancrini C, D'Alba I, Gabelli M, Gallo V, Giancotta C, Giordano P, Lassandro G, Martire B, Angarano R, Mastrodicasa E, Bava C, Miano M, Naviglio S, Verzegnassi F, Saracco P, Trizzino A, Biondi A, Pignata C, Moschese V. Rituximab Unveils Hypogammaglobulinemia and Immunodeficiency in Children with Autoimmune Cytopenia. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2019; 8:273-282. [PMID: 31377437 DOI: 10.1016/j.jaip.2019.07.032] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/27/2019] [Revised: 07/14/2019] [Accepted: 07/16/2019] [Indexed: 01/19/2023]
Abstract
BACKGROUND Rituximab (RTX; anti-CD20 mAb) is a treatment option in children with refractory immune thrombocytopenia, autoimmune hemolytic anemia (AHA), and Evans syndrome (ES). Prevalence and clinical course of RTX-induced hypogammaglobulinemia in these patients are poorly known. OBJECTIVE To evaluate the prevalence and risk factors for persistent hypogammaglobulinemia (PH) after RTX use. METHODS Clinical and immunologic data from children treated with RTX for immune thrombocytopenia, AHA, and ES were collected from 16 Italian centers and 1 UK center at pre-RTX time point (0), +6 months, and yearly, up to 4 years post-RTX. Patients with previously diagnosed malignancy or primary immune deficiency (PID) were excluded. RESULTS We analyzed 53 children treated with RTX for immune thrombocytopenia (n = 36), AHA (n = 13), and ES (n = 4). Median follow-up was 30 months (range, 12-48). Thirty-two percent of patients (17 of 53) experienced PH, defined as IgG levels less than 2 SD for age at last follow-up (>12 months after RTX). Significantly delayed B-cell recovery was observed in children experiencing PH (hazard ratio, 0.55; P < .05), and 6 of 17 (35%) patients had unresolved B-cell lymphopenia at last follow-up. PH was associated with IgA and IgM deficiency, younger age at RTX use (51 vs 116 months; P < .01), a diagnosis of AHA/ES, and better response to RTX. Nine patients with PH (9 of 17 [53%]) were eventually diagnosed with a PID. CONCLUSIONS Post-RTX PH is a frequent condition in children with autoimmune cytopenia; a sizable proportion of patients with post-RTX PH were eventually diagnosed with a PID. In-depth investigation for PID is therefore recommended in these patients.
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Affiliation(s)
| | - Maddalena Marinoni
- Paediatric Department, ASST-Sette Laghi, "F. Del Ponte" Hospital, Varese, Italy
| | - Simona Graziani
- Paediatric Immunopathology and Allergology Unit, Tor Vergata University Hospital, University of Roma Tor Vergata, Rome, Italy
| | - Keith Sibson
- Department of Haematology, Great Ormond Street Hospital, London, United Kingdom
| | - Federica Barzaghi
- Paediatric Immunohematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Patrizia Bertolini
- Paediatric Hematology Oncology Unit, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
| | - Loredana Chini
- Paediatric Immunopathology and Allergology Unit, Tor Vergata University Hospital, University of Roma Tor Vergata, Rome, Italy
| | - Paola Corti
- Paediatric Haematology, Fondazione MBBM, Monza, Italy
| | - Caterina Cancrini
- University Department of Pediatrics, Unit of Immune and Infectious Diseases, Childrens' Hospital Bambino Gesù, Rome, Italy; Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Irene D'Alba
- Paediatric Haematology-Oncology, Maternal Infant Hospital "G. Salesi", Ancona, Italy
| | - Maria Gabelli
- Department of Women's and Children's Health, Pediatric Onco-Hematology Unit, University of Padova, Padova, Italy
| | - Vera Gallo
- Department of Translational Medical Sciences, Section of Pediatrics, Federico II University, Naples, Italy
| | - Carmela Giancotta
- University Department of Pediatrics, Unit of Immune and Infectious Diseases, Childrens' Hospital Bambino Gesù, Rome, Italy
| | - Paola Giordano
- Department of Biomedical Sciences and Human Oncology, University "A. Moro", Bari, Italy
| | - Giuseppe Lassandro
- Department of Biomedical Sciences and Human Oncology, University "A. Moro", Bari, Italy
| | - Baldassare Martire
- Paediatric Hematology Oncology Unit, "Policlinico-Giovanni XXII" Hospital, University of Bari, Bari, Italy
| | - Rosa Angarano
- Paediatric Hematology Oncology Unit, "Policlinico-Giovanni XXII" Hospital, University of Bari, Bari, Italy
| | | | - Cecilia Bava
- Haematology Unit, IRCCS Istituto "G. Gaslini", Genova, Italy
| | - Maurizio Miano
- Haematology Unit, IRCCS Istituto "G. Gaslini", Genova, Italy
| | - Samuele Naviglio
- Pediatric Hematology-Oncology, Institute for Maternal and Child Health, IRCCS "Burlo Garofolo", Trieste, Italy
| | - Federico Verzegnassi
- Pediatric Hematology-Oncology, Institute for Maternal and Child Health, IRCCS "Burlo Garofolo", Trieste, Italy
| | - Paola Saracco
- Paediatric Haematology, Department of Paediatrics, University Hospital Città della Salute e della Scienza di Torino, Torino, Italy
| | - Antonino Trizzino
- Department of Pediatric Hematology and Oncology, ARNAS Civico Di Cristina and Benfratelli Hospital, Palermo, Italy
| | - Andrea Biondi
- Paediatric Haematology, Milano-Bicocca University, Monza, Italy
| | - Claudio Pignata
- Department of Women's and Children's Health, Pediatric Onco-Hematology Unit, University of Padova, Padova, Italy
| | - Viviana Moschese
- Paediatric Immunopathology and Allergology Unit, Tor Vergata University Hospital, University of Roma Tor Vergata, Rome, Italy
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Abstract
PURPOSE OF REVIEW Induction of lymphocyte depletion is increasingly used as a therapeutic strategy for central and peripheral neuroinflammatory disease. However, there is also a growing recognition of the treatment-related complication of secondary antibody deficiency (SAD). Although the occurrence of hypogammaglobulinaemia is a recognized phenomenon during immunomodulation, robust data on the coexistence of impaired responses to immunization, and significant and/or atypical infections is scarce. Here we review the literature on SAD in anti-CD20 therapy. RECENT FINDINGS Several factors that may increase the incidence of SAD have now been identified, including low levels of immunoglobulins prior to the commencement of B-cell ablation therapy, duration of maintenance therapy, and concurrent or prior use of other immunosuppressing agents such as cyclophosphamide and steroids. Measurement of disease-specific antibodies and vaccine response are likely to be helpful adjuncts to measurement of serum immunoglobulin levels during B-cell depleting therapy. Supportive treatment may include amending the treatment schedule to limit cumulative dose. SUMMARY B-cell depleting agents offer considerable therapeutic benefit in neurology. We propose modifications in current practice that include risk stratification and early identification of SAD, with the aim of minimising morbidity and mortality related to this underappreciated condition.
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24
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Deshayes S, Godeau B. Second-line and beyond: treatment options for primary persistent and chronic immune thrombocytopenia. Platelets 2019; 31:291-299. [DOI: 10.1080/09537104.2019.1636018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Affiliation(s)
- Samuel Deshayes
- Service de Médecine Interne, Normandie Univ, UNICAEN, CHU de Caen Normandie, Caen, France
- Service de Médecine Interne, Centre de Référence des Cytopénies Auto-Immunes de l’Adulte, Centre Hospitalier Universitaire Henri-Mondor, Assistance Publique-Hôpitaux de Paris, Université Paris Est Créteil, Créteil, France
| | - Bertrand Godeau
- Service de Médecine Interne, Centre de Référence des Cytopénies Auto-Immunes de l’Adulte, Centre Hospitalier Universitaire Henri-Mondor, Assistance Publique-Hôpitaux de Paris, Université Paris Est Créteil, Créteil, France
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25
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Lucchini E, Zaja F, Bussel J. Rituximab in the treatment of immune thrombocytopenia: what is the role of this agent in 2019? Haematologica 2019; 104:1124-1135. [PMID: 31126963 PMCID: PMC6545833 DOI: 10.3324/haematol.2019.218883] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Accepted: 05/09/2019] [Indexed: 01/19/2023] Open
Abstract
The use of rituximab for the treatment of immune thrombocytopenia was greeted enthusiastically: it led to up to 60% response rates, making it, nearly 20 years ago, the main alternative to splenectomy, with far fewer side effects. However, long-term follow-up data showed that only 20-30% of patients maintained the remission. No significant changes have been registered using different dose schedules and timing of administration, while the combination with other drugs seemed promising. Higher response rates have been observed in young women before the chronic phase, but apart from that, other clinical factors or biomarkers predictive of response are still lacking. In this review we examine the historical and current role of rituximab in the management of immune thrombocytopenia, 20 years after its first use for the treatment of autoimmune diseases.
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Affiliation(s)
- Elisa Lucchini
- SC Ematologia, Azienda Sanitaria Universitaria Integrata Trieste, Italy
| | - Francesco Zaja
- SC Ematologia, Azienda Sanitaria Universitaria Integrata Trieste, Italy
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26
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Gupta S, Pattanaik D, Krishnaswamy G. Common Variable Immune Deficiency and Associated Complications. Chest 2019; 156:579-593. [PMID: 31128118 DOI: 10.1016/j.chest.2019.05.009] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Revised: 05/05/2019] [Accepted: 05/13/2019] [Indexed: 12/25/2022] Open
Abstract
Common variable immunodeficiency disorders refer to a relatively common primary immune deficiency group of diseases that present with infectious and inflammatory complications secondary to defects in antibody production and sometimes in cellular immunity. The disorder often presents in middle age or later with recurrent sinopulmonary infections, bronchiectasis, or a plethora of noninfectious complications such as autoimmune disorders, granulomatous interstitial lung disease, GI diseases, malignancies (including lymphoma), and multisystem granulomatous disease resembling sarcoidosis. Infusion of immunoglobulin by IV or subcutaneous is the mainstay of therapy. Management of complications is often difficult as immune suppression may be necessary in these conditions and entails the use of medications and biologicals which may further increase the risk for infections. Specifically, bronchiectasis, granulomatous lymphocytic interstitial lung disease, repeated sinopulmonary infections, and malignancies are sequelae of antibody deficiency that may present to the pulmonologist. This review will provide an updated understanding of the molecular aspects, differential diagnosis, presentations, and the management of common variable immunodeficiency disorders.
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Affiliation(s)
- Siddhi Gupta
- Department of Medicine, Division of Infectious Disease, Wake Forest School of Medicine, Winston Salem, NC
| | - Debendra Pattanaik
- Division of Allergy, Immunology and Rheumatology, University of Tennessee Health Science Center, Memphis TN
| | - Guha Krishnaswamy
- Department of Medicine, Division of Infectious Disease, Wake Forest School of Medicine, Winston Salem, NC; Division of Infectious Disease, Pulmonary, Allergy and Immunology, Wake Forest School of Medicine, Winston Salem, NC; Department of Medicine, Division of Allergy and Immunology, W.G. (Bill) Hefner VA Medical Center, Salisbury, NC.
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27
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Lacombe V, Lozac'h P, Orvain C, Lavigne C, Miot C, Pellier I, Urbanski G. [Treatment of ITP and AIHA in CVID: A systematic literature review]. Rev Med Interne 2019; 40:491-500. [PMID: 31101329 DOI: 10.1016/j.revmed.2019.02.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Revised: 02/11/2019] [Accepted: 02/24/2019] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Ten to 15% of common variable immunodeficiencies (CVID) develop auto-immune hemolytic anemia (AIHA) and immune thrombocytopenia (ITP). Treatment is based on immunosuppressants, which produce blocking effects in the CVID. Our objective was to assess their risk-benefit ratio in these immunocompromised patients. METHODS We identified 17 articles detailing the treatment of AIHA and/or ITP in patients suffering from CVID through a systematic review of the MEDLINE database. RESULTS The increased infectious risk with corticosteroids does not call into question their place in the first line of treatment of ITP and AIHA in CVID. High-doses immunoglobulin therapy remain reserved for ITP with a high risk of bleeding. In second-line treatment, rituximab appears to be effective, with a lower infectious risk than the splenectomy. Immunosuppressants (azathioprine, methotrexate, mycophenolate, cyclophosphamide, vincristine, ciclosporine) are moderately effective and often lead to severe infections, meaning that their use is justified only in resistant cases and steroid-sparing. Dapsone, danazol and anti-D immunoglobulins have an unfavorable risk-benefit ratio. The place of TPO receptor agonists is still to be defined. The establishment of immunoglobulin replacement in the place of immunosuppressants (except for short-term corticotherapy) or splenectomy appears to be essential to limit the risk of infections, including in the absence of previous infections. CONCLUSION The presence of CVID does not mean that it is necessary to give up on corticosteroids as a first-line treatment and rituximab as a second-line treatment for AIHA and ITP, but it should be in addition to immunoglobulin replacement. A splenectomy should be reserved as a third-line treatment.
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Affiliation(s)
- V Lacombe
- Service de médecine interne et maladies vasculaires, CHU d'Angers, 4, rue Larrey, 49000 Angers, France
| | - P Lozac'h
- Service de médecine interne et maladies vasculaires, CHU d'Angers, 4, rue Larrey, 49000 Angers, France
| | - C Orvain
- Service des maladies du sang, CHU d'Angers, 4, rue Larrey, 49000 Angers, France
| | - C Lavigne
- Service de médecine interne et maladies vasculaires, CHU d'Angers, 4, rue Larrey, 49000 Angers, France; Centre de référence des déficits immunitaires primitifs CEREDIH, CHU d'Angers, site constitutif Angers, 4, rue Larrey, 49000 Angers, France
| | - C Miot
- Centre de référence des déficits immunitaires primitifs CEREDIH, CHU d'Angers, site constitutif Angers, 4, rue Larrey, 49000 Angers, France; Service d'immunologie-hématologie et oncologie pédiatriques, CHU d'Angers, 4, rue Larrey, 49000 Angers, France; Laboratoire d'immunologie et allergologie, CHU d'Angers, 4, rue Larrey, 49000 Angers, France
| | - I Pellier
- Centre de référence des déficits immunitaires primitifs CEREDIH, CHU d'Angers, site constitutif Angers, 4, rue Larrey, 49000 Angers, France; Service d'immunologie-hématologie et oncologie pédiatriques, CHU d'Angers, 4, rue Larrey, 49000 Angers, France
| | - G Urbanski
- Service de médecine interne et maladies vasculaires, CHU d'Angers, 4, rue Larrey, 49000 Angers, France; Centre de référence des déficits immunitaires primitifs CEREDIH, CHU d'Angers, site constitutif Angers, 4, rue Larrey, 49000 Angers, France.
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Wijetilleka S, Mukhtyar C, Jayne D, Ala A, Bright P, Chinoy H, Harper L, Kazmi M, Kiani-Alikhan S, Li C, Misbah S, Oni L, Price-Kuehne F, Salama A, Workman S, Wrench D, Karim MY. Immunoglobulin replacement for secondary immunodeficiency after B-cell targeted therapies in autoimmune rheumatic disease: Systematic literature review. Autoimmun Rev 2019; 18:535-541. [PMID: 30844552 DOI: 10.1016/j.autrev.2019.03.010] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Accepted: 12/25/2018] [Indexed: 01/11/2023]
Abstract
BACKGROUND Consensus guidelines are not available for the use of immunoglobulin replacement therapy (IGRT) in patients developing iatrogenic secondary antibody deficiency following B-cell targeted therapy (BCTT) in autoimmune rheumatic disease. OBJECTIVES To evaluate the role of IGRT to manage hypogammaglobulinemia following BCTT in autoimmune rheumatic disease (AIRD). METHODS Using an agreed search string we performed a systematic literature search on Medline with Pubmed as vendor. We limited the search to English language papers with abstracts published over the last 10 years. Abstracts were screened for original data regarding hypogammaglobulinemia following BCTT and the use of IGRT for hypogammaglobulinemia following BCTT. We also searched current recommendations from national/international organisations including British Society for Rheumatology, UK Department of Health, American College of Rheumatology, and American Academy of Asthma, Allergy and Immunology. RESULTS 222 abstracts were identified. Eight papers had original relevant data that met our search criteria. These studies were largely retrospective cohort studies with small patient numbers receiving IGRT. The literature highlights the induction of a sustained antibody deficiency, risk factors for hypogammaglobulinemia after BCTT including low baseline serum IgG levels, how to monitor patients for the development of hypogammaglobulinemia and the limited evidence available on intervention thresholds for commencing IGRT. CONCLUSION The benefit of BCTT needs to be balanced against the risk of inducing a sustained secondary antibody deficiency. Consensus guidelines would be useful to enable appropriate assessment prior to and following BCTT in preventing and diagnosing hypogammaglobulinemia. Definitions for symptomatic hypogammaglobulinemia, intervention thresholds and treatment targets for IGRT, and its cost-effectiveness are required.
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Affiliation(s)
| | - Chetan Mukhtyar
- Department of Rheumatology, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, Norfolk, UK.
| | - David Jayne
- Department of Medicine, University of Cambridge School of Clinical Medicine, Cambridge, UK.
| | - Aftab Ala
- Department of Gastroenterology and Hepatology, Royal Surrey County Hospital, Guildford, UK; Department of Clinical and Experimental Medicine, University of Surrey, Guildford, UK.
| | - Philip Bright
- Department of Immunology, North Bristol NHS Trust, Bristol, UK.
| | - Hector Chinoy
- Department of Rheumatology, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre, Salford, UK.
| | - Lorraine Harper
- Department of Nephrology, Institute of Clinical Sciences, College of Medical and Dental Science, University of Birmingham, Birmingham, UK.
| | - Majid Kazmi
- Department of Haematology, Guy's and St Thomas' NHS Foundation Trust, London, UK.
| | | | - Charles Li
- Department of Rheumatology, Royal Surrey County Hospital, Guildford, UK.
| | - Siraj Misbah
- Department of Immunology, Oxford University Hospitals, Oxford, UK.
| | - Louise Oni
- Department of Paediatric Nephrology, Alder Hey Children's NHS Foundation Trust Hospital, Liverpool, UK.
| | - Fiona Price-Kuehne
- Department of Paediatrics, University of Cambridge School of Clinical Medicine, Cambridge, UK.
| | - Alan Salama
- Department of Nephrology, University College London Centre for Nephrology, Royal Free Hospital, London, UK.
| | - Sarita Workman
- Department of Immunology, Royal Free London NHS Foundation Trust, London, UK.
| | - David Wrench
- Department of Haematology, Guy's and St Thomas' NHS Foundation Trust, London, UK.
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Cuker A. Transitioning patients with immune thrombocytopenia to second-line therapy: Challenges and best practices. Am J Hematol 2018; 93:816-823. [PMID: 29574922 PMCID: PMC6055642 DOI: 10.1002/ajh.25092] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Revised: 03/11/2018] [Accepted: 03/14/2018] [Indexed: 01/19/2023]
Abstract
In patients with immune thrombocytopenia who do not adequately respond to first-line therapy, there is no clear consensus on which second-line therapy to initiate and when. This situation leads to suboptimal approaches, including prolonged exposure to treatments that are not intended for long-term use (eg, corticosteroids) and overuse of off-label therapies (eg, rituximab) while approved, more efficacious options exist. These approaches may not only fail to address symptoms and burden of disease, but may also worsen health-related quality of life. A better understanding of available second-line treatments may ensure best use of therapeutic options and thereby optimize patient outcomes.
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Affiliation(s)
- Adam Cuker
- Department of Medicine and Department of Pathology & Laboratory Medicine, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvania
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Sacco KA, Abraham RS. Consequences of B-cell-depleting therapy: hypogammaglobulinemia and impaired B-cell reconstitution. Immunotherapy 2018; 10:713-728. [PMID: 29569510 DOI: 10.2217/imt-2017-0178] [Citation(s) in RCA: 78] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
Rituximab is a chimeric monoclonal antibody used to treat hematologic and autoimmune diseases by depleting CD20-expressing B cells. Patients may develop hypogammaglobulinemia following treatment, with some demonstrating failure of B-cell recovery. The true frequency of hypogammaglobulinemia and/or impaired B-cell reconstitution post rituximab is unknown due to the lack of prospective studies in different patient cohorts. The clinical significance remains controversial; some patients have recurrent infections while others are relatively asymptomatic. The aim of this review is to describe the prevalence of hypogammaglobulinemia and the associated risk for developing severe infection, in patients with differing underlying clinical conditions treated with rituximab. This may facilitate classification and prognostication of patients who develop these conditions and identify patients who may be at high risk of developing these complications, including those who may benefit from immunoglobulin replacement therapy.
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Affiliation(s)
- Keith A Sacco
- Department of Medicine, Mayo Clinic, Jacksonville, FL 32224, USA
| | - Roshini S Abraham
- Department of Laboratory Medicine & Pathology & Medicine, Mayo Clinic, Rochester, MN 55905, USA
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Ghrenassia E, Mariotte E, Azoulay E. Rituximab-related Severe Toxicity. ANNUAL UPDATE IN INTENSIVE CARE AND EMERGENCY MEDICINE 2018 2018. [PMCID: PMC7176228 DOI: 10.1007/978-3-319-73670-9_43] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Delayed recovery of serum immunoglobulin G is a poor prognostic marker in patients with follicular lymphoma treated with rituximab maintenance. Ann Hematol 2017; 97:289-297. [DOI: 10.1007/s00277-017-3175-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2017] [Accepted: 11/06/2017] [Indexed: 10/18/2022]
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Morishita KA, Tiller G, Cabral DA. Therapeutic Management of Pediatric Antineutrophil Cytoplasmic Antibody (ANCA)-Associated Vasculitis. CURRENT TREATMENT OPTIONS IN RHEUMATOLOGY 2017. [DOI: 10.1007/s40674-017-0077-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Li PH, Lau CS. Secondary antibody deficiency and immunoglobulin replacement. HONG KONG BULLETIN ON RHEUMATIC DISEASES 2017. [DOI: 10.1515/hkbrd-2017-0001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Abstract
Antibody deficiencies can be either primary or secondary, leading to significant morbidity and mortality without appropriate management. Secondary antibody deficiency can be due to various diseases or iatrogenic causes, especially with the use of immunosuppressive agents such as B-cell depleting therapies. Unlike its primary counterpart, little is known regarding the management of secondary antibody deficiency and it remains an underappreciated entity. This is a growing concern with the growing numbers of patients on various immunosuppressant therapies and increasing survivors of autoimmune diseases and haematological malignancies. In this report, we review the diagnosis and management of secondary antibody deficiency, especially after rituximab-induced hypogammaglobulinemia.
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Affiliation(s)
- Philip H. Li
- Division of Rheumatology and Clinical Immunology, Department of Medicine, Queen Mary Hospital , University of Hong Kong , Hong Kong , Hong Kong
| | - Chak-Sing Lau
- Division of Rheumatology and Clinical Immunology, Department of Medicine, Queen Mary Hospital , University of Hong Kong , Hong Kong , Hong Kong
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Rajput R, Denniston AK, Murray PI. False Negative Toxoplasma Serology in an Immunocompromised Patient with PCR Positive Ocular Toxoplasmosis. Ocul Immunol Inflamm 2017; 26:1200-1202. [PMID: 28700250 DOI: 10.1080/09273948.2017.1332769] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
PURPOSE The authors report a case of a 60-year-old Caucasian male with a background of treated Chronic Lymphocytic Leukaemia (CLL) with secondary hypogammaglobulinaemia present with toxoplasma chorioretinitis and negative serum toxoplasma serology on presentation and on subsequent reactivation. METHODS Retrospective case notes review with fundal photographs. RESULTS In this case, on initial presentation and on recurrence, the patient's serum anti-Toxoplasma IgG remained negative. The diagnosis was made on quantitative PCR of vitreous initially and aqueous humor on reactivation. CONCLUSIONS Despite negative serology, one must still consider ocular toxoplasmosis especially in CLL patients where the clinical picture could be compatible. Hypogammaglobulinaemia, the inability to produce IgG antibodies, is a well-recognized complication of CLL. Intraocular fluid sampling is essential in these cases where the sensitivity of PCR on either aqueous or vitreous humor has been shown to be higher in immunocompromised patients.
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Affiliation(s)
- Rehan Rajput
- a Birmingham and Midland Eye Centre, City Hospital, Sandwell and West Birmingham Hospitals NHS Trust , Birmingham , UK
| | - Alastair K Denniston
- b Department of Ophthalmology , Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust , Birmingham , UK
| | - Philip I Murray
- a Birmingham and Midland Eye Centre, City Hospital, Sandwell and West Birmingham Hospitals NHS Trust , Birmingham , UK.,c Academic Unit of Ophthalmology , Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham , Edgbaston, Birmingham , UK
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Ducassou S, Leverger G, Fernandes H, Chambost H, Bertrand Y, Armari-Alla C, Nelken B, Monpoux F, Guitton C, Leblanc T, Fisher A, Lejars O, Jeziorski E, Fouissac F, Lutz P, Pasquet M, Pellier I, Piguet C, Vic P, Bayart S, Marie-Cardine A, Michel M, Perel Y, Aladjidi N. Benefits of rituximab as a second-line treatment for autoimmune haemolytic anaemia in children: a prospective French cohort study. Br J Haematol 2017; 177:751-758. [PMID: 28444729 DOI: 10.1111/bjh.14627] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2016] [Accepted: 12/31/2016] [Indexed: 11/28/2022]
Abstract
Childhood autoimmune haemolytic anaemia (AIHA) requires second-line immunosuppressive therapy in 30-50% of cases. It appears that rituximab is indicated in such circumstances. This prospective national study reports the practice, efficacy and tolerance of rituximab in children with isolated AIHA and AIHA in the setting of Evans syndrome (ES). Sixty-one children were given rituximab between 2000 and 2014. The median interval from diagnosis to rituximab was 9·9 [interquartile range (IQR) 1·6-28·5] months. Forty-six patients responded (75%) and the 6-year relapse-free survival (RFS) was 48%. Twenty patients relapsed at a median interval of 10·8 (IQR 3·9-18·7) months, rituximab allowed steroid withdrawal in 44/61 (72%) of children. In isolated AIHA, complete response and 6-year RFS were significantly higher than in ES (P < 0·05). Ten out of 61 patients were infants, seven of who responded with a 6-year RFS of 71%. Among patients without immunoglobulin substitution before rituximab, 4 are still receiving substitutions. Five patients died, including one potentially attributable to rituximab. This large observational series of childhood AIHA established the rituximab benefit-risk ratio, allowing steroid withdrawal, with 37% of long-term responders, mainly in isolated AIHA. All subgroups of patients drew benefit. Our long-term results indicate the baseline to be challenged by new treatment approaches.
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Affiliation(s)
- Stéphane Ducassou
- Paediatric Oncology Haematology Unit/CEREVANCE/CIC 1401, Inserm CICP, University Hospital of Bordeaux, Paediatric Hospital, Bordeaux, France
| | - Guy Leverger
- Paediatric Onco-Haematology Unit, Hôpital Trousseau, APHP, Paris, France
| | - Helder Fernandes
- Paediatric Oncology Haematology Unit/CEREVANCE/CIC 1401, Inserm CICP, University Hospital of Bordeaux, Paediatric Hospital, Bordeaux, France
| | - Hervé Chambost
- Paediatric Haematology Unit, Hôpital La Timone Enfants - APHM, Marseille, France
| | - Yves Bertrand
- Paediatric Immuno-Haematology Unit, Institut d'Hématologie et d'Oncologie Pédiatrique (IHOP), Lyon, France
| | | | - Brigitte Nelken
- Paediatrics Unit, University Hospital of Lille, Lille, France
| | - Fabrice Monpoux
- Paediatric Onco-Haematology Unit, University Hospital of Nice, Nice, France
| | - Corinne Guitton
- Paediatrics Unit, University Hospital Bicêtre - APHP, Le Kremlin-Bicêtre, France
| | - Thierry Leblanc
- Haematology Unit, Hôpital Robert Debré - APHP, Paris, France
| | - Alain Fisher
- Immuno-Haematology Unit, Hôpital Necker - APHP, Paris, France
| | - Odile Lejars
- Paediatric Onco-Haematology Unit, University Hospital of Tours, Tours, France
| | - Eric Jeziorski
- Paediatric Onco-Haematology Unit, University Hospital of Montpellier, Montpellier, France
| | - Fanny Fouissac
- Paediatric Onco-Haematology Unit, University Hospital of Nancy, Nancy, France
| | - Patrick Lutz
- Paediatric Onco-Haematology Unit, University Hospital of Strasbourg, Strasbourg, France
| | - Marlène Pasquet
- Paediatric Onco-Haematology Unit, University Hospital of Toulouse, Toulouse, France
| | - Isabelle Pellier
- Paediatric Onco-Haematology Unit, University Hospital of Angers, Angers, France
| | - Christophe Piguet
- Paediatric Onco-Haematology Unit, University Hospital of Limoges, Limoges, France
| | - Philippe Vic
- Paediatric Unit, General Hospital of Quimper, Quimper, France
| | - Sophie Bayart
- Paediatric Onco-Haematology Unit, University Hospital of Rennes, Rennes, France
| | - Aude Marie-Cardine
- Paediatric Onco-Haematology Unit, University Hospital of Rouen, Rouen, France
| | - Marc Michel
- Department of Internal Medicine, Henri Mondor University Hospital, APHP, Université Paris-Est Créteil, Créteil, France
| | - Yves Perel
- Paediatric Oncology Haematology Unit/CEREVANCE/CIC 1401, Inserm CICP, University Hospital of Bordeaux, Paediatric Hospital, Bordeaux, France
| | - Nathalie Aladjidi
- Paediatric Oncology Haematology Unit/CEREVANCE/CIC 1401, Inserm CICP, University Hospital of Bordeaux, Paediatric Hospital, Bordeaux, France
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Cherin P, de Jaeger C, Crave JC, Delain JC, Tadmouri A, Amoura Z. Subcutaneous immunoglobulins for the treatment of a patient with antisynthetase syndrome and secondary chronic immunodeficiency after anti-CD20 treatment: a case report. J Med Case Rep 2017; 11:58. [PMID: 28257650 PMCID: PMC5336681 DOI: 10.1186/s13256-017-1211-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2016] [Accepted: 01/14/2017] [Indexed: 01/10/2023] Open
Abstract
Background Antisynthetase syndrome is a rare and debilitating multiorgan disease characterized by inflammatory myopathy, interstitial lung disease, cutaneous involvement, and frequent chronic inflammation of the joints. Standard treatments include corticosteroids and immunosuppressants. In some cases, treatment resistance may develop. Administration of immunoglobulins intravenously is recommended in patients with drug-resistant antisynthetase syndrome. Case presentation Here, we describe the case of a 56-year-old woman of Algerian origin. She is the first case of a patient with multidrug-resistant antisynthetase syndrome featuring pulmonary involvement and arthropathy, and chronic secondary immune deficiency with recurrent infections, after anti-CD20 treatment, in which her primary antisynthetase syndrome-related symptoms and secondary immune deficiency were treated successfully with subcutaneous administration of immunoglobulin. The administration of immunoglobulin subcutaneously was introduced at a dose of 2 g/kg per month and was well tolerated. Clinical improvement was observed within 3 months of initiation of subcutaneous administration of immunoglobulin. After 22 months of treatment, she showed a significant improvement in terms of muscle strength, pulmonary involvement, arthralgia, and immunodeficiency. Her serum creatine phosphokinase and C-reactive protein levels remained normal. Finally, she was compliant and entirely satisfied with the treatment. Conclusions Taken together, these observations suggest that administration of immunoglobulin subcutaneously may be a useful therapeutic approach to tackle steroid-refractory antisynthetase syndrome while ensuring minimal side effects and improved treatment compliance. This treatment also allowed, in our case, for the regression of the chronic immunodeficiency secondary to rituximab treatment.
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Affiliation(s)
- Patrick Cherin
- Department of Internal Medicine, Pitié-Salpetrière Hospital Group, 47-83 Boulevard de l'Hôpital, 75013, Paris, France.
| | | | | | | | | | - Zahir Amoura
- Department of Internal Medicine, Pitié-Salpetrière Hospital Group, 47-83 Boulevard de l'Hôpital, 75013, Paris, France
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Jolles S, Chapel H, Litzman J. When to initiate immunoglobulin replacement therapy (IGRT) in antibody deficiency: a practical approach. Clin Exp Immunol 2017; 188:333-341. [PMID: 28000208 DOI: 10.1111/cei.12915] [Citation(s) in RCA: 77] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/03/2016] [Indexed: 12/13/2022] Open
Abstract
Primary antibody deficiencies (PAD) constitute the majority of all primary immunodeficiency diseases (PID) and immunoglobulin replacement forms the mainstay of therapy for many patients in this category. Secondary antibody deficiencies (SAD) represent a larger and expanding number of patients resulting from the use of a wide range of immunosuppressive therapies, in particular those targeting B cells, and may also result from renal or gastrointestinal immunoglobulin losses. While there are clear similarities between primary and secondary antibody deficiencies, there are also significant differences. This review describes a practical approach to the clinical, laboratory and radiological assessment of patients with antibody deficiency, focusing on the factors that determine whether or not immunoglobulin replacement should be used. The decision to treat is more straightforward when defined diagnostic criteria for some of the major PADs, such as common variable immunodeficiency disorders (CVID) or X-linked agammaglobulinaemia (XLA), are fulfilled or, indeed, when there is a very low level of immunoglobulin production in association with an increased frequency of severe or recurrent infections in SAD. However, the presentation of many patients is less clear-cut and represents a considerable challenge in terms of the decision whether or not to treat and the best way in which to assess the outcome of therapy. This decision is important, not least to improve individual quality of life and reduce the morbidity and mortality associated with recurrent infections but also to avoid inappropriate exposure to blood products and to ensure that immunoglobulin, a costly and limited resource, is used to maximal benefit.
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Affiliation(s)
- S Jolles
- Immunodeficiency Centre for Wales, Department of Immunology, University Hospital of Wales, Cardiff, UK
| | - H Chapel
- Department of Clinical Immunology, University of Oxford, UK
| | - J Litzman
- Department of Clinical Immunology and Allergology, St Annes's University Hospital, Faculty of Medicine, Masaryk University, Brno, Czech Republic
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Arays R, Goyal S, Jordan KM. Common variable immunodeficiency, immune thrombocytopenia, rituximab and splenectomy: important considerations. Postgrad Med 2016; 128:567-72. [DOI: 10.1080/00325481.2016.1199250] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Bizjak M, Bruck O, Kanduc D, Praprotnik S, Shoenfeld Y. Vaccinations and secondary immune thrombocytopenia with antiphospholipid antibodies by human papillomavirus vaccine. Semin Hematol 2016; 53 Suppl 1:S48-50. [PMID: 27312165 DOI: 10.1053/j.seminhematol.2016.04.014] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
A 13-year-old girl developed immune thrombocytopenic purpura (ITP) and concomitant positive antiphospholipid antibodies (aPL) following vaccination with a quadrivalent human papillomavirus (HPV) vaccine. During the course of a disease, she developed clinical manifestation with bleeding and she was treated with intravenous immunoglobulins. Consequently, the number of her platelets remained critically low and she was put on corticosteroids and rituximab. Since then, her platelet count remain within the normal range, but her aPL are still present.
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Affiliation(s)
- Mojca Bizjak
- The Zabludowicz Center for Autoimmune Diseases, Chaim Sheba Medical Center, Tel-Hashomer, Israel
| | - Or Bruck
- The Zabludowicz Center for Autoimmune Diseases, Chaim Sheba Medical Center, Tel-Hashomer, Israel
| | - Darja Kanduc
- Department of Biosciences, Biotechnologies and Biopharmaceutics, University of Bari, Italy
| | - Sonja Praprotnik
- Department of Rheumatology, University Medical Centre, Ljubljana, Slovenia
| | - Yehuda Shoenfeld
- The Zabludowicz Center for Autoimmune Diseases, Chaim Sheba Medical Center, Tel-Hashomer, Israel; Incumbent of the Laura Schwarz-kipp chair for research of autoimmune diseases, Sackler Faculty of Medicine, Tel-Aviv University, Israel.
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Rituximab salvage therapy in adults with immune thrombocytopenia: retrospective study on efficacy and safety profiles. Int J Hematol 2016; 104:85-91. [PMID: 27040278 DOI: 10.1007/s12185-016-1992-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2015] [Revised: 03/10/2016] [Accepted: 03/15/2016] [Indexed: 01/19/2023]
Abstract
Splenectomy remains the preferred treatment for chronic immune thrombocytopenia (ITP) after corticosteroid failure, despite the risks of despite surgical complications and infection. The aim of this study was to assess the efficacy of and tolerance to rituximab through a retrospective analysis of 35 refractory/relapsing ITP patients treated from 2004 to 2013. The median age of subjects was 46 years (14-80). Rituximab was given at a weekly dose of 375 mg/m(2) for 4 weeks. Median time from diagnosis to first infusion was 17 months (1-362) and follow-up was 47 months (2-133). The overall response rates at 1 and 2 years after the first infusion were 47 and 38 %, with complete response rates of 24 and 25 %, respectively. Median duration of response was 38 months (1-123), with 37 % of patients maintaining a durable response (>1 year). Twenty-nine percent of patients had undergone splenectomy. A durable response after rituximab was more frequently observed in patients undergoing second-line therapy than those in third or later (83 versus 35 %, P = 0.01). Forty-four percent of patients experienced mild hypogammaglobulinaemia after rituximab, and no clinical infection occurred. To conclude, rituximab should be considered as an alternative treatment to splenectomy. Its efficacy and safety profile should lead us to choose this medical option therapy before surgery for ITP patients.
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Laribi K, Bolle D, Ghnaya H, Sandu A, Besançon A, Denizon N, Truong C, Pineau-Vincent F, de Materre AB. Rituximab is an effective and safe treatment of relapse in elderly patients with resistant warm AIHA. Ann Hematol 2016; 95:765-9. [PMID: 26858026 DOI: 10.1007/s00277-016-2605-2] [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] [Received: 06/02/2015] [Accepted: 01/27/2016] [Indexed: 11/25/2022]
Abstract
We evaluated the efficacy and safety of rituximab for the treatment of 23 elderly patients (median age 78 years) with warm autoimmune haemolytic anaemia (AIHA). The median follow-up was 31 months. Patients had received one to five previous treatments. Rituximab was administered by intravenous infusion at a dose of 375 mg/m(2) once weekly for 4 weeks. The OR rate was 86.9 % (CR = 39.1 %, PR = 47.8 %). Median OS was 87 months. The median OS of patients who reached CR could not be calculated, and that of patients with PR was 67 months. At last follow-up, eight of the 20 responding patients, including one patient in CR and seven in PR, had relapsed after a median of 6 months. Failure to achieve CR was a risk factor for relapse (p = 0.028). We did not identify any pretreatment characteristics predictive of response to rituximab. In conclusion, rituximab is an effective treatment for elderly patients with refractory warm AIHA.
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Affiliation(s)
- Kamel Laribi
- Department of Haematology, Centre Hospitalier, 194 Avenue Rubillard, 72000, Le Mans, France.
| | - Delphine Bolle
- Pharmacy Department, Centre hospitalier, Le Mans, France
| | - Habib Ghnaya
- Department of Haematology, Centre Hospitalier, 194 Avenue Rubillard, 72000, Le Mans, France
| | - Andrea Sandu
- Department of Haematology, Centre Hospitalier, 194 Avenue Rubillard, 72000, Le Mans, France
| | - Anne Besançon
- Department of Haematology, Centre Hospitalier, 194 Avenue Rubillard, 72000, Le Mans, France
| | - Nathalie Denizon
- Department of Haematology, Centre Hospitalier, 194 Avenue Rubillard, 72000, Le Mans, France
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Froissart A, Veyradier A, Hié M, Benhamou Y, Coppo P. Rituximab in autoimmune thrombotic thrombocytopenic purpura: A success story. Eur J Intern Med 2015; 26:659-65. [PMID: 26293834 DOI: 10.1016/j.ejim.2015.07.021] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Revised: 07/30/2015] [Accepted: 07/31/2015] [Indexed: 11/20/2022]
Abstract
Despite a significant improvement of thrombotic thrombocytopenic purpura (TTP) prognosis since the use of plasma exchange, morbidity and mortality remained significant because of poor response to standard treatment or exacerbations and relapses. Rituximab, a chimeric monoclonal antibody directed against the B-lymphocyte CD20 antigen, has shown a particular interest in this indication. Recent studies also reported strong evidence for its efficiency in the prevention of relapses. This review addresses these recent progresses and still opened questions in this topic: should rituximab be proposed in all patients at the acute phase? Should all patients benefit from a preemptive treatment? Is the infectious risk acceptable in this context?
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Affiliation(s)
- Antoine Froissart
- Service de médecine interne, CHI, Créteil, France; Centre de Référence des Microangiopathies Thrombotiques, AP-HP, Paris, France
| | - Agnès Veyradier
- Centre de Référence des Microangiopathies Thrombotiques, AP-HP, Paris, France; Service d'hématologie biologique, Hôpital Lariboisière, Paris, France; Université Paris Diderot, Sorbonne Paris Cité, Paris, France
| | - Miguel Hié
- Service de Médecine Interne, Hôpital la Pitié-Salpétrière, Paris, France
| | - Ygal Benhamou
- Centre de Référence des Microangiopathies Thrombotiques, AP-HP, Paris, France; Service de médecine interne, CHU Charles Nicolle, Rouen, France
| | - Paul Coppo
- Centre de Référence des Microangiopathies Thrombotiques, AP-HP, Paris, France; Service d'hématologie, Hôpital Saint Antoine, Paris, France; Inserm U1009, Institut Gustave Roussy, Villejuif, France.
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Hoffman TW, van Kessel DA, van Velzen-Blad H, Grutters JC, Rijkers GT. Antibody replacement therapy in primary antibody deficiencies and iatrogenic hypogammaglobulinemia. Expert Rev Clin Immunol 2015; 11:921-33. [DOI: 10.1586/1744666x.2015.1049599] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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Moulis G, Lapeyre-Mestre M, Mahévas M, Montastruc JL, Sailler L. Need for an improved vaccination rate in primary immune thrombocytopenia patients exposed to rituximab or splenectomy. A nationwide population-based study in France. Am J Hematol 2015; 90:301-5. [PMID: 25557586 DOI: 10.1002/ajh.23930] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2014] [Revised: 12/17/2014] [Accepted: 12/22/2014] [Indexed: 01/19/2023]
Abstract
International guidelines on immune thrombocytopenia (ITP) management recommend vaccination against Streptococcus pneumoniae (S.p.), Haemophilus influenza b (Hib) and Neisseiria meningitidis (N.m.) before splenectomy. French guidelines also recommend these vaccinations before rituximab. The aim of this study was to assess the application of these recommendations. The French Adult ITP: a French pHarmacoepidemiological study (FAITH, n°ENCEPP 4574) is aimed at following in the French national health insurance system database (SNIIRAM) the cohort of all incident and persistent or chronic primary ITP adults treated in France. We assessed vaccine exposure in the 1,106 patients who entered the FAITH cohort between 2009 and 2011. Vaccination was said "recommended" if performed at least 2 weeks before rituximab or splenectomy accordingly with French guidelines. Among the 423 non-splenectomized patients exposed to rituximab, vaccination rates against S.p., Hib and N.m. were respectively 32.4%, 18.9%, and 3.8%. It was recommended in 12.8%, 6.6%, and 1.2% of the patients, respectively. Among the 178 splenectomized patients, vaccination rates were 70.2%, 47.0%, and 11.9%, respectively (recommended: 60.1%, 35.7%, and 9.5%). Among the splenectomized patients previously exposed to rituximab (n = 67), 53.3% of the vaccinations occurred during the semester following a rituximab infusion that is during the maximal B-cell depletion period. In multivariate analyses, a disease duration exceeding 3 months was the sole factor associated to recommended vaccination in rituximab-treated patients as well as in splenectomized patients. This study stresses the need of better and earlier vaccination of ITP patients.
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Affiliation(s)
- Guillaume Moulis
- Service De Médecine Interne; CHU De Toulouse; Toulouse F-31000 France
- Inserm; UMR1027; Toulouse; F-31000 France; Université De Toulouse III, UMR1027; Toulouse F-31000 France
| | - Maryse Lapeyre-Mestre
- Inserm; UMR1027; Toulouse; F-31000 France; Université De Toulouse III, UMR1027; Toulouse F-31000 France
- Service De Pharmacologie Médicale Et Clinique; CHU De Toulouse; Toulouse F-31000 France
| | - Matthieu Mahévas
- Service De Médecine Interne; Centre De Référence Des Cytopénies auto-Immunes De L'adulte; Hôpital Henri Mondor; Assistance Publique-Hôpitaux De Paris; Université Paris Est Créteil; Créteil; F-94000 France; Etablissement Français Du Sang Ile De France, Inserm U955, Créteil, Hôpital Henri Mondor; Paris F-94000 France
| | - Jean-Louis Montastruc
- Inserm; UMR1027; Toulouse; F-31000 France; Université De Toulouse III, UMR1027; Toulouse F-31000 France
- Service De Pharmacologie Médicale Et Clinique; CHU De Toulouse; Toulouse F-31000 France
- Centre Midi-Pyrénées De PharmacoVigilance; De Pharmacoépidémiologie Et D'informations Sur Le Médicament; CHU De Toulouse; Toulouse F-31000 France
| | - Laurent Sailler
- Service De Médecine Interne; CHU De Toulouse; Toulouse F-31000 France
- Inserm; UMR1027; Toulouse; F-31000 France; Université De Toulouse III, UMR1027; Toulouse F-31000 France
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Reynaud Q, Durieu I, Dutertre M, Ledochowski S, Durupt S, Michallet AS, Vital-Durand D, Lega JC. Efficacy and safety of rituximab in auto-immune hemolytic anemia: A meta-analysis of 21 studies. Autoimmun Rev 2015; 14:304-13. [DOI: 10.1016/j.autrev.2014.11.014] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2014] [Accepted: 11/26/2014] [Indexed: 12/21/2022]
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