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Tisack A, Mohammad TF. Drug-Induced Pigmentation: A Review. Drugs 2024; 84:1071-1091. [PMID: 39085684 DOI: 10.1007/s40265-024-02062-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/04/2024] [Indexed: 08/02/2024]
Abstract
Drug-induced pigmentation (DIP) is estimated to account for 20% of all cases of acquired hyperpigmentation. Over 50 agents have been implicated, including antibiotics, antimalarials, antiretrovirals, antipsychotics, prostaglandin analogs, heavy metals, and chemotherapeutic agents. The skin, mucosal surfaces, nails, and hair can all be affected, with the color, distribution, onset, and duration of pigmentation varying between offending agents. Both a thorough physical examination and medication history are necessary to determine the offending agent. In terms of mechanism, DIP occurs most frequently through the accumulation of melanin within the dermis but also by drug accumulation, pigment synthesis, and iron deposition. Photoprotection, including applying a broad-spectrum sunscreen, wearing photoprotective clothing, and seeking shade, plays an important role in the prevention of exacerbation of DIP. Multiple lasers, including the picosecond alexandrite, Q-switched Nd:YAG, Q-switched alexandrite, and Q-switched ruby lasers, have been successful in obtaining clearance of DIP. In this review, we examine the unique characteristics of each of the inciting agents in terms of incidence, clinical presentation, time to onset and resolution, and pathogenesis.
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Affiliation(s)
- Aaron Tisack
- Department of Dermatology, Henry Ford Health, 3031 W Grand Blvd, Detroit, MI, 48202, USA
| | - Tasneem F Mohammad
- Department of Dermatology, Henry Ford Health, 3031 W Grand Blvd, Detroit, MI, 48202, USA.
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2
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Kim M, Arabi J, McCoy C, D'Souza A, Chhabra S, Abid MB, Thapa B, Dhakal B. Safety of Dapsone for Pneumocystis Jiroveci Pneumonia Prophylaxis in Patients With Multiple Myeloma. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2024:S2152-2650(24)00244-1. [PMID: 39043500 DOI: 10.1016/j.clml.2024.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/18/2024] [Accepted: 06/28/2024] [Indexed: 07/25/2024]
Affiliation(s)
- Mingee Kim
- School of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Jessica Arabi
- Department of Pharmacy, Rhode Island Hospital, Providence, Rhode Island; Department of Pharmacy, Froedtert and the Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Cole McCoy
- Division of Hematology/Oncology, Department of Medicine, Medical College of Wisconsin, Milwaukee WI
| | - Anita D'Souza
- Division of Hematology/Oncology, Department of Medicine, Medical College of Wisconsin, Milwaukee WI
| | - Saurabh Chhabra
- Division of Hematology/Oncology, Department of Medicine, Mayo Clinic Arizona, Phoenix, AZ
| | - Muhammad Bilal Abid
- Division of Hematology/Oncology, Department of Medicine, Medical College of Wisconsin, Milwaukee WI
| | - Bicky Thapa
- Division of Hematology/Oncology, Department of Medicine, Medical College of Wisconsin, Milwaukee WI
| | - Binod Dhakal
- Division of Hematology/Oncology, Department of Medicine, Medical College of Wisconsin, Milwaukee WI.
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3
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Zieneldien T, Kim J, Greene J. Breakthrough Pneumocystis jirovecii Pneumonia in an Allogeneic Hematopoietic Stem Cell Transplant Recipient. Cureus 2024; 16:e61890. [PMID: 38978902 PMCID: PMC11228424 DOI: 10.7759/cureus.61890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/07/2024] [Indexed: 07/10/2024] Open
Abstract
Pneumocystis carinii pneumonia (PCP), which is currently referred to as Pneumocystis jirovecii pneumonia, is an opportunistic fungal infection that commonly affects immunocompromised patients, and it is potentially fatal. Individuals at risk include those whose host immunity has been altered by underlying disease states, such as HIV and cancer patients, as well as transplant recipients and those taking immunosuppressive medications. Here, we present a case of a breakthrough PCP infection of an adult allogeneic hematopoietic stem cell transplant patient who was infected despite prophylaxis with inhaled pentamidine. The patient's transplant course was complicated by acute graft-versus-host disease (GVHD), which was treated with tacrolimus, prednisone, beclomethasone, and budesonide. Treatments for GVHD, which include immunosuppressive therapies, are a risk factor for PCP. Thus, the patient was on prophylactic treatment with inhaled pentamidine. The case presents challenges that immunocompromised patients face, particularly those undergoing allogeneic hematopoietic stem cell transplantation. While the patient received prophylactic treatment, there was still a breakthrough PCP infection. We highlight the risks this infection can cause and the need to promptly address these infections to prevent complications and optimize prophylactic regimens.
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Affiliation(s)
- Tarek Zieneldien
- College of Arts and Sciences, University of South Florida, Tampa, USA
| | - Janice Kim
- College of Arts and Sciences, University of South Florida, Tampa, USA
| | - John Greene
- Department of Internal Medicine, Moffitt Cancer Center, Tampa, USA
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4
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Espíndola KMM, Varela ELP, de Albuquerque RDFV, Figueiredo RA, dos Santos SM, Malcher NS, da S. Seabra PS, Fonseca ADN, de Azevedo Sousa KM, de Oliveira SBB, Carneiro ADS, Coleman MD, Monteiro MC. Alpha-Lipoic Acid and Its Enantiomers Prevent Methemoglobin Formation and DNA Damage Induced by Dapsone Hydroxylamine: Molecular Mechanism and Antioxidant Action. Int J Mol Sci 2022; 24:ijms24010057. [PMID: 36613503 PMCID: PMC9820452 DOI: 10.3390/ijms24010057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 10/14/2022] [Accepted: 10/23/2022] [Indexed: 12/24/2022] Open
Abstract
Dapsone (DDS) therapy can frequently lead to hematological side effects, such as methemoglobinemia and DNA damage. In this study, we aim to evaluate the protective effect of racemic alpha lipoic acid (ALA) and its enantiomers on methemoglobin induction. The pre- and post-treatment of erythrocytes with ALA, ALA isomers, or MB (methylene blue), and treatment with DDS-NOH (apsone hydroxylamine) was performed to assess the protective and inhibiting effect on methemoglobin (MetHb) formation. Methemoglobin percentage and DNA damage caused by dapsone and its metabolites were also determined by the comet assay. We also evaluated oxidative parameters such as SOD, GSH, TEAC (Trolox equivalent antioxidant capacity) and MDA (malondialdehyde). In pretreatment, ALA showed the best protector effect in 2.5 µg/mL of DDS-NOH. ALA (1000 µM) was able to inhibit the induced MetHb formation even at the highest concentrations of DDS-NOH. All ALA tested concentrations (100 and 1000 µM) were able to inhibit ROS and CAT activity, and induced increases in GSH production. ALA also showed an effect on DNA damage induced by DDS-NOH (2.5 µg/mL). Both isomers were able to inhibit MetHb formation and the S-ALA was able to elevate GSH levels by stimulating the production of this antioxidant. In post-treatment with the R-ALA, this enantiomer inhibited MetHb formation and increased GSH levels. The pretreatment with R-ALA or S-ALA prevented the increase in SOD and decrease in TEAC, while R-ALA decreased the levels of MDA; and this pretreatment with R-ALA or S-ALA showed the effect of ALA enantiomers on DNA damage. These data show that ALA can be used in future therapies in patients who use dapsone chronically, including leprosy patients.
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Affiliation(s)
- Kaio Murilo Monteiro Espíndola
- Postgraduate Program in Pharmacology and Biochemistry, Faculty of Pharmacy, Federal University of Pará/UFPA, Belém 66075-110, PA, Brazil
| | - Everton Luiz Pompeu Varela
- Postgraduate Program in Pharmaceutical Sciences, Faculty of Pharmacy, Federal University of Pará/UFPA, Belém 66075-110, PA, Brazil
| | | | - Rosiane Araújo Figueiredo
- Postgraduate Program in Pharmacology and Biochemistry, Faculty of Pharmacy, Federal University of Pará/UFPA, Belém 66075-110, PA, Brazil
| | - Sávio Monteiro dos Santos
- Postgraduate Program in Pharmaceutical Sciences, Faculty of Pharmacy, Federal University of Pará/UFPA, Belém 66075-110, PA, Brazil
| | - Nívea Silva Malcher
- Laboratory Immunology, Microbiology and In Vitro Assays (LABEIM), Faculty of Pharmacy, Federal University of Pará/UFPA, Belém 66075-110, PA, Brazil
| | - Pamela Suelen da S. Seabra
- Laboratory Immunology, Microbiology and In Vitro Assays (LABEIM), Faculty of Pharmacy, Federal University of Pará/UFPA, Belém 66075-110, PA, Brazil
| | - Andréia do Nascimento Fonseca
- Laboratory Immunology, Microbiology and In Vitro Assays (LABEIM), Faculty of Pharmacy, Federal University of Pará/UFPA, Belém 66075-110, PA, Brazil
| | - Karla Marcely de Azevedo Sousa
- Laboratory Immunology, Microbiology and In Vitro Assays (LABEIM), Faculty of Pharmacy, Federal University of Pará/UFPA, Belém 66075-110, PA, Brazil
| | - Susan Beatriz Batista de Oliveira
- Central Laboratory of the State of Pará-CLSP, Belém 66823-010, PA, Brazil
- Postgraduate Program in Neuroscience and Cell Biology, Faculty of Pharmacy, Federal University of Pará/UFPA, Belém 66075-110, PA, Brazil
| | - Agnaldo da Silva Carneiro
- Postgraduate Program in Medicinal Chemistry and Molecular Modeling, Faculty of Pharmacy, Federal University of Pará/UFPA, Belém 66075-110, PA, Brazil
| | - Michael D. Coleman
- College of Health and Life Sciences, Aston University, Aston Triangle, Birmingham B4 7ET, UK
| | - Marta Chagas Monteiro
- Postgraduate Program in Pharmacology and Biochemistry, Faculty of Pharmacy, Federal University of Pará/UFPA, Belém 66075-110, PA, Brazil
- Postgraduate Program in Pharmaceutical Sciences, Faculty of Pharmacy, Federal University of Pará/UFPA, Belém 66075-110, PA, Brazil
- Laboratory Immunology, Microbiology and In Vitro Assays (LABEIM), Faculty of Pharmacy, Federal University of Pará/UFPA, Belém 66075-110, PA, Brazil
- Correspondence:
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5
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Hemapriya J, Sehgal T, Kumar Datta S, Arulselvi S. Drug-induced methemoglobinemia. QJM 2022; 115:619-620. [PMID: 35786730 DOI: 10.1093/qjmed/hcac157] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2022] [Revised: 06/23/2022] [Indexed: 02/01/2023] Open
Affiliation(s)
- J Hemapriya
- Department of Laboratory Medicine, All India Institute of Medical Sciences, New Delhi 110029, India
| | - Tushar Sehgal
- Department of Laboratory Medicine, All India Institute of Medical Sciences, New Delhi 110029, India
| | - Sudip Kumar Datta
- Department of Laboratory Medicine, All India Institute of Medical Sciences, New Delhi 110029, India
| | - S Arulselvi
- Department of Laboratory Medicine, All India Institute of Medical Sciences, New Delhi 110029, India
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6
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Alyahya B, Alalshaikh A, Sabbahi G, Alnowiser M, Al-Mohawes M. Methylene Blue Infusion to Treat Severe Dapsone-Induced Methemoglobinemia in a Pediatric Patient. Cureus 2021; 13:e18853. [PMID: 34804706 PMCID: PMC8597667 DOI: 10.7759/cureus.18853] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/18/2021] [Indexed: 11/05/2022] Open
Abstract
Dapsone overdose is a well-known potent cause of methemoglobinemia and hemolytic anemia. We discuss a case of a two-year-old male who developed severe persistent methemoglobinemia treated with multiple doses of methylene blue (MB), multidose activated charcoal, and vitamin C. Methylene blue infusion (rather than bolus dosing) aided in controlling this patient's methemoglobin (MetHb) levels and symptoms and may reduce the total needed dose.
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Affiliation(s)
- Bader Alyahya
- Emergency Medicine, King Saud University, Riyadh, SAU
| | | | - Ghofran Sabbahi
- Pediatric Infectious Diseases, King Abdulaziz University Hospital, Jeddah, SAU
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7
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Infection risk and prophylaxis in patients with lymphoid cancer. Blood 2021; 139:1517-1528. [PMID: 34748625 DOI: 10.1182/blood.2019003687] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Accepted: 05/05/2021] [Indexed: 11/20/2022] Open
Abstract
Infections are a common cause of morbidity and mortality in patients with lymphoid cancer. With evolving cancer therapeutics, including new targeted and immunotherapies, clinicians need to be aware of additional risk factors and infections that may arise in patients treated with these agents. This "How I Treat" article will highlight fundamental issues including risk factors for infection, infectious diseases screenings and antimicrobial prophylaxis recommendations in patients with lymphoid cancers. We present 4 scenarios of patients with lymphoid cancers with varied infections and describe a treatment approach based on a combination of evidence-based data and experience, as there are limitations in objective infection data especially with newer agents. The goal of this discussion is to provide a framework for institutions and health care providers to develop their own approach in preventing and treating infections in patients with lymphoid cancer.
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8
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Classen AY, Henze L, von Lilienfeld-Toal M, Maschmeyer G, Sandherr M, Graeff LD, Alakel N, Christopeit M, Krause SW, Mayer K, Neumann S, Cornely OA, Penack O, Weißinger F, Wolf HH, Vehreschild JJ. Primary prophylaxis of bacterial infections and Pneumocystis jirovecii pneumonia in patients with hematologic malignancies and solid tumors: 2020 updated guidelines of the Infectious Diseases Working Party of the German Society of Hematology and Medical Oncology (AGIHO/DGHO). Ann Hematol 2021; 100:1603-1620. [PMID: 33846857 PMCID: PMC8116237 DOI: 10.1007/s00277-021-04452-9] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Accepted: 02/04/2021] [Indexed: 12/11/2022]
Abstract
Hematologic and oncologic patients with chemo- or immunotherapy-related immunosuppression are at substantial risk for bacterial infections and Pneumocystis jirovecii pneumonia (PcP). As bacterial resistances are increasing worldwide and new research reshapes our understanding of the interactions between the human host and bacterial commensals, administration of antibacterial prophylaxis has become a matter of discussion. This guideline constitutes an update of the 2013 published guideline of the Infectious Diseases Working Party (AGIHO) of the German Society for Hematology and Medical Oncology (DGHO). It gives an overview about current strategies for antibacterial prophylaxis in cancer patients while taking into account the impact of antibacterial prophylaxis on the human microbiome and resistance development. Current literature published from January 2012 to August 2020 was searched and evidence-based recommendations were developed by an expert panel. All recommendations were discussed and approved in a consensus conference of the AGIHO prior to publication. As a result, we present a comprehensive update and extension of our guideline for antibacterial and PcP prophylaxis in cancer patients.
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Affiliation(s)
- Annika Y Classen
- Faculty of Medicine and University Hospital Cologne, Department I for Internal Medicine, University of Cologne, Herderstr. 52-54, 50931, Cologne, Germany
- German Centre for Infection Research (DZIF), partner site Bonn-Cologne, Cologne, Germany
| | - Larissa Henze
- Department of Medicine, Clinic III - Hematology, Oncology, Palliative Medicine, Rostock University Medical Center, Rostock, Germany
| | - Marie von Lilienfeld-Toal
- Department of Hematology and Oncology, Clinic for Internal Medicine II, University Hospital Jena, Jena, Germany
| | - Georg Maschmeyer
- Hematology, Oncology and Palliative Care, Klinikum Ernst von Bergmann, Potsdam, Germany
| | - Michael Sandherr
- Specialist Clinic for Haematology and Oncology, Medical Care Center Penzberg, Penzberg, Germany
| | - Luisa Durán Graeff
- Faculty of Medicine and University Hospital Cologne, Department I for Internal Medicine, University of Cologne, Herderstr. 52-54, 50931, Cologne, Germany
- German Centre for Infection Research (DZIF), partner site Bonn-Cologne, Cologne, Germany
| | - Nael Alakel
- Department I of Internal Medicine, Hematology and Oncology, University Hospital Dresden, Dresden, Germany
| | - Maximilian Christopeit
- Department of Internal Medicine II, Hematology, Oncology, Clinical Immunology and Rheumatology, University Hospital Tübingen, Tübingen, Germany
| | - Stefan W Krause
- Department of Medicine 5 - Hematology and Oncology, University Hospital Erlangen, Erlangen, Germany
| | - Karin Mayer
- Medical Clinic III for Oncology, Hematology, Immunooncology and Rheumatology, University Hospital Bonn (UKB), Bonn, Germany
| | - Silke Neumann
- Interdisciplinary Center for Oncology, Wolfsburg, Germany
| | - Oliver A Cornely
- Faculty of Medicine and University Hospital Cologne, Department I for Internal Medicine, University of Cologne, Herderstr. 52-54, 50931, Cologne, Germany
- German Centre for Infection Research (DZIF), partner site Bonn-Cologne, Cologne, Germany
- Faculty of Medicine and University Hospital Cologne, Chair Translational Research, Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), University of Cologne, Cologne, Germany
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Clinical Trials Centre Cologne (ZKS Köln), University of Cologne, Cologne, Germany
| | - Olaf Penack
- Medical Department for Hematology, Oncology and Tumor Immunology, Charité Universitätsmedizin Berlin, Campus Virchow-Klinikum, Berlin, Germany
| | - Florian Weißinger
- Department for Internal Medicine, Hematology/Oncology, and Palliative Care, Evangelisches Klinikum Bethel v. Bodelschwinghsche Stiftungen Bethel, Bielefeld, Germany
| | - Hans-Heinrich Wolf
- Department IV of Internal Medicine, University Hospital Halle, Halle, Germany
| | - Jörg Janne Vehreschild
- Faculty of Medicine and University Hospital Cologne, Department I for Internal Medicine, University of Cologne, Herderstr. 52-54, 50931, Cologne, Germany.
- German Centre for Infection Research (DZIF), partner site Bonn-Cologne, Cologne, Germany.
- Department of Internal Medicine, Hematology/Oncology, Goethe University Frankfurt, Frankfurt am Main, Germany.
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9
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Hindka A, Huynh D, Verghese PS. Dapsone-induced methemoglobinemia in pediatrics post-renal transplant. Pediatr Transplant 2021; 25:e13921. [PMID: 33280223 DOI: 10.1111/petr.13921] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Revised: 08/16/2020] [Accepted: 10/26/2020] [Indexed: 01/02/2023]
Abstract
Dapsone has been utilized for the prevention of Pneumocystis jirovecii pneumonia in immunosuppressed patients including pediatric kidney transplant recipients, in whom trimethoprim-sulfamethoxazole (TMP-SMX) is contraindicated. Dapsone adverse effects include methemoglobinemia, but there are no reports of the burden and impact of methemoglobinemia in pediatric kidney recipients that are taking dapsone for PJP prophylaxis. We conducted a retrospective chart review of all pediatric kidney recipients who had received dapsone at any time posttransplant. The indication, duration, and adverse effects of dapsone therapy were assessed. In addition, methemoglobin levels were assessed, and summary statistics performed. Data demonstrated that more than half of the patients on dapsone were not screened for methemoglobinemia. Of those screened, there was a significantly higher acquired-methemoglobinemia (77%) than previously reported in the literature. We also demonstrate significantly more anemia in patients on dapsone. Methemoglobinemia did not affect patient or graft survival and resolved with cessation of dapsone. We conclude that pediatric kidney recipients often develop methemoglobinemia and / or anemia on dapsone. We recommend if pediatric transplant recipients are prescribed dapsone, routine testing for methemoglobinemia and anemia should be done.
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Affiliation(s)
- Aditi Hindka
- Division of Nephrology, Department of Pediatrics, University of Minnesota, Minneapolis, MN, USA.,Alabama College of Osteopathic Medicine, Dothan, AL, USA
| | - Dao Huynh
- Division of Nephrology, Department of Pediatrics, University of Minnesota, Minneapolis, MN, USA
| | - Priya S Verghese
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA.,Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
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10
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Efficacy and safety of trimethoprim-sulfamethoxazole for the prevention of pneumocystis pneumonia in human immunodeficiency virus-negative immunodeficient patients: A systematic review and meta-analysis. PLoS One 2021; 16:e0248524. [PMID: 33765022 PMCID: PMC7993619 DOI: 10.1371/journal.pone.0248524] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Accepted: 02/27/2021] [Indexed: 11/29/2022] Open
Abstract
Background Pneumocystis pneumonia (PCP) has a significant impact on the mortality of immunocompromised patients. It is not known whether the prophylactic application of trimethoprim-sulfamethoxazole (TMP-SMZ) can reduce the incidence of PCP and mortality in the human immunodeficiency virus (HIV)-negative immunodeficient population. The safety profile is also unknown. There have been few reports on this topic. The aim of this study was to systematically evaluate the efficacy and safety of the use of TMP-SMZ for the prevention of PCP in this population of patients from the perspective of evidence-based medicine. Methods A comprehensive search without restrictions on publication status or other parameters was conducted. Clinical randomized controlled trials (RCTs) or case-control trials (CCSs) of TMP-SMZ used for the prevention of PCP in HIV-negative immunocompromised populations were considered eligible. A meta-analysis was performed using the Mantel-Haenszel fixed-effects model or Mantel-Haenszel random-effects model, and odds ratios (ORs) with 95% confidence intervals (CIs) were calculated and reported. Results Of the 2392 records identified, 19 studies (n = 4135 patients) were included. The efficacy analysis results indicated that the PCP incidence was lower in the TMP-SMZ group than in the control group (OR = 0.27, 95% CI (0.10, 0.77), p = 0.01); however, the rate of drug discontinuation was higher in the TMP-SMZ group than in the control group (OR = 14.31, 95% CI (4.78, 42.91), p<0.00001). In addition, there was no statistically significant difference in the rate of mortality between the two groups (OR = 0.54, 95% CI (0.21, 1.37), p = 0.19). The safety analysis results showed that the rate of adverse events (AEs) was higher in the TMP-SMZ group than in the control group (OR = 1.92, 95% CI (1.06, 3.47), p = 0.03). Conclusions TMP-SMZ has a better effect than other drugs or the placebo with regard to preventing PCP in HIV-negative immunocompromised individuals, but it may not necessarily reduce the rate of mortality, the rate of drug discontinuation or AEs. Due to the limitations of the research methodologies used, additional large-scale clinical trials and well-designed research studies are needed to identify more effective therapies for the prevention of PCP.
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11
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Mantadakis E. Pneumocystis jirovecii Pneumonia in Children with Hematological Malignancies: Diagnosis and Approaches to Management. J Fungi (Basel) 2020; 6:E331. [PMID: 33276699 PMCID: PMC7761543 DOI: 10.3390/jof6040331] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 12/01/2020] [Accepted: 12/01/2020] [Indexed: 12/21/2022] Open
Abstract
Pneumocystis jirovecii pneumonia (PJP) is an opportunistic infection that mostly affects children with suppressed cellular immunity. PJP was the most common cause of infectious death in children with acute lymphoblastic leukemia prior to the inclusion of cotrimoxazole prophylaxis as part of the standard medical care in the late 1980s. Children with acute leukemia, lymphomas, and those undergoing hematopoietic stem cell transplantation, especially allogeneic transplantation, are also at high risk of PJP. Persistent lymphopenia, graft versus host disease, poor immune reconstitution, and lengthy use of corticosteroids are significant risk factors for PJP. Active infection may be due to reactivation of latent infection or recent acquisition from environmental exposure. Intense hypoxemia and impaired diffusing capacity of the lungs are hallmarks of PJP, while computerized tomography of the lungs is the diagnostic technique of choice. Immunofluorescence testing with monoclonal antibodies followed by fluorescent microscopy and polymerase chain reaction testing of respiratory specimens have emerged as the best diagnostic methods. Measurement of (1-3)-β-D-glucan in the serum has a high negative predictive value in ruling out PJP. Oral cotrimoxazole is effective for prophylaxis, but in intolerant patients, intravenous and aerosolized pentamidine, dapsone, and atovaquone are effective alternatives. Ιntravenous cotrimoxazole is the treatment of choice, but PJP has a high mortality even with appropriate therapy.
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Affiliation(s)
- Elpis Mantadakis
- Department of Pediatrics, Hematology/Oncology Unit, University General Hospital of Alexandroupolis, Democritus University of Thrace, 68 100 Alexandroupolis, Thrace, Greece
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12
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Bian Y, Kim K, An GJ, Ngo T, Bae ON, Lim KM, Chung JH. Dapsone Hydroxylamine, an Active Metabolite of Dapsone, Can Promote the Procoagulant Activity of Red Blood Cells and Thrombosis. Toxicol Sci 2020; 172:435-444. [PMID: 31428780 DOI: 10.1093/toxsci/kfz188] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Dapsone hydroxylamine (DDS-NHOH), N-hydroxylated metabolite of a sulfonamide antibiotic, dapsone, is responsible for various adverse effects of dapsone that include methemoglobinemia, hemolytic anemia, and thrombosis. However, the mechanism underlying DDS-NHOH-induced thrombosis remains unclear. Here, we demonstrated that DDS-NHOH, but not dapsone, could increase prothrombotic risks through inducing the procoagulant activity of red blood cells (RBCs). In freshly isolated human RBCs in vitro, sub-hemolytic concentrations of DDS-NHOH (10-50 μM) increased phosphatidylserine (PS) exposure and augmented the formation of PS-bearing microvesicles (MV). Reactive oxygen species (ROS) generation and the subsequent dysregulation of enzymes maintaining membrane phospholipid asymmetry were found to induce the procoagulant activity of DDS-NHOH. Dapsone hydroxylamine also accelerated thrombin generation and enhanced RBC self-aggregation and adherence of RBCs to endothelial cells in vitro. Most importantly, both the single dose of 50 or 100 mg/kg (i.p.) DDS-NHOH and repeated doses of 10 mg/kg per day (i.p.) for 4 days increased thrombus formation in rats (six rats per dose) in vivo, substantiating a potential prothrombotic risk of DDS-NHOH. Collectively, these results demonstrated the central role of RBC procoagulant activity induced by DDS-NHOH in the thrombotic risk of dapsone.
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Affiliation(s)
- Yiying Bian
- College of Pharmacy, Seoul National University, Seoul 151-742, Korea.,School of Public Health, China Medical University, Shenyang 110122, P.R. China
| | - Keunyoung Kim
- College of Pharmacy, Seoul National University, Seoul 151-742, Korea
| | - Gwang-Jin An
- College of Pharmacy, Seoul National University, Seoul 151-742, Korea
| | - Thien Ngo
- College of Pharmacy, Seoul National University, Seoul 151-742, Korea
| | - Ok-Nam Bae
- College of Pharmacy, Hanyang University, Ansan, Gyeonggido 426-791, Korea
| | - Kyung-Min Lim
- College of Pharmacy, Ewha Womans University, Seoul 120-750, Korea
| | - Jin-Ho Chung
- College of Pharmacy, Seoul National University, Seoul 151-742, Korea
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Corallo CE, Coutsouvelis J, Morgan S, Morrissey O, Avery S. Dapsone for Pneumocystis jirovecii pneumonia prophylaxis - applying theory to clinical practice with a focus on drug interactions. Drug Metab Pers Ther 2020; 35:dmpt-2019-0018. [PMID: 32681773 DOI: 10.1515/dmpt-2019-0018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Accepted: 05/14/2020] [Indexed: 11/15/2022]
Abstract
Pneumocystis jirovecii pneumonia (PJP) is a potentially life-threatening infection that occurs in immunocompromised individuals. The incidence can be as high as 80% in some groups but can be reduced to less than 1% with appropriate prophylaxis. HIV-infected patients with a low CD4 count are at the highest risk of PJP. Others at substantial risk include haematopoietic stem cell and solid organ transplant recipients, those with cancer (particularly haematologic malignancies), and those receiving glucocorticoids, chemotherapeutic agents, and other immunosuppressive medications. Trimethoprim-sulfamethoxazole is an established first-line line agent for prevention and treatment of PJP. However, in some situations, this medication cannot be used and dapsone is considered a suitable cost-effective second line agent. However, information on potential interactions with drugs commonly used in immunosuppressed patients is lacking or contradictory. In this this article we review the metabolic pathway of dapsone with a focus on interactions and clinical significance particularly in patients with haematological malignancies. An understanding of this process should optimise the use of this agent.
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Affiliation(s)
| | | | - Susan Morgan
- Alfred Health, Haematology, Melbourne, Victoria, Australia
| | - Orla Morrissey
- Alfred Health, Infectious Diseases, Melbourne, Victoria, Australia
| | - Sharon Avery
- Alfred Health, Haematology, Melbourne, Victoria, Australia
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Akinsomisoye OS, Gupta G, Raji Y. Experimental dapsone administration induces infertility in male Wistar rats: Mechanisms and clinical implications. ACTA ACUST UNITED AC 2019; 26:289-303. [PMID: 31387782 DOI: 10.1016/j.pathophys.2019.07.004] [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: 09/19/2018] [Revised: 03/07/2019] [Accepted: 07/27/2019] [Indexed: 10/26/2022]
Abstract
Dapsone (4, 4'-diaminodiphenylsulfone, DDS) is a potent anti-inflammatory and antibacterial compound which has been used in the treatment of leprosy, vasculitis and dermatitis herpetiformis, lupus erythematosus profundus and even as an antimalarial in combination with proguanil. This study investigated the effect of the administration of dapsone on the reproductive activities of male rats using in vivo and in vitro techniques. In the in vivo study, dapsone was administered orally to male Wistar rats for 5 days or 6 weeks after which their body weight, relative reproductive organ weights, sperm parameters and reproductive hormones were determined while testicular and epididymal histology were also assessed. Data were compared using analysis of variance and Students-Newman-Keuls multiple comparison test. For the in vitro study, Sertoli cells were cultured and treated with varying doses of dapsone at different durations, thereafter Sertoli cell viability and nuclei integrity were determined. Also, the genetic expressions of Glial cell line-derived neurotrophic factor (GDNF) and transferrin were assessed. The results obtained from the in vivo study showed a duration-dependent significant decrease in body and reproductive organ weights, sperm parameters and serum testosterone concentration. Testicular and epididymal histology also showed duration-dependent degenerative changes. However, all these changes were restored towards control values in the recovery experiment. The viability and deoxyribonucleic acid (DNA) integrity of the treated Sertoli cells showed dose and duration-dependent adverse effects while GDNF and transferrin showed normal genetic expressions. These results suggest that dapsone could induce male reproductive stress by affecting testicular and epididymal structure and function.
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Affiliation(s)
| | - Gopal Gupta
- Division of Endocrinology, Central Drug Research Institute, 226001 Lucknow, India.
| | - Yinusa Raji
- Department of Physiology, University of Ibadan, 900001 Ibadan, Nigeria.
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Shah K, Queener S, Cody V, Pace J, Gangjee A. Development of substituted pyrido[3,2-d]pyrimidines as potent and selective dihydrofolate reductase inhibitors for pneumocystis pneumonia infection. Bioorg Med Chem Lett 2019; 29:1874-1880. [PMID: 31176699 DOI: 10.1016/j.bmcl.2019.06.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2019] [Revised: 05/28/2019] [Accepted: 06/01/2019] [Indexed: 10/26/2022]
Abstract
Pneumocystis pneumonia (PCP) caused by Pneumocystis jirovecii (pj) can lead to serious health consequences in patients with an immunocompromised system. Trimethoprim (TMP), used as first-line therapy in combination with sulfamethoxazole, is a selective but only moderately potent pj dihydrofolate reductase (pjDHFR) inhibitor, whereas non-clinical pjDHFR inhibitors, such as, piritrexim and trimetrexate are potent but non-selective pjDHFR inhibitors. To meet the clinical needs for a potent and selective pjDHFR inhibitor for PCP treatment, fourteen 6-substituted pyrido[3,2-d]pyrimidines were developed. Comparison of the amino acid residues in the active site of pjDHFR and human DHFR (hDHFR) revealed prominent amino acid differences which could be exploited to structurally design potent and selective pjDHFR inhibitors. Molecular modeling followed by enzyme assays of the compounds revealed 15 as the best compound of the series with an IC50 of 80 nM and 28-fold selectivity for inhibiting pjDHFR over hDHFR. Compound 15 serves as the lead analog for further structural variations to afford more potent and selective pjDHFR inhibitors.
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Affiliation(s)
- Khushbu Shah
- Division of Medicinal Chemistry, Graduate School of Pharmaceutical Sciences, Duquesne University, Pittsburgh PA 15282, United States
| | - Sherry Queener
- Department of Pharmacology and Toxicology, Indiana University School of Medicine, Indianapolis, IN 46202, United States
| | - Vivian Cody
- Hauptman-Woodward Medical Research Institute, 700 Ellicott Street, Buffalo, NY 14203, United States
| | - Jim Pace
- Hauptman-Woodward Medical Research Institute, 700 Ellicott Street, Buffalo, NY 14203, United States
| | - Aleem Gangjee
- Division of Medicinal Chemistry, Graduate School of Pharmaceutical Sciences, Duquesne University, Pittsburgh PA 15282, United States.
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Shah K, Lin X, Queener SF, Cody V, Pace J, Gangjee A. Targeting species specific amino acid residues: Design, synthesis and biological evaluation of 6-substituted pyrrolo[2,3-d]pyrimidines as dihydrofolate reductase inhibitors and potential anti-opportunistic infection agents. Bioorg Med Chem 2018; 26:2640-2650. [PMID: 29691153 DOI: 10.1016/j.bmc.2018.04.032] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Revised: 04/04/2018] [Accepted: 04/14/2018] [Indexed: 11/28/2022]
Abstract
To combine the potency of trimetrexate (TMQ) or piritrexim (PTX) with the species selectivity of trimethoprim (TMP), target based design was carried out with the X-ray crystal structure of human dihydrofolate reductase (hDHFR) and the homology model of Pneumocystis jirovecii DHFR (pjDHFR). Using variation of amino acids such as Met33/Phe31 (in pjDHFR/hDHFR) that affect the binding of inhibitors due to their distinct positive or negative steric effect at the active binding site of the inhibitor, we designed a series of substituted-pyrrolo[2,3-d]pyrimidines. The best analogs displayed better potency (IC50) than PTX and high selectivity for pjDHFR versus hDHFR, with 4 exhibiting a selectivity for pjDHFR of 24-fold.
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Affiliation(s)
- Khushbu Shah
- Division of Medicinal Chemistry, Graduate School of Pharmaceutical Sciences, Duquesne University, Pittsburgh, PA 15282, United States
| | - Xin Lin
- Division of Medicinal Chemistry, Graduate School of Pharmaceutical Sciences, Duquesne University, Pittsburgh, PA 15282, United States
| | - Sherry F Queener
- Department of Pharmacology and Toxicology, Indiana University School of Medicine, Indianapolis, IN 46202, United States
| | - Vivian Cody
- Hauptman-Woodward Medical Research Institute, 700 Ellicott Street, Buffalo, NY 14203, United States
| | - Jim Pace
- Hauptman-Woodward Medical Research Institute, 700 Ellicott Street, Buffalo, NY 14203, United States
| | - Aleem Gangjee
- Division of Medicinal Chemistry, Graduate School of Pharmaceutical Sciences, Duquesne University, Pittsburgh, PA 15282, United States.
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Andrisani A, Donà G, Sabbadin C, Dall'Acqua S, Tibaldi E, Roveri A, Bosello Travain V, Brunati AM, Ambrosini G, Ragazzi E, Armanini D, Bordin L. Dapsone hydroxylamine-mediated alterations in human red blood cells from endometriotic patients. Gynecol Endocrinol 2017; 33:928-932. [PMID: 28557604 DOI: 10.1080/09513590.2017.1332177] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
Endometriosis, an estrogen-dependent chronic gynecological disease in women of reproductive age, is characterized by a systemic inflammation status involving also red blood cells (RBCs). In this study, we evaluated how the protein oxidative status could be involved in the worsening of RBC conditions due to dapsone intake in endometriotic women in potential treatment for skin or infection diseases. Blood samples from two groups of volunteers, control group (CG) and endometriosis patient group (PG), were analyzed for their content of band 3 tyrosine phosphorylation (Tyr-P) and high molecular weight aggregate (HMWA) in membranes, and glutathione (GSH) content and carbonic anhydrase (CA) activity in cytosol. In endometriotic patients, RBC showed the highest level of oxidative-related alterations both in membrane and cytosol. More interestingly, the addition of dapsone hydroxylamine (DDS-NHOH) could induce further increase of both membranes and cytosol markers, with an enhancement of CA activity reaching about 66% of the total cell enzyme amount. In conclusion, in PG the systemic inflammatory status leads to the inability of counteracting adjunctive oxidative stress, with a potential involvement of CA-related pathologies, such as glaucoma. Hence, the importance of the evaluation of therapeutic approaches worsening oxidative imbalance present in PG RBC is underlined.
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Affiliation(s)
- Alessandra Andrisani
- a Department of Women's and Children's Health , University of Padova , Padova , Italy
| | - Gabriella Donà
- b Department of Molecular Medicine - Biological Chemistry , University of Padova , Padova , Italy
| | - Chiara Sabbadin
- c Department of Medicine - Endocrinology , University of Padova , Padova , Italy
| | - Stefano Dall'Acqua
- d Department of Pharmaceutical and Pharmacological Sciences , University of Padova , Padova , Italy
| | - Elena Tibaldi
- b Department of Molecular Medicine - Biological Chemistry , University of Padova , Padova , Italy
| | - Antonella Roveri
- b Department of Molecular Medicine - Biological Chemistry , University of Padova , Padova , Italy
| | | | - Anna Maria Brunati
- b Department of Molecular Medicine - Biological Chemistry , University of Padova , Padova , Italy
| | - Guido Ambrosini
- a Department of Women's and Children's Health , University of Padova , Padova , Italy
| | - Eugenio Ragazzi
- d Department of Pharmaceutical and Pharmacological Sciences , University of Padova , Padova , Italy
| | - Decio Armanini
- c Department of Medicine - Endocrinology , University of Padova , Padova , Italy
| | - Luciana Bordin
- b Department of Molecular Medicine - Biological Chemistry , University of Padova , Padova , Italy
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Nazir HF, Elshinawy M, AlRawas A, Khater D, Zadjaly S, Wali Y. Efficacy and Safety of Dapsone Versus Trimethoprim/Sulfamethoxazol for Pneumocystis Jiroveci Prophylaxis in Children With Acute Lymphoblastic Leukemia With a Background of Ethnic Neutropenia. J Pediatr Hematol Oncol 2017; 39:203-208. [PMID: 28234744 DOI: 10.1097/mph.0000000000000804] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
STUDY OBJECTIVE To study dapsone in comparison with trimethoprim/sulfamethoxazole (TMP/SMX) for Pneumocystis jiroveci (PJP) prophylaxis in children with acute lymphoblastic leukemia (ALL). DESIGN A retrospective study with a prospective follow-up. PATIENTS Pediatric ALL patients diagnosed between May 2009 and May 2014, who are still receiving or have completed their maintenance chemotherapy. Patients who completed chemotherapy were prospectively followed up for neutropenia. METHODS TMP/SMX was used as the initial PJP prophylaxis. An alternative drug was indicated if the patient remained cytopenic for >3 weeks. Average absolute neutrophilic count (ANC), average % of oral mercaptopurine (6-MP), and methotrexate doses were calculated over a period of 6 months before and after shifting to dapsone. RESULTS Sixty-two ALL patients were eligible for analysis. Twenty-four patients (38.7%) received TMP/SMX for PJP prophylaxis, whereas 34 patients received Dapsone (54.8%). Only 3 patients received IV pentamidine (4.8%), whereas 1 patient (1.6%) received atovaquone. The incidence of prophylaxis failure was 1/1041 months on TMP/SMX and 1/528 months on dapsone. After shifting to dapsone, patients maintained significantly higher ANC (1.46±0.46 vs. 1.17±0.40, P=0.0053), and received significantly higher doses of 6-MP (62.61%±11.45 vs. 57.45±10.14, P=0.0081) and methotrexate (64.9%±14.29 vs. 56.5%±9.9, P=0.0176), with a significantly shorter duration of chemotherapy interruption (1.94±1.2 vs. 3.25±1.29 wk, P=0.0002). CONCLUSIONS Dapsone for PJP prophylaxis in ALL allowed patients to maintain higher ANC and to receive higher doses of chemotherapy, while maintaining a low incidence of PJP breakthrough infection.
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Affiliation(s)
- Hanan F Nazir
- *Child Health Department ‡Pharmacy Department, Sultan Qaboos University Hospital, Muscat, Oman †Department of Pediatrics, Faculty of Medicine, University of Alexandria, Alexandria, Egypt
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Dubey D, Blackburn K, Greenberg B, Stuve O, Vernino S. Diagnostic and therapeutic strategies for management of autoimmune encephalopathies. Expert Rev Neurother 2016; 16:937-49. [PMID: 27171736 DOI: 10.1080/14737175.2016.1189328] [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: 01/02/2023]
Abstract
INTRODUCTION The understanding of the etio-pathogenesis of autoimmune encephalopathy syndromes has grown significantly in recent years. These are potentially reversible conditions, with variable clinical presentation and potential dramatic response to immunotherapy. AREAS COVERED In this article we review various diagnostic techniques and therapeutic options for management of autoimmune encephalopathy. We also review medication adverse effects and monitoring strategies. Expert commentary: Early diagnosis and immunomodulatory treatment remains the cornerstone of management, to halt the underlying neuro-inflammatory process and prevent permanent neuronal injury. The availability of serological testing and various imaging modalities has further improved detection of these immune-mediated neurological disorders. Understanding the mechanisms and potential adverse effects of immunomodulatory therapies will help physicians to choose the most favorable therapeutic strategy for each patient.
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Affiliation(s)
- Divyanshu Dubey
- a Department of Neurology and Neurotherapeutics , UT Southwestern Medical Center , Dallas , TX , USA
| | - Kyle Blackburn
- a Department of Neurology and Neurotherapeutics , UT Southwestern Medical Center , Dallas , TX , USA
| | - Benjamin Greenberg
- a Department of Neurology and Neurotherapeutics , UT Southwestern Medical Center , Dallas , TX , USA
| | - Olaf Stuve
- a Department of Neurology and Neurotherapeutics , UT Southwestern Medical Center , Dallas , TX , USA.,b Neurology Section , VA North Texas Health Care System, Medical Service , Dallas , TX , USA
| | - Steven Vernino
- a Department of Neurology and Neurotherapeutics , UT Southwestern Medical Center , Dallas , TX , USA
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20
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Murphy AG, Grossman SA. Acute hemolysis in a patient with a newly diagnosed glioblastoma. CNS Oncol 2016; 5:125-9. [PMID: 27230975 DOI: 10.2217/cns-2015-0009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
We describe a 62-year-old of Egyptian origin who presented with sudden, severe and symptomatic anemia requiring hospitalization shortly after beginning concurrent radiation and temozolomide for his newly diagnosed glioblastoma. He had also recently been started on steroids, anticonvulsants and Pneumocystis jirovecii prophylaxis. He was ultimately diagnosed with G6PD deficiency with an acute hemolytic anemia precipitated by dapsone. Screening for G6PD deficiency should be considered in high-risk patient populations where P. jirovecii prophylaxis is planned.
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Affiliation(s)
- Adrian G Murphy
- Department of Oncology, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Stuart A Grossman
- Department of Oncology, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins School of Medicine, Baltimore, MD, USA
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21
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Maertens J, Cesaro S, Maschmeyer G, Einsele H, Donnelly JP, Alanio A, Hauser PM, Lagrou K, Melchers WJG, Helweg-Larsen J, Matos O, Bretagne S, Cordonnier C. ECIL guidelines for preventing Pneumocystis jirovecii pneumonia in patients with haematological malignancies and stem cell transplant recipients. J Antimicrob Chemother 2016; 71:2397-404. [PMID: 27550992 DOI: 10.1093/jac/dkw157] [Citation(s) in RCA: 175] [Impact Index Per Article: 21.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
The 5th European Conference on Infections in Leukaemia (ECIL-5) meeting aimed to establish evidence-based recommendations for the prophylaxis of Pneumocystis jirovecii pneumonia (PCP) in non-HIV-infected patients with an underlying haematological condition, including allogeneic HSCT recipients. Recommendations were based on the grading system of the IDSA. Trimethoprim/sulfamethoxazole given 2-3 times weekly is the drug of choice for the primary prophylaxis of PCP in adults ( A-II: ) and children ( A-I: ) and should be given during the entire period at risk. Recent data indicate that children may benefit equally from a once-weekly regimen ( B-II: ). All other drugs, including pentamidine, atovaquone and dapsone, are considered second-line alternatives when trimethoprim/sulfamethoxazole is poorly tolerated or contraindicated. The main indications of PCP prophylaxis are ALL, allogeneic HSCT, treatment with alemtuzumab, fludarabine/cyclophosphamide/rituximab combinations, >4 weeks of treatment with corticosteroids and well-defined primary immune deficiencies in children. Additional indications are proposed depending on the treatment regimen.
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Affiliation(s)
- Johan Maertens
- Department of Haematology, Acute Leukaemia and Stem Cell Transplantation Unit, University Hospitals Leuven, Campus Gasthuisberg, Leuven, Belgium
| | - Simone Cesaro
- Department of Haematology, Oncoematologia Pediatrica, Policlinico G. B. Rossi, Verona, Italy
| | - Georg Maschmeyer
- Department of Haematology, Oncology and Palliative Care, Ernst-von-Bergmann Klinikum, Potsdam, Germany
| | - Hermann Einsele
- Department of Internal Medicine II, Julius Maximilians University, Würzburg, Germany
| | - J Peter Donnelly
- Department of Haematology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Alexandre Alanio
- Parasitology-Mycology Laboratory, Groupe Hospitalier Lariboisière Saint-Louis Fernand Widal, Assistance Publique-Hôpitaux de Paris (AP-HP), Université Paris-Diderot, Sorbonne Paris Cité, and Institut Pasteur, Unité de Mycologie Moléculaire, CNRS URA3012, Centre National de Référence Mycoses Invasives et Antifongiques, Paris, France
| | - Philippe M Hauser
- Institute of Microbiology, Lausanne University Hospital and University, Lausanne, Switzerland
| | - Katrien Lagrou
- Department of Microbiology and Immunology, KU Leuven-University of Leuven, Leuven, Belgium and National Reference Center for Mycosis, Department of Laboratory Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Willem J G Melchers
- Department of Medical Microbiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jannik Helweg-Larsen
- Department of Infectious Diseases, Rigshospitalet-Copenhagen University Hospital, Copenhagen, Denmark
| | - Olga Matos
- Medical Parasitology Unit, Group of Opportunistic Protozoa/HIV and Other Protozoa, Global Health and Tropical Medicine, Instituto de Higiene e Medicina Tropical, Universidade NOVA de Lisboa, Lisboa, Portugal
| | - Stéphane Bretagne
- Parasitology-Mycology Laboratory, Groupe Hospitalier Lariboisière Saint-Louis Fernand Widal, Assistance Publique-Hôpitaux de Paris (AP-HP), Université Paris-Diderot, Sorbonne Paris Cité, and Institut Pasteur, Unité de Mycologie Moléculaire, CNRS URA3012, Centre National de Référence Mycoses Invasives et Antifongiques, Paris, France
| | - Catherine Cordonnier
- Department of Haematology, Henri Mondor Teaching Hospital, Assistance Publique-Hôpitaux de Paris, and Université Paris-Est-Créteil, Créteil, France
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Safe and Effective Prophylaxis with Bimonthly Intravenous Pentamidine in the Pediatric Hematopoietic Stem Cell Transplant Population. Pediatr Infect Dis J 2016; 35:135-41. [PMID: 26418240 DOI: 10.1097/inf.0000000000000946] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Without prophylaxis, Pneumocystis jiroveci pneumonia (PCP) develops in 5%-15% of pediatric hematopoietic stem cell transplant (HCT) patients with mortality above 50%. Trimethoprim-sulfamethoxazole is a standard PCP prophylaxis; pentamidine is frequently used as second-line prophylaxis because of trimethoprim-sulfamethoxazole's potential for cytopenias. Monthly intravenous (IV) pentamidine has variable efficacy with PCP infection rates of 0%-10% in pediatric patients, and higher breakthrough rates in those younger than 2 years. We hypothesized that bimonthly (twice monthly) pentamidine might have equivalent safety and improved efficacy; therefore, we conducted a retrospective analysis of bimonthly pentamidine PCP prophylaxis. METHODS We retrospectively reviewed records of all pediatric HCT patients who received bimonthly IV pentamidine between December 2006 and June 2013, and collected data regarding demographics, clinical course, prophylaxis rationale, laboratory values and adverse events. RESULTS Between December 2006 and June 2013, 111 pediatric HCT patients received bimonthly IV pentamidine (574 doses, 8758 patient-days); 31 patients were younger than 2 years at initiation. In the majority (53% of courses), pentamidine was initiated because of cytopenias. Fourteen patients (12.6% of patients, 2.4% of doses) experienced a side-effect prompting discontinuation, including 3 patients with infusion-related hypotension/anaphylaxis and 3 with acute pancreatic dysfunction. No patients [0% (95% confidence interval: 0-3.2)] developed PCP during or after bimonthly IV pentamidine prophylaxis. CONCLUSIONS Bimonthly IV pentamidine for PCP prophylaxis in the HCT pediatric population has comparable safety to monthly IV pentamidine and was highly effective, including in the very young. Bimonthly IV pentamidine should be considered in pediatric patients as second-line PCP prophylaxis.
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23
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Williams KM, Ahn KW, Chen M, Aljurf MD, Agwu AL, Chen AR, Walsh TJ, Szabolcs P, Boeckh MJ, Auletta JJ, Lindemans CA, Zanis-Neto J, Malvezzi M, Lister J, de Toledo Codina JS, Sackey K, Chakrabarty JLH, Ljungman P, Wingard JR, Seftel MD, Seo S, Hale GA, Wirk B, Smith MS, Savani BN, Lazarus HM, Marks DI, Ustun C, Abdel-Azim H, Dvorak CC, Szer J, Storek J, Yong A, Riches MR. The incidence, mortality and timing of Pneumocystis jiroveci pneumonia after hematopoietic cell transplantation: a CIBMTR analysis. Bone Marrow Transplant 2016; 51:573-80. [PMID: 26726945 PMCID: PMC4823157 DOI: 10.1038/bmt.2015.316] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2015] [Revised: 10/13/2015] [Accepted: 11/01/2015] [Indexed: 11/09/2022]
Abstract
Pneumocystis jiroveci pneumonia (PJP) is associated with high morbidity and mortality after hematopoietic stem cell transplantation (HSCT). Little is known about PJP infections after HSCT because of the rarity of disease given routine prophylaxis. We report the results of a Center for International Blood and Marrow Transplant Research study evaluating the incidence, timing, prophylaxis agents, risk factors and mortality of PJP after autologous (auto) and allogeneic (allo) HSCT. Between 1995 and 2005, 0.63% allo recipients and 0.28% auto recipients of first HSCT developed PJP. Cases occurred as early as 30 days to beyond a year after allo HSCT. A nested case cohort analysis with supplemental data (n=68 allo cases, n=111 allo controls) revealed that risk factors for PJP infection included lymphopenia and mismatch after HSCT. After allo or auto HSCT, overall survival was significantly poorer among cases vs controls (P=0.0004). After controlling for significant variables, the proportional hazards model revealed that PJP cases were 6.87 times more likely to die vs matched controls (P<0.0001). We conclude PJP infection is rare after HSCT but is associated with high mortality. Factors associated with GVHD and with poor immune reconstitution are among the risk factors for PJP and suggest that protracted prophylaxis for PJP in high-risk HSCT recipients may improve outcomes.
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Affiliation(s)
- K M Williams
- Children's Research Institute, Children's National Health System, Washington, DC, USA
| | - K W Ahn
- CIBMTR (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA.,Division of Biostatistics, Institute for Health and Society, Medical College of Wisconsin, Milwaukee, WI, USA
| | - M Chen
- CIBMTR (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - M D Aljurf
- Department of Oncology, King Faisal Specialist Hospital Center & Research, Riyadh, Saudi Arabia
| | - A L Agwu
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - A R Chen
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - T J Walsh
- Division of Blood and Marrow Transplantation and Cellular Therapies, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA, USA
| | - P Szabolcs
- Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - M J Boeckh
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - J J Auletta
- Divisions of Hematology/Oncology, Bone Marrow Transplantation and Infectious Diseases, Nationwide Children's Hospital, Columbus, OH, USA
| | - C A Lindemans
- Pediatric Blood and Marrow Transplantation Program, University Medical Center Utrecht, Utrecht, Netherlands
| | - J Zanis-Neto
- Hospital de Clínicas - Universidade Federal do Paraná, Curitiba, Brazil
| | - M Malvezzi
- Hospital de Clínicas - Universidade Federal do Paraná, Curitiba, Brazil
| | - J Lister
- Cell Transplantation Program, Western Pennsylvania Cancer Institute, Pittsburgh, PA, USA
| | - J S de Toledo Codina
- Paediatric Oncology, Haematology and SCT Department, Hospital Infantil Vall d'Hebron, Barcelona, Spain
| | - K Sackey
- Department of Pediatric Hematology/Oncology, King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia
| | - J L H Chakrabarty
- Department of Hematology/Oncology, University of Oklahoma, Oklahoma City, OK, USA
| | - P Ljungman
- Department of Hematology, Karolinska University, Stockholm, Sweden
| | - J R Wingard
- Division of Hematology & Oncology, Department of Medicine, University of Florida, Gainesville, FL, USA
| | - M D Seftel
- Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - S Seo
- Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - G A Hale
- Department of Hematology/Oncology, All Children's Hospital, St. Petersburg, FL, USA
| | - B Wirk
- Division of Bone Marrow Transplant, Seattle Cancer Care Alliance, Seattle, WA, USA
| | - M S Smith
- Viracor-IBT Laboratories, Lee's Summit, MO, USA
| | - B N Savani
- Division of Hematology/Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - H M Lazarus
- Seidman Cancer Center, University Hospitals Case Medical Center, Cleveland, OH, USA
| | - D I Marks
- Pediatric Bone Marrow Transplant, University Hospitals Bristol NHS Trust, Bristol, UK
| | - C Ustun
- Division of Hematology, Oncology and Transplantation, Department of Medicine, University of Minnesota Medical Center, Minneapolis, MN, USA
| | - H Abdel-Azim
- Division of Hematology, Oncology and Blood & Marrow Transplantation, Children's Hospital Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, CA, USA
| | - C C Dvorak
- Department of Pediatrics, University of California San Francisco Medical Center, San Francisco, CA, USA
| | - J Szer
- Department Clinical Haematology and Bone Marrow Transplantation, Royal Melbourne Hospital, Victoria, Australia
| | - J Storek
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - A Yong
- Royal Adelaide Hospital/SA Pathology and School of Medicine, University of Adelaide, Adelaide, Australia
| | - M R Riches
- Division of Hematology and Oncology, Department of Medicine, University of North Carolina, Chapel Hill, NC, USA
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Ljungman P, Snydman D, Boeckh M. Pneumonia After Hematopoietic Stem Cell Transplantation. TRANSPLANT INFECTIONS 2016. [PMCID: PMC7153442 DOI: 10.1007/978-3-319-28797-3_16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Pneumonia is the main cause of morbidity and mortality after hematopoietic stem cell transplantation. Two thirds of pneumonias observed after both autologous and allogeneic stem cell transplantations are of infectious origin, and coinfections are frequent. One third is due to noninfectious process, such as alveolar hemorrhage, alveolar proteinosis, or alloimmune pulmonary complications such as bronchiolitis obliterans or idiopathic interstitial pneumonitis. Most of these noninfectious complications may require treatment with corticosteroids which may be deleterious in infection. On the other hand, these complications either mimic or may be complicated with infections. Therefore, a precise diagnosis of pneumonia is of crucial importance to decide of the optimal treatment. CT scan is the best procedure for imaging of the lung. Although several indirect biomarkers, such as serum or plasma galactomannan or (1-3) β(beta)-G-glucan, can help in the etiological diagnosis, only direct invasive investigations provide the best chance to identify the cause(s) of pneumonia. Bronchoalveolar lavage (BAL) under fiberoptic bronchoscopy is the procedure of choice to identify the cause of pulmonary infection. It is safe and reproducible, and its diagnostic yield is around 50 % if the BAL fluid is processed at the laboratory according to a prespecified protocol established between the transplanter, the infectious diseases’ specialist, the pneumologist, and the laboratory, allowing the identification of the most likely hypotheses. Transbronchial biopsy does not provide significant additional information to BAL in most cases and more often complicates with bleeding and pneumothorax. In case of a noncontributory BAL, the decision to proceed to a second BAL, a transthoracic biopsy, or a surgical biopsy should be cautiously weighted in a multidisciplinary approach in regard to the benefits and risks of invasive procedures versus empirical treatment.
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Affiliation(s)
- Per Ljungman
- Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - David Snydman
- Tufts University School of Medicine Tufts Medical Center, Boston, Massachusetts USA
| | - Michael Boeckh
- University of Washington Fred Hutchinson Cancer Research Center, Seattle, Washington USA
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Risks and Epidemiology of Infections After Hematopoietic Stem Cell Transplantation. TRANSPLANT INFECTIONS 2016. [PMCID: PMC7124050 DOI: 10.1007/978-3-319-28797-3_6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Infections following HCT are frequently related to risk factors caused by the procedure itself. Neutropenia and mucositis predispose to bacterial infections. Prolonged neutropenia increases the likelihood of invasive fungal infection. GVHD and its treatment create the most important easily identifiable risk period for a variety of infectious complications, particularly mold infections. Profound, prolonged T cell immunodeficiency, present after T cell-depleted or cord blood transplants, is the main risk factor for viral problems like disseminated adenovirus disease or EBV-related posttransplant lymphoproliferative disorder.
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Aguado JM, Cruz JJ, Virizuela JA, Aguilar M, Carmona A, Cassinello J, Gudiol C, Jiménez Fonseca P, Lizasoain M, Marco F, Ruiz I, Ruiz M, Salavert M, Vicente D, Carratalà J. Management of Infection and Febrile Neutropenia in Patients with Solid Cancer. Enferm Infecc Microbiol Clin 2015; 35:451-460. [PMID: 26279208 DOI: 10.1016/j.eimc.2015.06.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2015] [Revised: 05/24/2015] [Accepted: 06/15/2015] [Indexed: 12/22/2022]
Abstract
A group of experts from the Spanish Society of Infectious Diseases and Clinical Microbiology (SEIMC) and the Spanish Society of Medical Oncology (SEOM) have reviewed in this paper the main aspects to be considered in the evaluation of patients with solid cancer and infectious diseases. They have established a series of recommendations on the prevention of the most prevalent infections in these patients, the use of vaccines, the control measures of vascular catheter infection and prevention of infections before certain surgical procedures. Also the criteria for management of febrile neutropenia and the use of colony-stimulating factors were revised. Finally they provide a series of recommendations for the treatment of cancer patients with severe infection. The document is completed with a series of measures for the control of hospital infection.
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Affiliation(s)
- José María Aguado
- Unidad de Enfermedades Infecciosas, Hospital Universitario 12 de Octubre, Madrid, España.
| | - Juan Jesús Cruz
- Servicio de Oncología Médica, Hospital Clínico Universitario de Salamanca, Salamanca, España
| | - Juan Antonio Virizuela
- Servicio de Oncología Médica, Hospital Universitario Virgen de Macarena, Sevilla, España
| | - Manuela Aguilar
- Unidad de Enfermedades Infecciosas, Hospital Universitario Virgen del Rocío, Sevilla, España
| | - Alberto Carmona
- Servicio de Oncología Médica, Hospital General Universitario Morales Meseguer, Murcia, España
| | - Javier Cassinello
- Servicio de Oncología Médica, Hospital Universitario de Guadalajara, Guadalajara, España
| | - Carlota Gudiol
- Servicio de Enfermedades Infecciosas, Hospital Universitari de Bellvitge, Barcelona, España
| | - Paula Jiménez Fonseca
- Servicio de Oncología Médica, Hospital Universitario Central de Asturias, Oviedo, Asturias, España
| | - Manuel Lizasoain
- Unidad de Enfermedades Infecciosas, Hospital Universitario 12 de Octubre, Madrid, España
| | - Francesc Marco
- Laboratori de Microbiologia, Centre de Diagnòstic Biomèdic (CDB), ISGlobal, Barcelona Ctr. Int. Health Res. (CRESIB), Hospital Clínic - Universitat de Barcelona, Barcelona, España
| | - Isabel Ruiz
- Servicio de Enfermedades Infecciosas, Hospital Universitari Vall d'Hebron, Barcelona, España
| | - Maribel Ruiz
- Servicio de Oncología Médica, Hospital Universitari Vall d'Hebron, Barcelona, España
| | - Miguel Salavert
- Servicio de Enfermedades Infecciosas, Hospital Universitari i Politècnic La Fe, Valencia, España
| | - David Vicente
- Servicio de Oncología Médica, Hospital Universitario Virgen de Macarena, Sevilla, España
| | - Jordi Carratalà
- Servicio de Enfermedades Infecciosas, Hospital Universitari de Bellvitge, Barcelona, España
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Clark A, Hemmelgarn T, Danziger-Isakov L, Teusink A. Intravenous pentamidine for Pneumocystis carinii/jiroveci pneumonia prophylaxis in pediatric transplant patients. Pediatr Transplant 2015; 19:326-31. [PMID: 25712369 DOI: 10.1111/petr.12441] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/16/2015] [Indexed: 11/30/2022]
Abstract
SMX/TMP is the current gold standard for prophylaxis against PCP in immunocompromised pediatric patients. Currently, there are several second-line options for prophylaxis but many, including intravenous (IV) pentamidine, have not been reported to be as effective or as safe as SMX/TMP in the pediatric transplant population. This study is to determine the efficacy and safety of IV pentamidine in preventing PCP in pediatric transplant patients. A retrospective chart review was conducted to evaluate all transplant patients that received at least one dose of IV pentamidine from January 2010 to July 2013. The primary outcome, IV pentamidine efficacy, was evaluated by the incidence of PCP diagnosis for 28 days after the last dose of IV pentamidine if patient was transitioned to another agent for PCP prophylaxis. Patients on IV pentamidine for entire course of PCP prophylaxis were followed at least six months after discontinuation of IV pentamidine. The safety of IV pentamidine was assessed by the incidence of adverse events leading to pentamidine discontinuation. All data were analyzed using descriptive statistics. All transplant patients at CCHMC who had received IV pentamidine were reviewed, and 333 patients met inclusion criteria. The overall incidence of PCP was found to be 0.3% for pediatric transplant patients on pentamidine. Pentamidine was found to be safe, and the incidence of adverse events leading to discontinuation was 6% with the most common reason being tachycardia 2.1%. IV pentamidine is safe and effective as PCP prophylaxis in pediatric transplant patients with a PCP breakthrough rate of 0.3% (1 of 333 patients), and only 20 adverse events led to discontinuation. We recommend that IV pentamidine be considered as a second-line option in pediatric transplant patients who cannot tolerate SMX/TMP.
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Affiliation(s)
- Abigail Clark
- Pharmacy Department, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
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Young JAH, Weisdorf DJ. Infections in Recipients of Hematopoietic Stem Cell Transplants. MANDELL, DOUGLAS, AND BENNETT'S PRINCIPLES AND PRACTICE OF INFECTIOUS DISEASES 2015. [PMCID: PMC7152282 DOI: 10.1016/b978-1-4557-4801-3.00312-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Delayed opportunistic infections in hematopoietic stem cell transplantation patients: a surmountable challenge. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2013; 2012:265-70. [PMID: 23233590 DOI: 10.1182/asheducation-2012.1.265] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Changes in the transplantation procedure and the implementation of effective supportive care strategies have decreased the incidence of infectious complications early after conditioning therapy for allogeneic hematopoietic stem cell transplantation (HCT) and have extended the duration of risks later. Therefore, the types of infections that cause significant morbidity and the timing of risks have changed. These late infections are caused by all types of organisms, bacterial, viral, and fungal, but risks are predictable and surmountable with the use of tailored prevention strategies. Specifically, recent studies document prolonged risks for bacterial infections in the setting of GVHD, especially those caused by encapsulated organisms and those secondary to impaired Ab responses. Both prophylaxis and vaccination strategies can be used as a means to prevent infections, which typically manifest in the respiratory tract. Multiple viruses cause infection later after HCT, including several herpesviruses (eg, CMV and varicella zoster virus) and other respiratory viruses such as influenza and adenovirus. These infections can cause severe disease with diagnostic challenges, but prevention strategies using enhanced monitoring and/or prophylaxis may be effective. Finally, fungi also cause disease late after HCT, especially filamentous fungi (eg, Aspergillus species and Mucormycoses) and Pneumocystis jiroveci; prophylactic strategies may be used successfully to prevent invasive infection. Late infections and methods to prevent them are reviewed herein.
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McKeon A. Immunotherapeutics for Autoimmune Encephalopathies and Dementias. Curr Treat Options Neurol 2013; 15:723-37. [DOI: 10.1007/s11940-013-0251-8] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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31
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Delayed opportunistic infections in hematopoietic stem cell transplantation patients: a surmountable challenge. Hematology 2012. [DOI: 10.1182/asheducation.v2012.1.265.3800160] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Abstract
Changes in the transplantation procedure and the implementation of effective supportive care strategies have decreased the incidence of infectious complications early after conditioning therapy for allogeneic hematopoietic stem cell transplantation (HCT) and have extended the duration of risks later. Therefore, the types of infections that cause significant morbidity and the timing of risks have changed. These late infections are caused by all types of organisms, bacterial, viral, and fungal, but risks are predictable and surmountable with the use of tailored prevention strategies. Specifically, recent studies document prolonged risks for bacterial infections in the setting of GVHD, especially those caused by encapsulated organisms and those secondary to impaired Ab responses. Both prophylaxis and vaccination strategies can be used as a means to prevent infections, which typically manifest in the respiratory tract. Multiple viruses cause infection later after HCT, including several herpesviruses (eg, CMV and varicella zoster virus) and other respiratory viruses such as influenza and adenovirus. These infections can cause severe disease with diagnostic challenges, but prevention strategies using enhanced monitoring and/or prophylaxis may be effective. Finally, fungi also cause disease late after HCT, especially filamentous fungi (eg, Aspergillus species and Mucormycoses) and Pneumocystis jiroveci; prophylactic strategies may be used successfully to prevent invasive infection. Late infections and methods to prevent them are reviewed herein.
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FÖRNER WOLFGANG, BADAWI HASSANM. A DFT ANALYSIS OF THE MOLECULAR STRUCTURES AND VIBRATIONAL SPECTRA OF 4,4′-SULFONYLDIPHENOL. JOURNAL OF THEORETICAL & COMPUTATIONAL CHEMISTRY 2012. [DOI: 10.1142/s0219633612500563] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
We have studied the structural properties and vibrational spectra of Bisphenol S (4,4′-sulfonyldi-phenol) with the help of Density Functional Calculations using a 6-311G∗∗ basis set. In addition we recorded experimental spectra in our laboratory. With the help of the GaussView program we could provide a complete assignment of the vibrational lines to the calculated normal modes of the molecule. The calculated and experimental vibrational spectra agree rather well with each other and we found the properties of Bisphenol S to be rather similar to the sulfa drug dapsone studied earlier. Interestingly, the electron donating power of an OH aubstituent at a phenyl ring seems to be less effective than that of an NH2 (in dapsone) substituent, because in Bisphenol S the relative intensity of the ring breathing line in the Raman spectrum appears to be much larger than in dapsone. We reach this conclusion about the electron donating powers of susbtituents, because in an early study on chlorine substituted anilines we have found that the larger the electron density in the ring becomes, the more the relative intensity of that line diminishes.
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Affiliation(s)
- WOLFGANG FÖRNER
- Department of Chemistry, King Fahd University of Petroleum and Minerals Dhahran 31261, Saudi Arabia
| | - HASSAN M. BADAWI
- Department of Chemistry, King Fahd University of Petroleum and Minerals Dhahran 31261, Saudi Arabia
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Efficacy of a viral load-based, risk-adapted, preemptive treatment strategy for prevention of cytomegalovirus disease after hematopoietic cell transplantation. Biol Blood Marrow Transplant 2012; 18:1687-99. [PMID: 22683614 DOI: 10.1016/j.bbmt.2012.05.015] [Citation(s) in RCA: 129] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2012] [Accepted: 05/21/2012] [Indexed: 01/02/2023]
Abstract
Cytomegalovirus (CMV) surveillance and preemptive therapy is the most commonly used strategy for CMV disease prevention in hematopoietic cell transplantation recipients. In 2007, we introduced a CMV prevention strategy for patients at risk for CMV disease using quantitative PCR surveillance, with treatment thresholds determined by patient risk factors. Patients (N = 367) received preemptive therapy either at a plasma viral load of ≥500 copies/mL, at ≥100 copies/mL if receiving ≥1 mg/kg of prednisone or anti-T cell therapies, or if a ≥5-fold viral load increase from baseline was detected. Compared with patients before 2007 undergoing antigenemia-based surveillance (n = 690) with preemptive therapy initiated for any positive level, the risk-adapted PCR-based strategy resulted in similar use of antiviral agents, and similar risks of CMV disease, toxicity, and nonrelapse mortality in multivariable models. The cumulative incidence of CMV disease by day 100 was 5.2% in the PCR group compared with 5.8% in the antigenemia group (1 year: 9.1% PCR vs 9.6% antigenemia). Breakthrough CMV disease in the PCR group was predominantly in the gastrointestinal (GI) tract (15 of 19 cases; 79%). However, unlike CMV pneumonia, CMV GI disease was not associated with increased nonrelapse mortality (adjusted hazard ratio, 1.19; P = .70 [GI disease] vs 8.18; P < .001 [pneumonia]). Thus, the transition to a preemptive therapy strategy based on CMV viral load and host risk factors successfully prevented CMV disease without increasing the proportion of patients receiving preemptive therapy and attributable toxicity. Breakthrough disease in PCR-based preemptive therapy occurs at a low incidence and presents primarily as GI disease, which is more likely to be responsive to antiviral therapy.
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34
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Kelly EM, Jonathan D, Jeffrey PG. Dapsone-Induced Methemoglobinemia in a Patient with Acute Lymphocytic Leukemia Admitted with Severe Legionella Pneumonia. Hosp Pharm 2012. [DOI: 10.1310/hpj4701-42] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Dapsone is an antibacterial medication used as an alternative to the first-line therapy (sulfamethoxazole-trimethoprim) for Pneumocystis pneumonia prophylaxis. Methemoglobinemia is a known toxicity of dapsone. However, dapsone-induced methemoglobinemia in an acute lymphocytic leukemia (ALL) patient with severe Legionella pneumonia has not been previously reported. We describe a 37-year-old male with ALL who was admitted for severe Legionella pneumonia sepsis, rhabdomyolysis, and multiple organ failure. The patient was started on broad-spectrum antibiotics and subsequently intubated for respiratory failure. The patient's methemoglobin level was 24.5%. The repeat methemoglobin level was 28.7%; intravenous methylene blue 100 mg was given for a total of 2 doses after which the methemoglobin level decreased to 2.5%. The patient was extubated 4 days after the second dose of methylene blue. He was later discharged home in stable condition. This patient developed severe sepsis with multiorgan failure, which resulted in acute liver and renal insufficiencies. The decreased metabolism and excretion of dapsone and its toxic metabolite is the likely cause of methemoglobinemia in this patient. Immunocompromised oncology patients who develop severe sepsis require careful monitoring for dapsone-induced methemoglobinemia. Liver dysfunction and renal failure may both potentiate toxicity with prophylactic doses of dapsone.
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Affiliation(s)
- E. Martin Kelly
- Department of Pharmacy, University of North Carolina Hospitals and Clinics, Chapel Hill, North Carolina
| | - Daining Jonathan
- Department of Medicine, University of Maryland Medical Center, Baltimore, Maryland
| | - P. Gonzales Jeffrey
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, Maryland
- Medical Intensive Care Unit, University of Maryland Medical Center, Baltimore, Maryland
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Nakamae H, Storer B, Sandmaier BM, Maloney DG, Davis C, Corey L, Storb R, Boeckh M. Cytopenias after day 28 in allogeneic hematopoietic cell transplantation: impact of recipient/donor factors, transplant conditions and myelotoxic drugs. Haematologica 2011; 96:1838-45. [PMID: 21880629 DOI: 10.3324/haematol.2011.044966] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Secondary cytopenias are serious complications following hematopoietic cell transplantation. Etiologies include myelotoxic agents, viral infections, and possibly transplant-related factors such as the intensity of the conditioning regimen and the source of stem cells. DESIGN AND METHODS We retrospectively analyzed data from 2162 hematopoietic cell transplant recipients to examine the effect of these factors on overall cytopenias occurring after 28 days in hematopoietic cell transplantation. RESULTS Advanced age of the patient, recipient cytomegalovirus seropositivity, unrelated donor status, human leukocyte antigen mismatch and lower doses of transplanted CD34(+) cells (≤ 6.4×10(6)/kg) significantly increased the risk of cytopenias after day 28. Non-myeloablative hematopoietic cell transplantation had protective effects on anemia and thrombocytopenia after day 28 (adjusted odds ratio 0.76, probability value of 0.05 and adjusted odds ratio 0.31, probability value of <0.0001, respectively) but not on overall or ganciclovir-related neutropenia. This lack of protection appeared to be due to the use of mycophenolate mofetil in the majority of recipients of non-myeloablative hematopoietic cell transplants. Peripheral blood stem cells did not confer protection from cytopenias when compared to bone marrow. CONCLUSIONS Elderly patients appear to be more prone to cumulative toxicities of post-transplant drug regimens, but non-myeloablative conditioning, optimized human leukocyte antigen matching, and higher doses of CD34(+) cell infusions may reduce the risk of cytopenia after day 28.
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Affiliation(s)
- Hirohisa Nakamae
- Fred Hutchinson Cancer Research Center, Seattle, WA 98109-1024, USA
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Barclay JA, Ziemba SE, Ibrahim RB. Dapsone-induced methemoglobinemia: a primer for clinicians. Ann Pharmacother 2011; 45:1103-15. [PMID: 21852596 DOI: 10.1345/aph.1q139] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVE To present a comprehensive review of dapsone-induced methemoglobinemia and its management. DATA SOURCES Literature retrieval was accessed through MEDLINE (1966-March 2011), Cochrane Library, and EMBASE, using the terms dapsone and methemoglobinemia. STUDY SELECTION AND DATA EXTRACTION All case reports, small case series, and randomized controlled trials published in English were evaluated. Because of the absence of comprehensive updates on this topic since 1996, publications between 1997 and March 2011 were included in this review. DATA SYNTHESIS Between 1997 and March 2011, the majority of publications describing methemoglobinemia associated with dapsone use reported this adverse effect at therapeutic doses. Excluding overdose situations, 18 described symptomatic dapsone-associated methemoglobinemia and clinical presentation ranging from cyanosis to dyspnea. In almost all of the accounts, patients had a concurrent event such as anemia or pneumonia, suggesting an interplay between these comorbidities and the onset of symptomatic methemoglobinemia. Delayed hemolytic anemia was seen in patients with high methemoglobin levels at presentation. Management in most cases consisted of administration of methylene blue. Overall, most reports described a successful outcome, and no mortality resulted from methemoglobinemia associated with therapeutic use. CONCLUSIONS Clinicians should recognize methemoglobinemia as an adverse effect associated with dapsone use and the potential factors that precipitate it. They should also know how to promptly and effectively manage this event.
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Affiliation(s)
- James A Barclay
- Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Allied Health Professions, Wayne State University, Detroit, MI, USA.
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Abstract
Pneumocystis pneumonia (PCP) can be life threatening for children receiving chemotherapy and immunosuppressive medication, including high-dose steroids. Although there are no current guidelines for prophylaxis in pediatric oncology patients, ongoing studies are evaluating the efficacy, side effects, ease of administration, and compliance of drugs used for PCP prophylaxis. Drugs currently being prescribed in practice include Bactrim, pentamidine, dapsone, and atovaquone. Bactrim remains superior for preventing PCP, but alternatives are being analyzed and investigated for those unable to tolerate Bactrim because of drug allergy or side effects. Educating patients and families about the importance of PCP prophylaxis and compliance should be a priority for all health care providers caring for children receiving immunosuppressive medications, including chemotherapy.
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High prevalence of Dapsone-induced oxidant hemolysis in North American SCT recipients without glucose-6-phosphate-dehydrogenase deficiency. Bone Marrow Transplant 2011; 47:399-403. [PMID: 21478917 DOI: 10.1038/bmt.2011.83] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Dapsone (4-4'-diaminodiphenylsulfone) is commonly used for Pneumocystis jirovecii pneumonia (PCP) prophylaxis in immunocompromised patients. Oxidant hemolysis is a known complication of dapsone, but its frequency in adult patients who have undergone a SCT for hematological malignancies is not well established. We studied the presence of oxidant hemolysis, by combining examination of RBC morphology and laboratory data, in 30 patients who underwent a SCT and received dapsone for PCP prophylaxis, and compared this group with 26 patients who underwent a SCT and received trimethoprim-sulfamethoxazole (TMP-SMX) for PCP prophylaxis. All patients had normal glucose-6-phosphate dehydrogenase (G6PDH) enzymatic activity. In SCT patients, dapsone compared with TMP-SMX for PCP prophylaxis was associated with a high incidence of oxidant hemolysis (87 vs 0%, P<0.001), and the morphological evaluation of oxidant hemolysis correlated well with laboratory evidence of hemolysis. Dapsone-induced oxidant hemolysis in SCT patients is 20-fold higher than the reported rate in the population of HIV-infected patients, and thus much higher than the prevalence of G6PDH variants in the general population. In our patients, it manifested clinically as a lower Hb that was not significant enough to result in increased packed RBC transfusions.
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Bordin L, Fiore C, Zen F, Coleman MD, Ragazzi E, Clari G. Dapsone hydroxylamine induces premature removal of human erythrocytes by membrane reorganization and antibody binding. Br J Pharmacol 2011; 161:1186-99. [PMID: 20662842 DOI: 10.1111/j.1476-5381.2010.00962.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND AND PURPOSE N-hydroxylation of dapsone leads to the formation of the toxic hydroxylamines responsible for the clinical methaemoglobinaemia associated with dapsone therapy. Dapsone has been associated with decreased lifespan of erythrocytes, with consequences such as anaemia and morbidity in patients treated with dapsone for malaria. Here, we investigated how dapsone and/or its hydroxylamine derivative (DDS-NHOH) induced erythrocyte membrane alterations that could lead to premature cell removal. EXPERIMENTAL APPROACH Erythrocytes from healthy donors were subjected to incubation with dapsone and DDS-NHOH for varying times and the band 3 protein tyrosine-phosphorylation process, band 3 aggregation, membrane alteration and IgG binding were all examined and compared with erythrocytes from two patients receiving dapsone therapy. KEY RESULTS The hydroxylamine derivative, but not dapsone (the parent sulphone) altered membrane protein interactions, leading both to aggregation of band 3 protein and to circulating autologous antibody binding, shown in erythrocytes from patients receiving dapsone therapy. The band 3 tyrosine-phosphorylation process can be used as a diagnostic system to monitor membrane alterations both in vitro, assessing concentration and time-dependent effects of DDS-NHOH treatment, and in vivo, evaluating erythrocytes from dapsone-treated patients, in resting or oxidatively stimulated conditions. CONCLUSIONS AND IMPLICATIONS DDS-NHOH-induced alterations of human erythrocytes can be directly monitored in vitro by tyrosine-phosphorylation level and formation of band 3 protein aggregates. The latter, together with antibody-mediated labelling of erythrocytes, also observed after clinical use of dapsone, may lead to shortening of erythrocyte lifespan.
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Affiliation(s)
- Luciana Bordin
- Department of Biological Chemistry, University of Padova, Viale G. Colombo 3, Padua, Italy.
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Tomblyn M, Chiller T, Einsele H, Gress R, Sepkowitz K, Storek J, Wingard JR, Young JAH, Boeckh MJ, Boeckh MA. Guidelines for preventing infectious complications among hematopoietic cell transplantation recipients: a global perspective. Biol Blood Marrow Transplant 2009; 15:1143-238. [PMID: 19747629 PMCID: PMC3103296 DOI: 10.1016/j.bbmt.2009.06.019] [Citation(s) in RCA: 1169] [Impact Index Per Article: 77.9] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2009] [Accepted: 06/23/2009] [Indexed: 02/07/2023]
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42
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Dapsone-induced Hemolytic Anemia in Lung Allograft Recipients. J Heart Lung Transplant 2008; 27:1198-202. [DOI: 10.1016/j.healun.2008.07.025] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2008] [Revised: 07/01/2008] [Accepted: 07/29/2008] [Indexed: 11/21/2022] Open
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Scott BL, Park JY, Deeg HJ, Marr KA, Boeckh M, Chauncey TR, Appelbaum FR, Storb R, Storer BE. Pretransplant neutropenia is associated with poor-risk cytogenetic features and increased infection-related mortality in patients with myelodysplastic syndromes. Biol Blood Marrow Transplant 2008; 14:799-806. [PMID: 18541200 DOI: 10.1016/j.bbmt.2008.04.011] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2008] [Accepted: 04/21/2008] [Indexed: 10/22/2022]
Abstract
A retrospective cohort analysis was performed to determine the impact of neutropenia on the outcome of hematopoietic cell transplantation (HSCT) in patients with myelodysplasia (MDS). Among 291 consecutive patients, 178 (61%) had absolute neutrophil counts (ANCs) <1500/microL and 113 (39%) had ANCs > or =1500/microL within 2 weeks before HSCT. Neutropenic patients more often had poor-risk karyotypes (34% versus 12%, P < .0001) and high-risk International Prognostic Scoring System scores (37% versus 18%, P = .0006). After HSCT, the rate of infections caused by Gram-positive bacteria and invasive fungal infections was significantly increased among neutropenic patients (rate ratio [RR] 1.77, P = .02 and RR = 2.56, P = .03, respectively), whereas infections caused by Gram-negative bacteria were not affected (RR 1.33, P = .53). The hazards of nonrelapse mortality (NRM) (hazard ratio [HR] = 1.62 [1.1-2.4], P = .01), overall mortality (HR = 1.55 [1.1-2.1], P = 0.007), and infection-related mortality (HR = 2.22 [1.2-4.2], P = .01) were increased in neutropenic patients, whereas relapse, engraftment, and graft-versus-host-disease were not affected. After adjusting for cytogenetic risk and marrow myeloblast percentages, neutropenic patients remained at significant hazard for infection-related mortality (HR = 1.94 [1.0-3.8], P = .05), but not for overall mortality or NRM. We propose that intensified strategies to prevent infections should be implemented in MDS patients with preexisting neutropenia who undergo HSCT.
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Affiliation(s)
- Bart L Scott
- Fred Hutchinson Cancer Research Center, Seattle, Washington 98109-1024, USA.
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Erard V, Guthrie KA, Varley C, Heugel J, Wald A, Flowers MED, Corey L, Boeckh M. One-year acyclovir prophylaxis for preventing varicella-zoster virus disease after hematopoietic cell transplantation: no evidence of rebound varicella-zoster virus disease after drug discontinuation. Blood 2007; 110:3071-7. [PMID: 17515400 DOI: 10.1182/blood-2007-03-077644] [Citation(s) in RCA: 117] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Abstract
No consensus exists on whether acyclovir prophylaxis should be given for varicella-zoster virus (VZV) prophylaxis after hematopoietic cell transplantation because of the concern of “rebound” VZV disease after discontinuation of prophylaxis. To determine whether rebound VZV disease is an important clinical problem and whether prolonging prophylaxis beyond 1 year is beneficial, we examined 3 sequential cohorts receiving acyclovir from day of transplantation until engraftment for prevention of herpes simplex virus reactivation (n = 932); acyclovir or valacyclovir 1 year (n = 1117); or acyclovir/valacyclovir for at least 1 year or longer if patients remained on immunosuppressive drugs (n = 586). In multivariable statistical models, prophylaxis given for 1 year significantly reduced VZV disease (P < .001) without evidence of rebound VZV disease. Continuation of prophylaxis beyond 1 year in allogeneic recipients who remained on immunosuppressive drugs led to a further reduction in VZV disease (P = .01) but VZV disease developed in 6.1% during the second year while receiving this strategy. In conclusion, acyclovir/valacyclovir prophylaxis given for 1 year led to a persistent benefit after drug discontinuation and no evidence of a rebound effect. To effectively prevent VZV disease in long-term hematopoietic cell transplantation survivors, additional approaches such as vaccination will probably be required.
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Affiliation(s)
- Veronique Erard
- Division of Clinical Research, Fred Hutchinson Cancer Research Center, Seattle, WA 98109-1024, USA
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Au WY. Relevance of drug allergy history after allogeneic hemopoietic stem cell transplantation. Bone Marrow Transplant 2007; 40:179-80. [PMID: 17530004 DOI: 10.1038/sj.bmt.1705705] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Dunford LM, Roy DM, Hahn TE, Padmanabhan S, Segal BH, Almyroudis N, McCarthy PL, Battiwalla M. Dapsone-Induced Methemoglobinemia after Hematopoietic Stem Cell Transplantation. Biol Blood Marrow Transplant 2006; 12:241-2. [PMID: 16443522 DOI: 10.1016/j.bbmt.2005.10.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2005] [Accepted: 10/12/2005] [Indexed: 10/25/2022]
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Abidi MH, Kozlowski JR, Ibrahim RB, Peres E. The sulfone syndrome secondary to dapsone prophylaxis in a patient undergoing unrelated hematopoietic stem cell transplantation. Hematol Oncol 2006; 24:164-5. [PMID: 16639690 DOI: 10.1002/hon.780] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Dapsone is commonly used for pneumocystis carinii pneumonia (PCP) prophylaxis in immunocompromised patients. It has been used as an alternative therapy in the hematopoietic stem cell transplant (HSCT) setting in patients who can't tolerate trimethoprim-sulfamethoxazole. The Sulfone syndrome is not a well-known sequela of dapsone therapy and occurs at various doses, ranging from 50-300 mg/d. In all cases the syndrome occurs within 2 months of initiating therapy. Its clinical manifestations include: fever, methemoglobinemia, hemolytic anemia, exfoliative dermatitis and transaminits. A 51-year old female underwent a matched unrelated hematopoiectic stem cell transplant for acute mylogenous leukemia. Dapsone therapy was initiated on day +28 at a dose of 100 mg/day for PCP prophylaxis secondary to the patient's history of a sulfonamide allergy. On day +59, one month after initiation of therapy she developed hepatitis, hemolytic anemia, fever and methemoglobinemia of 8%. She was transferred to the intensive care unit and subsequently developed an exfoliative dermatitis. We conclude that the clinical presentation of this patient after HSCT on dapsone therapy coincide with the sulfone syndrome not previously described in a patients after HSCT.
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MESH Headings
- Anemia, Hemolytic/chemically induced
- Anemia, Hemolytic/pathology
- Chemical and Drug Induced Liver Injury/etiology
- Chemical and Drug Induced Liver Injury/pathology
- Dapsone/administration & dosage
- Dapsone/adverse effects
- Dermatitis, Exfoliative/chemically induced
- Dermatitis, Exfoliative/pathology
- Drug Hypersensitivity
- Fatal Outcome
- Female
- Hematopoietic Stem Cell Transplantation
- Humans
- Leukemia, Myeloid, Acute/complications
- Leukemia, Myeloid, Acute/pathology
- Leukemia, Myeloid, Acute/therapy
- Middle Aged
- Pneumonia, Pneumocystis/etiology
- Pneumonia, Pneumocystis/pathology
- Pneumonia, Pneumocystis/prevention & control
- Sulfonamides/adverse effects
- Syndrome
- Transplantation, Homologous
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Affiliation(s)
- Muneer H Abidi
- Division of Hematology & Oncology, Department of Pharmacy, Barbara Ann Karmanos Cancer Institute, Eugene Applebaum College of Pharmacy and Allied Health, Wayne State University, Detroit, Michigan 48201, USA
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