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Fan W, Par-Young J, Li K, Zhang Y, Xiao P, Hua L, Leng L, Chen X, Bucala R. Clinical features and high-risk indicators of central nervous system involvement in primary Sjögren's syndrome. Clin Rheumatol 2023; 42:443-451. [PMID: 36401063 PMCID: PMC9873757 DOI: 10.1007/s10067-022-06448-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 11/05/2022] [Accepted: 11/10/2022] [Indexed: 11/21/2022]
Abstract
BACKGROUND Evidence for central nervous system involvement in primary Sjögren's syndrome (pSS) patients is controversial and extremely limited. We aimed to describe the clinical profiles and high-risk indicators of primary Sjögren's syndrome (pSS) patients with central nervous system (CNS) involvement (pSS-CNS). METHODS A total of 412 participants with pSS from a hospital in China from January 2012 to December 2019 were enrolled in the retrospective study. 42 pSS-CNS patients were compared with 370 pSS patients without CNS involvement. The clinical features, laboratory examinations, imaging characteristics, and treatment of the pSS-CNS cases were systematically analyzed. Potential risk factors related to pSS-CNS patients were identified by multivariate logistic regression analysis. RESULTS The prevalence of central nervous system involvement in the studied pSS patients was 10.2% (42/412), with 31.3% (14/42) of pSS patients having neurological manifestations as the initial symptom. The manifestations of hemiparesis (35.7%, 15/42), paraparesis (28.6%, 12/42), dysphonia (31.0%, 13/42), blurred vision (21.4%, 9/42), and dysfunctional proprioception (23.8%, 10/42) were more common in the pSS-CNS patients. Cerebral infarction (57.1%, 24/42), demyelination (31.0%, 13/42), myelitis (23.8%, 11/42), and angiostenosis (21.4%, 9/42) were most often found on MRI or CT scan imaging in the pSS-CNS patients. Intrathecal IgG level and total protein of cerebrospinal fluid were increased in 50% (8/16) of the pSS-CNS group. In comparison with patients without CNS involvement, the pSS-CNS patients were found to also have kidney and lung involvement, hematologic abnormalities, positive ANA and anti-SSA antibody tests, and reduced complement 3 (C3) and complement 4 (C4) levels (all p < 0.05). The prevalence of lung involvement, immune thrombocytopenia, and high-titer ANA (1:1000) were significantly higher in pSS-CNS disease activity compared to those in the moderately active group. Multivariate analysis identified lung involvement, anti-SSA positivity, and low C3 levels as prognostic factors for pSS-CNS. After high-dose glucocorticoids and immunosuppressive therapy, 60.5% (26/38) of pSS-CNS patients improved, 36.8% (14/38) were unresponsive to treatment, and 2.6% (1/38) died. CONCLUSION Clinical features are diverse in pSS-CNS patients, and the morbidity rate is low. CNS involvement was the initial presentation in state percentage here pSS patients. Pulmonary involvement, a positive anti-SSA antibody test, and reduced C3 levels are potential risk factors for CNS involvement in pSS. Treatment with high-dose glucocorticoids and immunosuppressive therapy appeared effective in 60% of pSS-CNS patients. Key Points • The CNS manifestations of pSS are diverse, and CNS imaging and CSF analysis are important for the diagnosis. • Pulmonary involvement, positive anti-SSA, and reduced C3 levels are potential risk factors of pSS-CNS. • About 60% of pSS-CNS patients were responsive to high-dose glucocorticoid administration and immunosuppressive therapy.
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Affiliation(s)
- Wei Fan
- Department of Rheumatology and Immunology, The Second Affiliated Hospital of Xiamen Medical College, Xiamen Medical College, Xiamen, 361021, China.
| | - Jennefer Par-Young
- Department of Internal Medicine, Section of Rheumatology, Allergy & Immunology, Yale University School of Medicine, New Haven, CT, 06520, USA
| | - Kaiyan Li
- Department of Rheumatology and Immunology, The Second Affiliated Hospital of Xiamen Medical College, Xiamen Medical College, Xiamen, 361021, China
| | - Yi Zhang
- Department of Rheumatology and Immunology, The Second Affiliated Hospital of Xiamen Medical College, Xiamen Medical College, Xiamen, 361021, China
| | - Pingping Xiao
- Department of Rheumatology and Immunology, The Second Affiliated Hospital of Xiamen Medical College, Xiamen Medical College, Xiamen, 361021, China
| | - Li Hua
- Department of Rheumatology and Immunology, The Second Affiliated Hospital of Xiamen Medical College, Xiamen Medical College, Xiamen, 361021, China
| | - Lin Leng
- Department of Internal Medicine, Section of Rheumatology, Allergy & Immunology, Yale University School of Medicine, New Haven, CT, 06520, USA
| | - Xuyan Chen
- Department of Rheumatology and Immunology, The Second Affiliated Hospital of Xiamen Medical College, Xiamen Medical College, Xiamen, 361021, China
| | - Richard Bucala
- Department of Internal Medicine, Section of Rheumatology, Allergy & Immunology, Yale University School of Medicine, New Haven, CT, 06520, USA.
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Liu L, Tang L, Zhang L, Li X, Huang P, Xiong J, Xiao Y, Liu L. The First Case Report of Preschool-Onset SS/SLE Coexisting With NMOSD of Chinese Origin. Front Immunol 2022; 13:887041. [PMID: 35585974 PMCID: PMC9108358 DOI: 10.3389/fimmu.2022.887041] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 04/01/2022] [Indexed: 11/20/2022] Open
Abstract
Systemic lupus erythematosus (SLE) is an autoimmune connective tissue disease (CTD), the main features of which are multiple serum autoantibodies and extensive involvement of multiple systems. The onset age of patients varies from childhood to middle age, with nearly 1/5 in childhood. Sjogren’s syndrome (SS) is also an autoimmune disease characterized by high-degree lymphocytic infiltration of exocrine glands, usually occurring in middle-aged and older women, and rarely in childhood. Neuromyelitis optica spectrum disorder (NMOSD) is an immune-mediated inflammatory demyelinating disease of the central nervous system (CNS) mainly involving the optic nerve and spinal cord. The coexistence of NMOSD and SLE and/or SS is well recognized by both neurologists and rheumatologists, but cases in children have been rarely reported. In this paper, we reported a case of a girl with onset at age 5 clinically featured by recurrent parotid gland enlargement, pancytopenia, hypocomplementemia, multiple positive serum antibodies, and cirrhosis. She was initially diagnosed with SS/SLE overlap syndrome at age 5. Four years later, the patient suffered a sudden vision loss and was examined to have positive AQP4 antibodies in serum and cerebrospinal fluid (CSF), and long segmental spinal swelling, in line with the diagnostic criteria for NMOSD. Up to now, the current patient is of the youngest onset age to develop SS/SLE coexisting with NMOSD, also with cirrhosis. It is important for clinicians to be aware of the possibility of CTDs coexisting with NMOSD in children, especially in those with positive anti-multiple autoantibodies, and to decrease the rate of missed diagnosis.
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Affiliation(s)
- Liqun Liu
- Department of Pediatrics, The Second Xiangya Hospital of Central South University, Changsha, China
- Department of Pediatric Neurology, Children’s Medical Center, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Li Tang
- Department of Pediatrics, The Second Xiangya Hospital of Central South University, Changsha, China
- Department of Pediatric Neurology, Children’s Medical Center, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Lu Zhang
- Department of Pediatrics, The Second Xiangya Hospital of Central South University, Changsha, China
- Department of Pediatric Neurology, Children’s Medical Center, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Xingfang Li
- Department of Pediatrics, The Second Xiangya Hospital of Central South University, Changsha, China
- Department of Pediatric Neurology, Children’s Medical Center, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Peng Huang
- Department of Pediatrics, The Second Xiangya Hospital of Central South University, Changsha, China
- Department of Pediatric Neurology, Children’s Medical Center, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Jie Xiong
- Department of Pediatrics, The Second Xiangya Hospital of Central South University, Changsha, China
- Department of Pediatric Neurology, Children’s Medical Center, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Yangyang Xiao
- Department of Pediatrics, The Second Xiangya Hospital of Central South University, Changsha, China
- Department of Pediatric Neurology, Children’s Medical Center, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Lingjuan Liu
- Department of Pediatrics, The Second Xiangya Hospital of Central South University, Changsha, China
- Department of Pediatric Neurology, Children’s Medical Center, The Second Xiangya Hospital of Central South University, Changsha, China
- *Correspondence: Lingjuan Liu,
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Frohman EM, Villemarette-Pittman NR, Rodriguez A, Glanzman R, Rugheimer S, Komogortsev O, Zamvil SS, Cruz RA, Varkey TC, Frohman AN, Frohman AR, Parsons MS, Konkle EH, Frohman TC. Application of an evidence-based, out-patient treatment strategy for COVID-19: Multidisciplinary medical practice principles to prevent severe disease. J Neurol Sci 2021; 426:117463. [PMID: 33971376 PMCID: PMC8055502 DOI: 10.1016/j.jns.2021.117463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 04/12/2021] [Indexed: 11/10/2022]
Abstract
The COVID-19 pandemic has devastated individuals, families, and institutions throughout the world. Despite the breakneck speed of vaccine development, the human population remains at risk of further devastation. The decision to not become vaccinated, the protracted rollout of available vaccine, vaccine failure, mutational forms of the SARS virus, which may exhibit mounting resistance to our molecular strike at only one form of the viral family, and the rapid ability of the virus(es) to hitch a ride on our global transportation systems, means that we are will likely continue to confront an invisible, yet devastating foe. The enemy targets one of our human physiology's most important and vulnerable life-preserving body tissues, our broncho-alveolar gas exchange apparatus. Notwithstanding the fear and the fury of this microbe's potential to raise existential questions across the entire spectrum of human endeavor, the application of an early treatment intervention initiative may represent a crucial tool in our defensive strategy. This strategy is driven by evidence-based medical practice principles, those not likely to become antiquated, given the molecular diversity and mutational evolution of this very clever "world traveler".
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Affiliation(s)
- Elliot M Frohman
- Laboratory of Neuroimmunology, Professor Lawrence Steinman, Stanford University School of Medicine, United States of America.
| | | | - Adriana Rodriguez
- Department of Emergency Medicine, Cook Children's Medical Center, Ft. Worth, TX, United States of America
| | - Robert Glanzman
- Clene Nanomedicine, Inc., Salt Lake City, UT 84121, United States of America.
| | - Sarah Rugheimer
- Department of Physics, University Oxford, Oxford OX1 3PU, UK.
| | - Oleg Komogortsev
- Department of Computer Sciences, Texas State University, San Marcos, TX, United States of America.
| | - Scott S Zamvil
- Department of Neurology and Program in Immunology, University of California San Francisco, San Francisco, CA, United States of America.
| | - Roberto Alejandro Cruz
- Department of Neurology, Doctor's Health at Renaissance Health Neurology Institute, United States of America; Department of Neurology, University of Texas Rio Grande Valley School of Medicine, United States of America.
| | - Thomas C Varkey
- Dell Medical School, University of Texas at Austin, United States of America.
| | | | | | - Matthew S Parsons
- Division of Microbiology and Immunology, Yerkes National Primate Research Center, United States of America; Department of Pathology and Laboratory Medicine, Emory University, Atlanta, GA, United States of America.
| | | | - Teresa C Frohman
- Laboratory of Neuroimmunology, Professor Lawrence Steinman, Stanford University School of Medicine, United States of America.
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4
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Neuromyelitis Optica Spectrum Disorders (NMOSD) and Connective Tissue Disease (CTD): an Update for the Rheumatologist. Curr Rheumatol Rep 2021; 23:33. [PMID: 33909180 DOI: 10.1007/s11926-021-01000-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/23/2021] [Indexed: 01/31/2023]
Abstract
PURPOSE OF REVIEW To review the pathophysiology, presentation, and treatment of neuromyelitis optica spectrum disorder (NMOSD) and its association with systemic lupus erythematosus (SLE) and Sjogren's syndrome (SS). RECENT FINDINGS NMOSD is an autoimmune disorder of the central nervous system that primarily targets astrocytes. Although the prevalence is unknown, the coexistence of NMOSD and SLE/SS is well-recognized. Patients with both NMOSD and SLE or SS require may require unique approaches to diagnosis and management. Coexistence of NMOSD and SLE/SS is important for the rheumatologist and neurologist to be able to recognize. For the rheumatologist, NMOSD and its neurologic symptoms represent a distinct disease process from neurologic complications of the patient's underlying connective tissue disease, and it requires distinct acute and chronic management. For the neurologist, the coexistence of SLE and SS can help to establish a diagnosis of NMOSD, or in some situations, the development of neurologic symptoms secondary to NMOSD can lead to the diagnosis of connective tissue disease.
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5
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B Cells and Antibodies as Targets of Therapeutic Intervention in Neuromyelitis Optica Spectrum Disorders. Pharmaceuticals (Basel) 2021; 14:ph14010037. [PMID: 33419217 PMCID: PMC7825598 DOI: 10.3390/ph14010037] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Revised: 01/02/2021] [Accepted: 01/03/2021] [Indexed: 12/11/2022] Open
Abstract
The first description of neuromyelitis optica by Eugène Devic and Fernand Gault dates back to the 19th century, but only the discovery of aquaporin-4 autoantibodies in a major subset of affected patients in 2004 led to a fundamentally revised disease concept: Neuromyelits optica spectrum disorders (NMOSD) are now considered autoantibody-mediated autoimmune diseases, bringing the pivotal pathogenetic role of B cells and plasma cells into focus. Not long ago, there was no approved medication for this deleterious disease and off-label therapies were the only treatment options for affected patients. Within the last years, there has been a tremendous development of novel therapies with diverse treatment strategies: immunosuppression, B cell depletion, complement factor antagonism and interleukin-6 receptor blockage were shown to be effective and promising therapeutic interventions. This has led to the long-expected official approval of eculizumab in 2019 and inebilizumab in 2020. In this article, we review current pathogenetic concepts in NMOSD with a focus on the role of B cells and autoantibodies as major contributors to the propagation of these diseases. Lastly, by highlighting promising experimental and future treatment options, we aim to round up the current state of knowledge on the therapeutic arsenal in NMOSD.
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6
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Wallach AI, Tremblay M, Kister I. Advances in the Treatment of Neuromyelitis Optica Spectrum Disorder. Neurol Clin 2020; 39:35-49. [PMID: 33223088 DOI: 10.1016/j.ncl.2020.09.003] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Neuromyelitis optica spectrum disorder (NMOSD) is a rare, relapsing-remitting neuroinflammatory disorder of the central nervous system. Advances in the understanding of NMOSD pathogenesis and identification of the NMO-specific pathogenic anti-AQP4 autoantibody have led to the development of highly effective disease-modifying strategies. Five placebo-controlled, randomized trials for NMOSD have been successfully completed as of 2020. These trials support the efficacy of rituximab and tocilizumab and led to the FDA approval of eculizumab, satralizumab and inebilizumab for NMOSD. Our review provides an update on these evidence-based disease-modifying therapies and discussed the treatment of acute relapses in NMOSD.
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Affiliation(s)
- Asya Izraelit Wallach
- Alfiero and Lucia Palestroni MS Comprehensive Care Center, Holy Name Medical Center, 718 Teaneck Road, Teaneck, NJ 07666, USA.
| | - Matthew Tremblay
- MS Comprehensive Care Center, RWJ Barnabas Health, 200 South Orange Avenue, Suite 124-A, Livingston, NJ 07039, USA
| | - Ilya Kister
- Department of Neurology, Comprehensive MS Center, NYU Grossman School of Medicine, 240 East 38th Street, New York, NY 10016, USA
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7
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Letertre MPM, Munjoma N, Wolfer K, Pechlivanis A, McDonald JAK, Hardwick RN, Cherrington NJ, Coen M, Nicholson JK, Hoyles L, Swann JR, Wilson ID. A Two-Way Interaction between Methotrexate and the Gut Microbiota of Male Sprague-Dawley Rats. J Proteome Res 2020; 19:3326-3339. [PMID: 32544340 PMCID: PMC7426014 DOI: 10.1021/acs.jproteome.0c00230] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Methotrexate (MTX) is a chemotherapeutic agent that can cause a range of toxic side effects including gastrointestinal damage, hepatotoxicity, myelosuppression, and nephrotoxicity and has potentially complex interactions with the gut microbiome. Following untargeted UPLC-qtof-MS analysis of urine and fecal samples from male Sprague-Dawley rats administered at either 0, 10, 40, or 100 mg/kg of MTX, dose-dependent changes in the endogenous metabolite profiles were detected. Semiquantitative targeted UPLC-MS detected MTX excreted in urine as well as MTX and two metabolites, 2,4-diamino-N-10-methylpteroic acid (DAMPA) and 7-hydroxy-MTX, in the feces. DAMPA is produced by the bacterial enzyme carboxypeptidase glutamate 2 (CPDG2) in the gut. Microbiota profiling (16S rRNA gene amplicon sequencing) of fecal samples showed an increase in the relative abundance of Firmicutes over the Bacteroidetes at low doses of MTX but the reverse at high doses. Firmicutes relative abundance was positively correlated with DAMPA excretion in feces at 48 h, which were both lower at 100 mg/kg compared to that seen at 40 mg/kg. Overall, chronic exposure to MTX appears to induce community and functionality changes in the intestinal microbiota, inducing downstream perturbations in CPDG2 activity, and thus may delay MTX detoxication to DAMPA. This reduction in metabolic clearance might be associated with increased gastrointestinal toxicity.
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Affiliation(s)
- Marine P M Letertre
- Department of Metabolism, Digestion and Reproduction, Faculty of Medicine, Imperial College, London SW7 2AZ, U.K
| | | | - Kate Wolfer
- Department of Metabolism, Digestion and Reproduction, Faculty of Medicine, Imperial College, London SW7 2AZ, U.K
| | - Alexandros Pechlivanis
- Department of Metabolism, Digestion and Reproduction, Faculty of Medicine, Imperial College, London SW7 2AZ, U.K.,Center for Interdisciplinary Research of the Aristotle University of Thessaloniki (KEDEK), 57001 Thessaloniki, Greece.,Department of Chemistry, Aristotle University of Thessaloniki, 54124 Thessaloniki, Greece
| | - Julie A K McDonald
- Department of Metabolism, Digestion and Reproduction, Faculty of Medicine, Imperial College, London SW7 2AZ, U.K
| | - Rhiannon N Hardwick
- Department of Pharmacology and Toxicology, College of Pharmacy, University of Arizona, Tuscon, Arizona 85721, United States
| | - Nathan J Cherrington
- Department of Pharmacology and Toxicology, College of Pharmacy, University of Arizona, Tuscon, Arizona 85721, United States
| | - Muireann Coen
- Department of Metabolism, Digestion and Reproduction, Faculty of Medicine, Imperial College, London SW7 2AZ, U.K.,Oncology Safety, Clinical Pharmacology & Safety Sciences, R&D, Astra Zeneca, Cambridge CB4 0WG, U.K
| | - Jeremy K Nicholson
- Australian National Phenome Centre, Health Futures Institute, Murdoch University, Murdoch, WA 6150, Australia
| | - Lesley Hoyles
- Department of Metabolism, Digestion and Reproduction, Faculty of Medicine, Imperial College, London SW7 2AZ, U.K.,Department of Biosciences, Nottingham Trent University, Nottingham NG11 8NS, U.K
| | - Jonathan R Swann
- Department of Metabolism, Digestion and Reproduction, Faculty of Medicine, Imperial College, London SW7 2AZ, U.K
| | - Ian D Wilson
- Department of Metabolism, Digestion and Reproduction, Faculty of Medicine, Imperial College, London SW7 2AZ, U.K
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Frohman EM, Villemarette-Pittman NR, Melamed E, Cruz RA, Longmuir R, Varkey TC, Steinman L, Zamvil SS, Frohman TC. Part I. SARS-CoV-2 triggered 'PANIC' attack in severe COVID-19. J Neurol Sci 2020; 415:116936. [PMID: 32532449 PMCID: PMC7241348 DOI: 10.1016/j.jns.2020.116936] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 05/18/2020] [Accepted: 05/18/2020] [Indexed: 12/14/2022]
Abstract
The coronavirus disease 2019 (COVID-19) pandemic has produced a world-wide collapse of social and economic infrastructure, as well as constrained our freedom of movement. This respiratory tract infection is nefarious in how it targets the most distal and highly vulnerable aspect of the human bronchopulmonary tree, specifically, the delicate yet irreplaceable alveoli that are responsible for the loading of oxygen upon red cell hemoglobin for use by all of the body's tissues. In most symptomatic individuals, the disease is a mild immune-mediated syndrome, with limited damage to the lung tissues. About 20% of those affected experience a disease course characterized by a cataclysmic set of immune activation responses that can culminate in the diffuse and irreversible obliteration of the distal alveoli, leading to a virtual collapse of the gas-exchange apparatus. Here, in Part I of a duology on the characterization and potential treatment for COVID-19, we define severe COVID-19 as a consequence of the ability of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) to trigger what we now designate for the first time as a ‘Prolific Activation of a Network-Immune-Inflammatory Crisis’, or ‘PANIC’ Attack, in the alveolar tree. In Part II we describe an immunotherapeutic hypothesis worthy of the organization of a randomized clinical trial in order to ascertain whether a repurposed, generic, inexpensive, and widely available agent is capable of abolishing ‘PANIC’; thereby preventing or mitigating severe COVID-19, with monumental ramifications for world health, and the global pandemic that continues to threaten it.
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Affiliation(s)
- Elliot M Frohman
- Department of Neurology, The Dell Medical School, The University of Texas at Austin, Austin, TX, United States of America; Department of Neurosurgery, The Dell Medical School, The University of Texas at Austin, Austin, TX, United States of America; Department of Ophthalmology, The Dell Medical School, The University of Texas at Austin, Austin, TX, United States of America.
| | | | - Esther Melamed
- Department of Neurology, The Dell Medical School, The University of Texas at Austin, Austin, TX, United States of America.
| | - Roberto Alejandro Cruz
- Department of Neurology, The Dell Medical School, The University of Texas at Austin, Austin, TX, United States of America.
| | - Reid Longmuir
- Department of Ophthalmology and Visual Sciences, Vanderbilt University Medical Center, Nashville, TN, United States of America; Veterans Affairs Medical Center, Nashville, TN, United States of America
| | - Thomas C Varkey
- Department of Neurology, The Dell Medical School, The University of Texas at Austin, Austin, TX, United States of America; Colangelo College of Business, Grand Canyon University Phoenix, AZ, United States of America
| | - Lawrence Steinman
- Department of Neurology, Stanford University School of Medicine, Palo Alto, California, United States of America.
| | - Scott S Zamvil
- Department of Neurology and Program in Immunology, University of California San Francisco, San Francisco, California, United States of America.
| | - Teresa C Frohman
- Department of Neurology, The Dell Medical School, The University of Texas at Austin, Austin, TX, United States of America; Department of Neurosurgery, The Dell Medical School, The University of Texas at Austin, Austin, TX, United States of America; Department of Ophthalmology, The Dell Medical School, The University of Texas at Austin, Austin, TX, United States of America.
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Frohman EM, Villemarette-Pittman NR, Cruz RA, Longmuir R, Rowe V, Rowe ES, Varkey TC, Steinman L, Zamvil SS, Frohman TC. Part II. high-dose methotrexate with leucovorin rescue for severe COVID-19: An immune stabilization strategy for SARS-CoV-2 induced 'PANIC' attack. J Neurol Sci 2020; 415:116935. [PMID: 32534807 PMCID: PMC7241359 DOI: 10.1016/j.jns.2020.116935] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 05/18/2020] [Indexed: 12/31/2022]
Abstract
Here, in Part II of a duology on the characterization and potential treatment for COVID-19, we characterize the application of an innovative treatment regimen for the prevention of the transition from mild to severe COVID-19, as well as detail an intensive immunotherapy intervention hypothesis. We propose as a putative randomized controlled trial that high-dose methotrexate with leucovorin (HDMTX-LR) rescue can abolish ‘PANIC’, thereby ‘left-shifting’ severe COVID-19 patients to the group majority of those infected with SARS-CoV-2, who are designated as having mild, even asymptomatic, disease. HDMTX-LR is endowed with broadly pleiotropic properties and is a repurposed, generic, inexpensive, and widely available agent which can be administered early in the course of severe COVID-19 thus rescuing the critical and irreplaceable gas-exchange alveoli. Further, we describe a preventative treatment intervention regimen for those designated as having mild to moderate COVID-19 disease, but who exhibit features which herald the transition to the severe variant of this disease. Both of our proposed hypothesis-driven questions should be urgently subjected to rigorous assessment in the context of randomized controlled trials, in order to confirm or refute the contention that the approaches characterized herein, are in fact capable of exerting mitigating, if not abolishing, effects upon SARS-CoV-2 triggered ‘PANIC Attack’. Confirmation of our immunotherapy hypothesis would have far-reaching ramifications for the current pandemic, along with yielding invaluable lessons which could be leveraged to more effectively prepare for the next challenge to global health.
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Affiliation(s)
- Elliot M Frohman
- Department of Neurology, The Dell Medical School, The University of Texas at Austin, Austin, TX, United States of America; Department of Neurosurgery, The Dell Medical School, The University of Texas at Austin, Austin, TX, United States of America; Department of Ophthalmology, The Dell Medical School, The University of Texas at Austin, Austin, TX, United States of America.
| | | | - Roberto Alejandro Cruz
- Department of Neurology, The Dell Medical School, The University of Texas at Austin, Austin, TX, United States of America.
| | - Reid Longmuir
- Department of Ophthalmology and Visual Sciences, Vanderbilt University Medical Center, Nashville, TN, United States of America; Veterans Affairs Medical Center, Nashville, TN, United States of America
| | - Vernon Rowe
- Rowe Neurology Institute, Lenexa, KS, United States of America.
| | | | - Thomas C Varkey
- Department of Neurology, The Dell Medical School, The University of Texas at Austin, Austin, TX, United States of America; The Colangelo College of Business, at Grand Canyon University, Phoenix, AZ, United States of America.
| | - Lawrence Steinman
- Department of Neurology, Stanford University School of Medicine, Palo Alto, CA, United States of America.
| | - Scott S Zamvil
- Department of Neurology and Program in Immunology, University of California San Francisco, San Francisco, CA, United States of America.
| | - Teresa C Frohman
- Department of Neurology, The Dell Medical School, The University of Texas at Austin, Austin, TX, United States of America; Department of Neurosurgery, The Dell Medical School, The University of Texas at Austin, Austin, TX, United States of America; Department of Ophthalmology, The Dell Medical School, The University of Texas at Austin, Austin, TX, United States of America.
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10
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Huang X, Fang Q, Rao T, Zhou L, Zeng X, Tan Z, Chen L, Ouyang D. Leucovorin ameliorated methotrexate induced intestinal toxicity via modulation of the gut microbiota. Toxicol Appl Pharmacol 2020; 391:114900. [PMID: 32061593 DOI: 10.1016/j.taap.2020.114900] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Revised: 01/22/2020] [Accepted: 01/24/2020] [Indexed: 12/17/2022]
Abstract
Methotrexate (MTX) is a widely used therapeutic agent for the treatment of cancer and autoimmune diseases. However, its efficacy is often limited by adverse effects, such as intestinal toxicity. Although treatment with leucovorin (LV) is the most common method to reduce the toxic effects of MTX, it may also compromise the therapeutic effects of MTX. The gut microbiome has been reported to be associated with the intestinal toxicity of MTX. In this study, the intestinal damage of MTX was ameliorated by treatment with LV. Moreover, the population, diversity, and principal components of the gut microbiota in MTX-treated mice were restored by treatment with LV. The only element of the gut microbiota that was significantly changed after treatment with LV was Bifidobacterium, and supplementation with Bifidobacterium longum ameliorated MTX-induced intestinal damage. In conclusion, our results suggest that the balance and the composition of gut microbiota have an important role in the LV-mediated protection against MTX-induced intestinal toxicity. This work provides foundation of data in support of a new potential mechanism for the prevention of MTX-induced intestinal toxicity.
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Affiliation(s)
- Xinyi Huang
- Department of Clinical Pharmacology, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha 410008, PR China; Institute of Clinical Pharmacology, Central South University, Hunan Key Laboratory of Pharmacogenetics, 110 Xiangya Road, Changsha 410078, PR China; Engineering Research Center of Applied Technology of Pharmacogenomics, Ministry of Education, 110 Xiangya Road, Changsha 410078, PR China; National Clinical Research Center for Geriatric Disorders, 87 Xiangya Road, Changsha 410008, Hunan, PR China; Hunan Key Laboratory for Bioanalysis of Complex Matrix Samples, Changsha Duxact Biotech Co., Ltd., Changsha 411000, PR China
| | - Qing Fang
- Department of Clinical Pharmacology, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha 410008, PR China; Institute of Clinical Pharmacology, Central South University, Hunan Key Laboratory of Pharmacogenetics, 110 Xiangya Road, Changsha 410078, PR China; Engineering Research Center of Applied Technology of Pharmacogenomics, Ministry of Education, 110 Xiangya Road, Changsha 410078, PR China; National Clinical Research Center for Geriatric Disorders, 87 Xiangya Road, Changsha 410008, Hunan, PR China; Hunan Key Laboratory for Bioanalysis of Complex Matrix Samples, Changsha Duxact Biotech Co., Ltd., Changsha 411000, PR China
| | - Tai Rao
- Department of Clinical Pharmacology, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha 410008, PR China; Institute of Clinical Pharmacology, Central South University, Hunan Key Laboratory of Pharmacogenetics, 110 Xiangya Road, Changsha 410078, PR China; Engineering Research Center of Applied Technology of Pharmacogenomics, Ministry of Education, 110 Xiangya Road, Changsha 410078, PR China; National Clinical Research Center for Geriatric Disorders, 87 Xiangya Road, Changsha 410008, Hunan, PR China; Hunan Key Laboratory for Bioanalysis of Complex Matrix Samples, Changsha Duxact Biotech Co., Ltd., Changsha 411000, PR China
| | - Luping Zhou
- Department of Clinical Pharmacology, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha 410008, PR China; Institute of Clinical Pharmacology, Central South University, Hunan Key Laboratory of Pharmacogenetics, 110 Xiangya Road, Changsha 410078, PR China; Engineering Research Center of Applied Technology of Pharmacogenomics, Ministry of Education, 110 Xiangya Road, Changsha 410078, PR China; National Clinical Research Center for Geriatric Disorders, 87 Xiangya Road, Changsha 410008, Hunan, PR China; Hunan Key Laboratory for Bioanalysis of Complex Matrix Samples, Changsha Duxact Biotech Co., Ltd., Changsha 411000, PR China
| | - Xiangchang Zeng
- Department of Clinical Pharmacology, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha 410008, PR China; Institute of Clinical Pharmacology, Central South University, Hunan Key Laboratory of Pharmacogenetics, 110 Xiangya Road, Changsha 410078, PR China; Engineering Research Center of Applied Technology of Pharmacogenomics, Ministry of Education, 110 Xiangya Road, Changsha 410078, PR China; National Clinical Research Center for Geriatric Disorders, 87 Xiangya Road, Changsha 410008, Hunan, PR China; Hunan Key Laboratory for Bioanalysis of Complex Matrix Samples, Changsha Duxact Biotech Co., Ltd., Changsha 411000, PR China
| | - Zhirong Tan
- Department of Clinical Pharmacology, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha 410008, PR China; Institute of Clinical Pharmacology, Central South University, Hunan Key Laboratory of Pharmacogenetics, 110 Xiangya Road, Changsha 410078, PR China; Engineering Research Center of Applied Technology of Pharmacogenomics, Ministry of Education, 110 Xiangya Road, Changsha 410078, PR China; National Clinical Research Center for Geriatric Disorders, 87 Xiangya Road, Changsha 410008, Hunan, PR China; Hunan Key Laboratory for Bioanalysis of Complex Matrix Samples, Changsha Duxact Biotech Co., Ltd., Changsha 411000, PR China
| | - Lulu Chen
- Hunan Key Laboratory for Bioanalysis of Complex Matrix Samples, Changsha Duxact Biotech Co., Ltd., Changsha 411000, PR China
| | - Dongsheng Ouyang
- Department of Clinical Pharmacology, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha 410008, PR China; Institute of Clinical Pharmacology, Central South University, Hunan Key Laboratory of Pharmacogenetics, 110 Xiangya Road, Changsha 410078, PR China; Engineering Research Center of Applied Technology of Pharmacogenomics, Ministry of Education, 110 Xiangya Road, Changsha 410078, PR China; National Clinical Research Center for Geriatric Disorders, 87 Xiangya Road, Changsha 410008, Hunan, PR China; Hunan Key Laboratory for Bioanalysis of Complex Matrix Samples, Changsha Duxact Biotech Co., Ltd., Changsha 411000, PR China.
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Pınar N, Kaplan M, Özgür T, Özcan O. Ameliorating effects of tempol on methotrexate-induced liver injury in rats. Biomed Pharmacother 2018; 102:758-764. [DOI: 10.1016/j.biopha.2018.03.147] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Revised: 03/19/2018] [Accepted: 03/23/2018] [Indexed: 02/01/2023] Open
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Choi JH, Wallach AI, Rosales D, Margiewicz SE, Belmont HM, Lucchinetti CF, Minen MT. Clinical Reasoning: A 50-year-old woman with SLE and a tumefactive lesion. Neurology 2017; 89:e140-e145. [DOI: 10.1212/wnl.0000000000004386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Bradshaw MJ, Cho TA, Chow FC. Central Nervous System Infections Associated with Immunosuppressive Therapy for Rheumatic Disease. Rheum Dis Clin North Am 2017; 43:607-619. [PMID: 29061246 DOI: 10.1016/j.rdc.2017.06.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Patients on immunosuppressive therapy for rheumatic diseases are at increased risk of infection. Although infections of the central nervous system (CNS) are less common compared with other sites, patients on broadly immunosuppressive and biologic immunomodulatory agents may be susceptible to more severe, disseminated forms of infection, including of the CNS. Certain key principles regarding infection risk apply across immunosuppressive therapies, including increased risk with higher doses and longer duration of therapy and with combination therapy. Providers should be aware of the CNS infection risk related to immunosuppressant use to help guide best practices for screening and prophylaxis.
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Affiliation(s)
- Michael J Bradshaw
- Partners Multiple Sclerosis Center, Brigham and Women's Hospital and Massachusetts General Hospital, 60 Fenwood Road, 4th floor, Boston, MA 02115, USA
| | - Tracey A Cho
- Department of Neurology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| | - Felicia C Chow
- Department of Neurology and Division of Infectious Diseases, University of California, San Francisco, Zuckerberg San Francisco General Hospital, 1001 Potrero Avenue, Building 1, Room 101, San Francisco, CA 94110, USA.
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