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Zain A, Akram MS, Ashfaq F, Ans A, Ans HH. Comparative Analysis of Intravenous Immunoglobulins (IVIg) vs Plasmapheresis (PLEX) in the Management of Myasthenic Crisis. Cureus 2024; 16:e68895. [PMID: 39376877 PMCID: PMC11458158 DOI: 10.7759/cureus.68895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/06/2024] [Indexed: 10/09/2024] Open
Abstract
Myasthenia gravis (MG) is an autoimmune disorder affecting postsynaptic membranes in neuromuscular junctions, presenting as fatigable muscle weakness. Myasthenic crisis is a life-threatening complication characterized by severe respiratory insufficiency necessitating invasive or noninvasive ventilation. Two rapid therapies used to manage myasthenic crises are intravenous immunoglobulins (IVIg) and plasmapheresis (PLEX). Their comparative effectiveness remains equivocal. Our article examines evidence from several clinical trials and observational studies, in order to determine the superiority of one treatment over the other. Multiple factors can complicate the choices between two treatments. We concluded that the choice between PLEX and IVIg is multifaceted, guided by individual patient characteristics, institutional resources, and clinician preference. While PLEX can be considered as first-line for rapid clinical outcomes, it is hard to pick one treatment over the other, and careful consideration of comorbidities and resource availability is crucial. Our article highlights the need for further research to establish definitive guidelines and enhance patient outcomes in myasthenic crisis patients.
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Affiliation(s)
- Ahmad Zain
- Internal Medicine, Services Hospital Lahore, Lahore, PAK
| | | | | | - Armghan Ans
- Internal Medicine, Services Institute of Medical Sciences, Lahore, PAK
- Neurology, Medical College of Wisconsin, Milwaukee, USA
- Vascular Neurology, University of Pittsburgh Medical Center, Pittsburgh, USA
| | - Hasaan H Ans
- Internal Medicine, FMH College of Medicine & Dentistry, Lahore, PAK
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Ramdas S, Painho T, Vanegas MI, Famili DT, Lim MJ, Jungbluth H. Targeted Treatments for Myasthenia Gravis in Children and Adolescents. Paediatr Drugs 2024:10.1007/s40272-024-00649-3. [PMID: 39198371 DOI: 10.1007/s40272-024-00649-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/04/2024] [Indexed: 09/01/2024]
Abstract
Myasthenia gravis (MG) is an antibody-mediated disorder of the neuromuscular junction affecting children and adults. MG is a treatable condition with most patients requiring immunosuppression for disease control and/or remission. Juvenile myasthenia gravis (JMG) is rare in comparison with adult-onset MG but given the same underlying pathophysiology, treatment strategies are similar to those in adults. Until recently, there were only a few randomised controlled trials (RCTs) for MG treatments in adults and none in children, and management strategies were primarily based on expert consensus. In addition, treatment options for refractory MG cases have been severely limited, resulting in poor long-term quality of life in such patients due to the significant disease burden. Recently, there have been several RCTs focussing on novel therapeutic strategies with potentially promising outcomes, suggesting a change in MG management over the coming years and access to more effective and faster-acting drugs for MG patients. This paper will review current and new MG treatments including efgartigimod, eculizumab, rozanolixizumab, ravulizumab, and zilucoplan, with a focus on juvenile myasthenia gravis.
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Affiliation(s)
- Sithara Ramdas
- Department of Paediatrics, MDUK Neuromuscular Centre, University of Oxford, Oxford, UK
- Department of Paediatric Neurology, John Radcliffe Hospital, Oxford, UK
| | - Teresa Painho
- Department of Paediatrics, MDUK Neuromuscular Centre, University of Oxford, Oxford, UK
- Neurology Unit, Hospital Dona Estefânia, Unidade Local de Saúde São José, Centro Clínico Académico de Lisboa, Lisbon, Portugal
| | - Maria I Vanegas
- Department of Paediatric Neurology, Evelina London Children's Hospital, Guy's & St. Thomas' Hospital NHS Foundation Trust, Children's Neurosciences Centre, F02-Becket House, Lambeth Palace Road, London, SE1 7EU, UK
| | - Dennis T Famili
- Department of Paediatric Neurology, Evelina London Children's Hospital, Guy's & St. Thomas' Hospital NHS Foundation Trust, Children's Neurosciences Centre, F02-Becket House, Lambeth Palace Road, London, SE1 7EU, UK
| | - Ming J Lim
- Department of Paediatric Neurology, Evelina London Children's Hospital, Guy's & St. Thomas' Hospital NHS Foundation Trust, Children's Neurosciences Centre, F02-Becket House, Lambeth Palace Road, London, SE1 7EU, UK
- Women and Children's Health, Faculty of Life Sciences and Medicine (FoLSM), King's College London, London, UK
| | - Heinz Jungbluth
- Department of Paediatric Neurology, Evelina London Children's Hospital, Guy's & St. Thomas' Hospital NHS Foundation Trust, Children's Neurosciences Centre, F02-Becket House, Lambeth Palace Road, London, SE1 7EU, UK.
- Randall Centre for Cell and Molecular Biophysics, Muscle Signalling Section, Faculty of Life Sciences and Medicine (FoLSM), King's College London, London, UK.
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Liu S, Zhang WW, Jia L, Zhang HL. Guillain-Barré syndrome: immunopathogenesis and therapeutic targets. Expert Opin Ther Targets 2024; 28:131-143. [PMID: 38470316 DOI: 10.1080/14728222.2024.2330435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2023] [Accepted: 03/10/2024] [Indexed: 03/13/2024]
Abstract
INTRODUCTION Guillain-Barré syndrome (GBS) is a group of acute immune-mediated disorders in the peripheral nervous system. Both infectious and noninfectious factors are associated with GBS, which may act as triggers of autoimmune responses leading to neural damage and dysfunction. AREAS COVERED Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and its vaccines as well as flaviviruses have been associated with GBS, although a robust conclusion has yet to be reached. Immunomodulatory treatments, including intravenous immunoglobulins (IVIg) and plasma exchange (PE), have long been the first-line therapies for GBS. Depending on GBS subtype and severity at initial presentation, the efficacy of IVIg and PE can be variable. Several new therapies showing benefits to experimental animals merit further investigation before translation into clinical practice. We review the state-of-the-art knowledge on the immunopathogenesis of GBS in the context of coronavirus disease 2019 (COVID-19). Immunomodulatory therapies in GBS, including IVIg, PE, corticosteroids, and potential therapies, are summarized. EXPERT OPINION The association with SARS-CoV-2 remains uncertain, with geographical differences that are difficult to explain. Evidence and guidelines are lacking for the decision-making of initiating immunomodulatory therapies in mildly affected patients or patients with regional subtypes of GBS.
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Affiliation(s)
- Shan Liu
- Department of Nuclear Medicine, Second Hospital of Jilin University, Changchun, China
| | - Wei Wei Zhang
- Department of Neurology, First Hospital of Jilin University, Jilin University, Changchun, China
| | - Linpei Jia
- Department of Nephrology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Hong-Liang Zhang
- Department of Life Sciences, National Natural Science Foundation of China, Beijing, China
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Rajabally YA. Chronic Inflammatory Demyelinating Polyradiculoneuropathy: Current Therapeutic Approaches and Future Outlooks. Immunotargets Ther 2024; 13:99-110. [PMID: 38435981 PMCID: PMC10906673 DOI: 10.2147/itt.s388151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 02/02/2024] [Indexed: 03/05/2024] Open
Abstract
Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) is a treatable autoimmune disorder, for which different treatment options are available. Current first-line evidence-based therapies for CIDP include intravenous and subcutaneous immunoglobulins, corticosteroids and plasma exchanges. Despite lack of evidence, cyclophosphamide, rituximab and mycophenolate mofetil are commonly used in circumstances of refractoriness and, more debatably, of perceived overdependence on first-line therapies. Rituximab is currently the object of a randomized controlled trial for CIDP. Based on case series, and although rarely considered, haematopoietic autologous stem cell transplants may be effective in refractory disease, with low mortality and high remission rates. A new therapeutic option has appeared with efgartigimod, a neonatal Fc receptor blocker, recently shown to significantly lower relapse rate versus placebo, after withdrawal from previous immunotherapy. Other neonatal Fc receptor blockers, nipocalimab and batoclimab, are under study. The C1 complement-inhibitor SAR445088, acting in the proximal portion of the classical complement system, is currently the subject of a new study in treatment-responsive, refractory and treatment-naïve subjects. Finally, Bruton Tyrosine Kinase inhibitors, which exert anti-B cell effects, may represent another future research avenue. The widening of the therapeutic armamentarium enhances the need for improved evaluation of treatment effects and reliable biomarkers in CIDP.
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Affiliation(s)
- Yusuf A Rajabally
- Inflammatory Neuropathy Clinic, Department of Neurology, University Hospitals Birmingham, Birmingham, B15 2TH, United Kingdom
- Aston Medical School, Aston University, Birmingham, United Kingdom
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Jiang M, Lam L, Kovoor JG, Kimber J, Gupta AK, Stretton B, Goh R, Bacchi S. Intravenous immunoglobulin alteration in response to adverse reactions in neurological conditions: A retrospective cohort study. Transfus Med 2023; 33:478-482. [PMID: 37964154 DOI: 10.1111/tme.13013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 09/22/2023] [Accepted: 09/26/2023] [Indexed: 11/16/2023]
Abstract
INTRODUCTION Intravenous immunoglobulin (IVIg) is an important treatment in a range of neurological conditions. There is currently limited evidence regarding the frequency and management of IVIg-associated adverse reactions (AR) in neurological disorders. METHODS A single-centre 18-month retrospective cohort study was conducted for all patients at a single tertiary hospital receiving IVIg as an inpatient or the medical day unit. Electronic medical record AR and alerts were reviewed for entries relating to IVIg, and prescribing records associated with recent IVIg administration were reviewed for the use of premedications. Case note review was undertaken to identify AR associated with alterations in IVIg treatment (such as reduction in rate, use of premedications or cessation of IVIg). Demographic, patient, and treatment factors were analysed for associations with AR necessitating alteration in IVIg treatment. RESULTS This study included 98 individuals who received IVIg during the study period. Of these, 12 (12.1%) patients required an alteration in their IVIg treatment. In total, 3 (3.1%) of the 98 included patients required a reduced rate of IVIg, and 10 (10.2%) patients received premedication. The most common premedications were normal saline at the time of the infusion, cetirizine, and hydrocortisone. No demographic factors, indications or comorbidities were found to be associated with an increased likelihood of AR. However, an IVIg daily dose of >35 g and >45 g were associated with an increased likelihood of requiring IVIg treatment alteration due to AR. CONCLUSIONS Alterations to IVIg treatment due to AR are commonly required in neurology patients, and may be associated with higher daily doses of IVIg.
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Affiliation(s)
- Melinda Jiang
- Neurology Department, Royal Adelaide Hospital, Adelaide, South Australia, Australia
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
| | - Lydia Lam
- Neurology Department, Royal Adelaide Hospital, Adelaide, South Australia, Australia
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
| | - Joshua G Kovoor
- Neurology Department, Royal Adelaide Hospital, Adelaide, South Australia, Australia
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
| | - James Kimber
- Neurology Department, Royal Adelaide Hospital, Adelaide, South Australia, Australia
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
| | - Aashray K Gupta
- Neurology Department, Royal Adelaide Hospital, Adelaide, South Australia, Australia
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
| | - Brandon Stretton
- Neurology Department, Royal Adelaide Hospital, Adelaide, South Australia, Australia
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
| | - Rudy Goh
- Neurology Department, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Stephen Bacchi
- Neurology Department, Royal Adelaide Hospital, Adelaide, South Australia, Australia
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
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Abstract
The autoimmune inflammatory myopathies constitute a heterogeneous group of acquired myopathies that have in common the presence of endomysial inflammation and moderate to severe muscle weakness. Based on currently evolved distinct clinical, histologic, immunopathologic, and autoantibody features, these disorders can be best classified as dermatomyositis, necrotizing autoimmune myositis, antisynthetase syndrome-overlap myositis, and inclusion body myositis. Although polymyositis is no longer considered a distinct subset but rather an extinct entity, it is herein described because its clinicopathologic information has provided over many years fundamental information on T-cell-mediated myocytotoxicity, especially in reference to inclusion body myositis. Each inflammatory myopathy subset has distinct immunopathogenesis, prognosis, and response to immunotherapies, necessitating the need to correctly diagnose each subtype from the outset and avoid disease mimics. The paper describes the main clinical characteristics that aid in the diagnosis of each myositis subtype, highlights the distinct features on muscle morphology and immunopathology, elaborates on the potential role of autoantibodies in pathogenesis or diagnosis , and clarifies common uncertainties in reference to putative triggering factors such as statins and viruses including the 2019-coronavirus-2 pandemic. It extensively describes the main autoimmune markers related to autoinvasive myocytotoxic T-cells, activated B-cells, complement, cytokines, and the possible role of innate immunity. The concomitant myodegenerative features seen in inclusion body myositis along with their interrelationship between inflammation and degeneration are specifically emphasized. Finally, practical guidelines on the best therapeutic approaches are summarized based on up-to-date knowledge and controlled studies, highlighting the prospects of future immunotherapies and ongoing controversies.
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Affiliation(s)
- Marinos C Dalakas
- Department of Neurology, Thomas Jefferson University, Philadelphia, PA, United States; Neuroimmunology Unit National and Kapodistrian University of Athens Medical School, Athens, Greece.
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Dalakas MC, Latov N, Kuitwaard K. Intravenous immunoglobulin in chronic inflammatory demyelinating polyradiculoneuropathy (CIDP): mechanisms of action and clinical and genetic considerations. Expert Rev Neurother 2022; 22:953-962. [PMID: 36645654 DOI: 10.1080/14737175.2022.2169134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
INTRODUCTION Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) is an autoimmune peripheral nerve disorder that is characterized by subacute onset, progressive or relapsing weakness, and sensory deficits. Proven treatments include intravenous immunoglobulin (IVIg), corticosteroids, and plasma exchange. This review focuses on the mechanisms of action, pharmacodynamics, genetic variations, and disease characteristics that can affect the efficacy of IVIg. AREAS COVERED The proposed mechanisms of action of IVIg that can mediate its therapeutic effects are reviewed. These include anti-idiotypic interactions, inhibition of neonatal Fc receptors (FcRn), anti-complement activity, upregulation of inhibitory FcγRIIB receptors, and downregulation of macrophage activation or co-stimulatory and adhesion molecules. Clinical and genetic factors that can affect the therapeutic response include misdiagnosis, degree of axonal damage, pharmacokinetic variability, and genetic variations. EXPERT OPINION The mechanisms of action of IVIg in CIDP and their relative contribution to its efficacy are subject of ongoing investigation. Studies in other autoimmune neurological conditions, in addition, highlight the role of key immunopathological pathways and factors that are likely to be affected. Further investigation into the pathogenesis of CIDP and the mechanisms of action of IVIg may lead to the development of improved diagnostics, better utilization of IVIg, and more targeted and effective therapies.
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Affiliation(s)
- Marinos C Dalakas
- Department of Neurology, Thomas Jefferson Neuroimmunology Unit, Philadelphia, PA and National and Department of Pathophysiology, Kapodistrian University of Athens, Greece
| | - Norman Latov
- Neuroimmunology Unit, Weill Cornell Medical College, New York, NY, USA
| | - Krista Kuitwaard
- Department of Neurology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands.,Department of Neurology, Albert Schweitzer Hospital, Dordrecht, The Netherlands
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Hanaford A, Johnson SC. The immune system as a driver of mitochondrial disease pathogenesis: a review of evidence. Orphanet J Rare Dis 2022; 17:335. [PMID: 36056365 PMCID: PMC9438277 DOI: 10.1186/s13023-022-02495-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2022] [Accepted: 08/15/2022] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Genetic mitochondrial diseases represent a significant challenge to human health. These diseases are extraordinarily heterogeneous in clinical presentation and genetic origin, and often involve multi-system disease with severe progressive symptoms. Mitochondrial diseases represent the most common cause of inherited metabolic disorders and one of the most common causes of inherited neurologic diseases, yet no proven therapeutic strategies yet exist. The basic cell and molecular mechanisms underlying the pathogenesis of mitochondrial diseases have not been resolved, hampering efforts to develop therapeutic agents. MAIN BODY In recent pre-clinical work, we have shown that pharmacologic agents targeting the immune system can prevent disease in the Ndufs4(KO) model of Leigh syndrome, indicating that the immune system plays a causal role in the pathogenesis of at least this form of mitochondrial disease. Intriguingly, a number of case reports have indicated that immune-targeting therapeutics may be beneficial in the setting of genetic mitochondrial disease. Here, we summarize clinical and pre-clinical evidence suggesting a key role for the immune system in mediating the pathogenesis of at least some forms of genetic mitochondrial disease. CONCLUSIONS Significant clinical and pre-clinical evidence indicates a key role for the immune system as a significant in the pathogenesis of at least some forms of genetic mitochondrial disease.
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Affiliation(s)
- Allison Hanaford
- Center for Integrative Brain Research, Seattle Children's Research Institute, 1900 9th Ave., JMB-925, Seattle, WA, 98101, USA
| | - Simon C Johnson
- Center for Integrative Brain Research, Seattle Children's Research Institute, 1900 9th Ave., JMB-925, Seattle, WA, 98101, USA.
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, WA, USA.
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA.
- Department of Neurology, University of Washington, Seattle, WA, USA.
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Efficacy and safety of intravenous high-dose immunoglobulin in treatment of the severe form of Japanese encephalitis. Neurol Sci 2022; 43:3911-3918. [DOI: 10.1007/s10072-022-05891-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2021] [Accepted: 01/09/2022] [Indexed: 10/19/2022]
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Rajabally YA. Immunoglobulin and Monoclonal Antibody Therapies in Guillain-Barré Syndrome. Neurotherapeutics 2022; 19:885-896. [PMID: 35648286 PMCID: PMC9159039 DOI: 10.1007/s13311-022-01253-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/20/2022] [Indexed: 12/29/2022] Open
Abstract
Guillain-Barré syndrome (GBS) is an acute autoimmune polyradiculoneuropathy affecting 1-2 subjects per 100,000 every year worldwide. It causes, in its classic form, symmetric weakness in the proximal and distal limb muscles with common involvement of the cranial nerves, particularly facial weakness. Respiratory function is compromised in a case in four. Randomised controlled trials have demonstrated the benefit of therapeutic plasma exchange in hastening time to recovery. Intravenous immunoglobulin was subsequently shown to be as efficacious as plasma exchange in adult subjects. In children, few trials have shown the benefit of intravenous immunoglobulin versus supportive care. Pharmacokinetic studies suggested a relationship between increase in immunoglobulin G level post-infusion and outcome, implying administration of larger doses may be beneficial in subjects with poor prognosis. However, a subsequent trial of a second dose of immunoglobulin in such subjects failed to show improved outcome, while demonstrating a higher risk of thromboembolic side-effects. Monoclonal antibody therapy has more recently been investigated for GBS, after multiple studies in animal models, with different agents and variable postulated mechanisms of action. Eculizumab, a humanised monoclonal antibody against the complement protein C5, was tested in in two randomised, double-blind, placebo-controlled phase 2 trials. Neither showed benefit versus immunoglobulins alone on disability level at 4 weeks, although one study importantly suggested possible, clinically highly relevant, late effects on normalising function. A phase 3 trial is in progress. Preliminary results of a placebo-controlled ongoing study of ANX005, a humanised recombinant antibody against C1q inhibiting the complement cascade, have been promising.
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Affiliation(s)
- Yusuf A Rajabally
- Aston Medical School, Aston University, Birmingham, B4 7ET, UK.
- Inflammatory Neuropathy Clinic, University Hospitals Birmingham, Queen Elizabeth Hospital, Birmingham, B15 2TH, UK.
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Doyle C, Eustace K. Pompholyx as a side effect of intravenous immunoglobulin (IVIg). BMJ Case Rep 2022; 15:e248772. [PMID: 35354565 PMCID: PMC8968538 DOI: 10.1136/bcr-2022-248772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/14/2022] [Indexed: 11/04/2022] Open
Abstract
Intravenous immunoglobulin (IVIg) is increasingly used across multiple specialties for the treatment of inflammatory and autoimmune diseases. Cutaneous reactions to IVIg are generally minor. Pompholyx is a common eruption of small vesicles on the palms, soles, and/or lateral aspects of the fingers. It has a multifactorial aetiology but is rarely attributed to being a drug-related side effect. We describe a 43-year-old woman presenting with peripheral sensory neuropathy who developed pompholyx eczema on both palms following treatment with IVIg.
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Principles and Guidelines of Immunotherapy in Neuromuscular Disorders. Neuromuscul Disord 2022. [DOI: 10.1016/b978-0-323-71317-7.00007-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Treatment and Management of Autoimmune Myopathies. Neuromuscul Disord 2022. [DOI: 10.1016/b978-0-323-71317-7.00022-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Morales-Ruiz V, Juárez-Vaquera VH, Rosetti-Sciutto M, Sánchez-Muñoz F, Adalid-Peralta L. Efficacy of intravenous immunoglobulin in autoimmune neurological diseases. Literature systematic review and meta-analysis. Autoimmun Rev 2021; 21:103019. [PMID: 34920107 DOI: 10.1016/j.autrev.2021.103019] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Accepted: 12/12/2021] [Indexed: 12/23/2022]
Abstract
BACKGROUND Corticosteroids are the first-line treatment for several common autoimmune neurological diseases. Other therapeutic approaches, including intravenous immunoglobulin (IVIg) and plasmapheresis, have shown mixed results in patient improvement. OBJECTIVE To compare the efficacy of IVIg administration with that of corticosteroids, plasmapheresis, and placebo in autoimmune neurological diseases like Guillain-Barré syndrome, myasthenia gravis, chronic inflammatory demyelinating polyneuropathy, optic neuritis, and multiple sclerosis. METHODS A systematic review was performed on the databases PubMed, MEDLINE, Embase, and Cochrane. Controlled, randomized studies comparing the efficacy of IVIg with placebo, plasmapheresis, and/or glucocorticoid administration were selected. Only studies reporting the number of patients who improved after treatment were included, irrespective of language or publication year. In total, 23 reports were included in the meta-analysis study. RESULTS Our meta-analysis showed a beneficial effect of IVIg administration on patient improvement over placebo (OR = 2.79, CI [95%] = 1.40-5.55, P = 0.01). Meanwhile, IVIg administration showed virtually identical effects to plasmapheresis (OR = 0.83, CI [95%] = 0.45-1.55, P < 0.01). Finally, no significant differences were found in the efficacy of IVIg and glucocorticoid administration (OR = 0.98, Cl [95%] = 0.58-1.68, P = 0.13). CONCLUSION IVIg can be regarded as a viable therapeutic approach, either as a first- or second-line therapy, and as an adjuvant therapy for autoimmune neurological diseases.
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Affiliation(s)
- Valeria Morales-Ruiz
- Unidad Periférica para el Estudio de la Neuroinflamación en Patologías Neurológicas del Instituto de Investigaciones Biomédicas de la UNAM en el Instituto Nacional de Neurología y Neurocirugía, Insurgentes Sur 3877, Col. La Fama, Ciudad de México 14269, Mexico; Posgrado en Ciencias Biológicas, Universidad Nacional Autónoma de México, Av. Ciudad Universitaria 3000, Coyoacán, Ciudad de México 04510, Mexico
| | - Víctor Hugo Juárez-Vaquera
- Unidad Periférica para el Estudio de la Neuroinflamación en Patologías Neurológicas del Instituto de Investigaciones Biomédicas de la UNAM en el Instituto Nacional de Neurología y Neurocirugía, Insurgentes Sur 3877, Col. La Fama, Ciudad de México 14269, Mexico
| | - Marcos Rosetti-Sciutto
- Instituto de Investigaciones Biomédicas, Universidad Nacional Autónoma de México, Ciudad de México 04510, Mexico; Instituto Nacional de Psiquiatría Ramón de la Fuente Muñiz, México-Xochimilco 101, Col. Huipulco, Ciudad de México 14370, Mexico
| | - Fausto Sánchez-Muñoz
- Instituto Nacional de Cardiología Ignacio Chávez, Juan Badiano 1, Col. Belisario Domínguez Secc. 16, Ciudad de México 14080, Mexico
| | - Laura Adalid-Peralta
- Unidad Periférica para el Estudio de la Neuroinflamación en Patologías Neurológicas del Instituto de Investigaciones Biomédicas de la UNAM en el Instituto Nacional de Neurología y Neurocirugía, Insurgentes Sur 3877, Col. La Fama, Ciudad de México 14269, Mexico; Instituto Nacional de Neurología y Neurocirugía, Insurgentes Sur 3877, Col. La Fama, Ciudad de México 14269, Mexico.
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Dalakas MC. Update on Intravenous Immunoglobulin in Neurology: Modulating Neuro-autoimmunity, Evolving Factors on Efficacy and Dosing and Challenges on Stopping Chronic IVIg Therapy. Neurotherapeutics 2021; 18:2397-2418. [PMID: 34766257 PMCID: PMC8585501 DOI: 10.1007/s13311-021-01108-4] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/11/2021] [Indexed: 02/07/2023] Open
Abstract
In the last 25 years, intravenous immunoglobulin (IVIg) has had a major impact in the successful treatment of previously untreatable or poorly controlled autoimmune neurological disorders. Derived from thousands of healthy donors, IVIg contains IgG1 isotypes of idiotypic antibodies that have the potential to bind pathogenic autoantibodies or cross-react with various antigenic peptides, including proteins conserved among the "common cold"-pre-pandemic coronaviruses; as a result, after IVIg infusions, some of the patients' sera may transiently become positive for various neuronal antibodies, even for anti-SARS-CoV-2, necessitating caution in separating antibodies derived from the infused IVIg or acquired humoral immunity. IVIg exerts multiple effects on the immunoregulatory network by variably affecting autoantibodies, complement activation, FcRn saturation, FcγRIIb receptors, cytokines, and inflammatory mediators. Based on randomized controlled trials, IVIg is approved for the treatment of GBS, CIDP, MMN and dermatomyositis; has been effective in, myasthenia gravis exacerbations, and stiff-person syndrome; and exhibits convincing efficacy in autoimmune epilepsy, neuromyelitis, and autoimmune encephalitis. Recent evidence suggests that polymorphisms in the genes encoding FcRn and FcγRIIB may influence the catabolism of infused IgG or its anti-inflammatory effects, impacting on individualized dosing or efficacy. For chronic maintenance therapy, IVIg and subcutaneous IgG are effective in controlled studies only in CIDP and MMN preventing relapses and axonal loss up to 48 weeks; in practice, however, IVIg is continuously used for years in all the aforementioned neurological conditions, like is a "forever necessary therapy" for maintaining stability, generating challenges on when and how to stop it. Because about 35-40% of patients on chronic therapy do not exhibit objective neurological signs of worsening after stopping IVIg but express subjective symptoms of fatigue, pains, spasms, or a feeling of generalized weakness, a conditioning effect combined with fear that discontinuing chronic therapy may destabilize a multi-year stability status is likely. The dilemmas of continuing chronic therapy, the importance of adjusting dosing and scheduling or periodically stopping IVIg to objectively assess necessity, and concerns in accurately interpreting IVIg-dependency are discussed. Finally, the merit of subcutaneous IgG, the ineffectiveness of IVIg in IgG4-neurological autoimmunities, and genetic factors affecting IVIg dosing and efficacy are addressed.
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Affiliation(s)
- Marinos C Dalakas
- Department of Neurology, Thomas Jefferson University, Philadelphia, PA, USA.
- Neuroimmunology Unit, Dept. of Pathophysiology, National and Kapodistrian University of Athens Medical School, Athens, Greece.
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16
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Janssen JBE, Leow TYS, Herbschleb KH, Gijtenbeek JMM, Boers-Sonderen MJ, Gerritsen WR, Westdorp H. Immune Checkpoint Inhibitor-related Guillain-Barré Syndrome: A Case Series and Review of the Literature. J Immunother 2021; 44:276-282. [PMID: 33758147 DOI: 10.1097/cji.0000000000000364] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2020] [Accepted: 02/02/2021] [Indexed: 12/26/2022]
Abstract
Immune checkpoint inhibitors (ICIs) have been approved for the treatment of various malignancies with promising clinical outcomes. Treatment can, however, be accompanied by serious immune-related adverse events. Neurological adverse events like Guillain-Barré syndrome (GBS) are rare but potentially life-threatening. We present 3 cases of ICI-related GBS; review cases described in current literature, and discuss treatment strategies. Three patients developed GBS after ICI treatment. The first case with pembrolizumab had a fatal outcome despite treatment with multiple regimens, including steroids and intravenous immunoglobulin (IVIg). The other 2 cases with nivolumab-induced and pembrolizumab-induced GBS, respectively, responded well to treatment with IVIg and steroids. In the current literature, a total of 31 other cases were found. Treatment for ICI-related GBS mostly consisted of concurrent IVIg and steroids (44%), which led to clinical improvement in 73%. Most patients recovered with remaining symptoms (68%), while 10 patients developed respiratory failure (29%) and 6 patients (18%) died. ICI-related GBS should be suspected in patients on ICI treatment who develop subacute progressive weakness of the limbs, sensory loss, and areflexia. On the basis of the guidelines recommendations and our review of the literature, we advise first-line therapy with concurrent IVIg 0.4 g/kg/d for 5 days and prednisolone 1-2 mg/kg/d. Discontinuation of immunotherapy after ICI-related GBS is advised.
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Affiliation(s)
| | | | - Karin H Herbschleb
- Department of Internal Medicine, St. Antonius Ziekenhuis, Nieuwegein, The Netherlands
| | | | | | - Winald R Gerritsen
- Departments of Medical Oncology
- Department of Tumor Immunology, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen
| | - Harm Westdorp
- Departments of Medical Oncology
- Department of Tumor Immunology, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen
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17
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Choi AY, Manook M, Olaso D, Ezekian B, Park J, Freischlag K, Jackson A, Knechtle S, Kwun J. Emerging New Approaches in Desensitization: Targeted Therapies for HLA Sensitization. Front Immunol 2021; 12:694763. [PMID: 34177960 PMCID: PMC8226120 DOI: 10.3389/fimmu.2021.694763] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 05/24/2021] [Indexed: 01/11/2023] Open
Abstract
There is an urgent need for therapeutic interventions for desensitization and antibody-mediated rejection (AMR) in sensitized patients with preformed or de novo donor-specific HLA antibodies (DSA). The risk of AMR and allograft loss in sensitized patients is increased due to preformed DSA detected at time of transplant or the reactivation of HLA memory after transplantation, causing acute and chronic AMR. Alternatively, de novo DSA that develops post-transplant due to inadequate immunosuppression and again may lead to acute and chronic AMR or even allograft loss. Circulating antibody, the final product of the humoral immune response, has been the primary target of desensitization and AMR treatment. However, in many cases these protocols fail to achieve efficient removal of all DSA and long-term outcomes of patients with persistent DSA are far worse when compared to non-sensitized patients. We believe that targeting multiple components of humoral immunity will lead to improved outcomes for such patients. In this review, we will briefly discuss conventional desensitization methods targeting antibody or B cell removal and then present a mechanistically designed desensitization regimen targeting plasma cells and the humoral response.
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Affiliation(s)
| | | | | | | | | | | | | | - Stuart Knechtle
- Duke Transplant Center, Department of Surgery, Duke University Medical Center, Durham, NC, United States
| | - Jean Kwun
- Duke Transplant Center, Department of Surgery, Duke University Medical Center, Durham, NC, United States
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18
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Dalakas MC. Progress in the therapy of myasthenia gravis: getting closer to effective targeted immunotherapies. Curr Opin Neurol 2021; 33:545-552. [PMID: 32833750 DOI: 10.1097/wco.0000000000000858] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW To provide an update on immunomodulating and immunosuppressive therapies in myasthenia gravis and highlight newly approved, or pending approval, therapies with new biologics. RECENT FINDINGS Preoperative IVIg is not needed to prevent myasthenic crisis in stable myasthenia gravis patients scheduled for surgery under general anesthesia, based on controlled data. Rituximab, if initiated early in new-onset myasthenia gravis, can lead to faster and more sustained remission even without immunotherapies in 35% of patients at 2 years. Biomarkers determining the timing for follow-up infusions in Rituximab-responding AChR-positive patients are discussed. Most patients with MuSK-positive myasthenia gravis treated with Rituximab have sustained long-term remission with persistent reduction of IgG4 anti-MuSK antibodies. Eculizumb in the extension REGAIN study showed sustained long-term pharmacological remissions and reduced exacerbations. Three new biologic agents showed promising results in phase-II controlled myasthenia gravis trials: Zilucoplan, a subcutaneous macrocyclic peptide inhibiting complement C5; Efgartigimod, an IgG1-derived Fc fragment binding to neonatal FcRn receptor; and Rozanolixizumab, a high-affinity anti-FcRn monoclonal antibody. Finally, the safety of ongoing myasthenia gravis immunotherapies during COVID19 pandemic is discussed. SUMMARY New biologics against B cells, complement and FcRn receptor, are bringing us closer to successful targeted immunotherapies in the chronic management of myasthenia gravis promising an exciting future for antibody-mediated neurological diseases.
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Affiliation(s)
- Marinos C Dalakas
- Department of Neurology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA.,Neuroimmunology Unit, National and Kapodistrian University of Athens Medical School, Athens, Greece
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19
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Application of intravenous immunoglobulin (IVIG) to modulate inflammation in critical COVID-19 - A theoretical perspective. Med Hypotheses 2021; 151:110592. [PMID: 33878626 PMCID: PMC8032597 DOI: 10.1016/j.mehy.2021.110592] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Revised: 04/01/2021] [Accepted: 04/05/2021] [Indexed: 12/15/2022]
Abstract
COVID-19 is an airway disease that has affected ~125 million people worldwide, caused by a novel coronavirus termed severe acute respiratory syndrome coronavirus 2 (SARS-CoV2), spread through respiratory droplets, direct contact, and aerosol transmission. Although most patients presenting with absent or mild symptoms recover completely, the highest morbidity and mortality rates are seen in the elderly, and patients with comorbidities such as cardiovascular diseases, cancer, immunosuppressive diseases, diabetes, and pre-existing respiratory illnesses. Several therapeutic strategies have been examined, but a wide-ranging therapeutic option for particularly severe cases of COVID-19 remains to be elucidated. Considering the indications presented by COVID-19 patients who present similarly with inflammatory conditions, intravenous immunoglobulin (IVIG) administration has been examined as a possible route to reduce proinflammatory markers such as ESR, CRP and ferritin by reducing inflammation, based on its anti-inflammatory effects as indicated by utilisation of IVIG for numerous other inflammatory conditions. Herein, summarising the recent key clinical evaluations of IVIG administration, we present our hypothesis that administration of IVIG within a specific dosage would be extremely beneficial towards reducing mortality and perhaps even the length of hospitalisation of patients exhibiting severe COVID-19 symptoms.
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20
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Algahtani H, Shirah B, Algahtani S, Attar A, Abuzinadah AR. Mills' syndrome: Reporting the disease course with a monthly intravenous immunoglobulin program. J Neuroimmunol 2021; 355:577562. [PMID: 33813319 DOI: 10.1016/j.jneuroim.2021.577562] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 03/27/2021] [Accepted: 03/29/2021] [Indexed: 02/08/2023]
Abstract
Mills' syndrome is an extremely rare, slowly progressive, unilateral ascending or descending clinical syndrome of upper motor neuron-predominant hemiparesis. In this article, we describe a case of a middle-aged woman (initial presentation and three years follow-up) who presented with progressive ascending hemiparesis with clinically isolated upper motor neuron signs and normal sensory examination. The patient received monthly intravenous immunoglobulin (IVIG) for three years with no progression of her weakness. To our best knowledge, the response of Mills' syndrome to such an IVIG program has not been reported in the literature so far. We aim to document the clinical response to IVIG in such rare syndrome.
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Affiliation(s)
- Hussein Algahtani
- King Abdulaziz Medical City, Jeddah, Saudi Arabia; King Saud bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia; King Abdullah International Medical Research Center, Jeddah, Saudi Arabia.
| | - Bader Shirah
- King Saud bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia; King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
| | | | - Ahmed Attar
- King Abdulaziz Medical City, Jeddah, Saudi Arabia
| | - Ahmad R Abuzinadah
- Neurology Division, Internal Medicine Department, College of Medicine and King Abdulaziz University Hospital, King Abdulaziz University, Jeddah, Saudi Arabia
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21
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Alzuabi MA, Manolopoulos A, Elmashala A, Odabashian R, Naddaf E, Murad MH. Immunoglobulin for myasthenia gravis. Hippokratia 2020. [DOI: 10.1002/14651858.cd013801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Muayad A Alzuabi
- Department of Neuroscience, Division of Clinical Neurology; Medical University of South Carolina; Charleston SC USA
| | - Apostolos Manolopoulos
- Clinical Research and Evidence-Based Medicine Unit, Second Medical Department; Aristotle University of Thessaloniki; Thessaloniki Greece
| | - Amjad Elmashala
- Department of Neurology; Iowa University Hospitals; Iowa City IA USA
| | - Roupen Odabashian
- Department of Internal Medicine; University of Toronto; Toronto Canada
| | - Elie Naddaf
- Department of Neurology; Mayo Clinic; Rochester MN USA
| | - M Hassan Murad
- Mayo Evidence-based Practice Center (EPC); Mayo Clinic; Rochester MN USA
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22
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Koike H, Katsuno M. Pathophysiology of Chronic Inflammatory Demyelinating Polyneuropathy: Insights into Classification and Therapeutic Strategy. Neurol Ther 2020; 9:213-227. [PMID: 32410146 PMCID: PMC7606443 DOI: 10.1007/s40120-020-00190-8] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Indexed: 01/11/2023] Open
Abstract
Chronic inflammatory demyelinating polyneuropathy (CIDP) is classically defined as polyneuropathy with symmetric involvement of the proximal and distal portions of the limbs. In addition to this "typical CIDP", the currently prevailing diagnostic criteria proposed by the European Federation of Neurological Societies and Peripheral Nerve Society (EFNS/PNS) define "atypical CIDP" as encompassing the multifocal acquired demyelinating sensory and motor (MADSAM), distal acquired demyelinating symmetric (DADS), pure sensory, pure motor, and focal subtypes. Although macrophage-induced demyelination is considered pivotal to the pathogenesis of CIDP, recent studies have indicated the presence of distinctive mechanisms initiated by autoantibodies against paranodal junction proteins, such as neurofascin 155 and contactin 1. These findings led to the emergence of the concept of nodopathy or paranodopathy. Patients with these antibodies tend to show clinical features compatible with typical CIDP or DADS, particularly the latter. In contrast, classical macrophage-induced demyelination is commonly found in some patients in each major subtype, including the typical CIDP, DADS, MADSAM, and pure sensory subtypes. Differences in the distribution of lesions and the repair processes underlying demyelination by Schwann cells may determine the differences among subtypes. In particular, the preferential involvement of proximal and distal nerve segments has been suggested to occur in typical CIDP, whereas the involvement of the middle nerve segments is conspicuous in MADSAM. These findings suggest that humoral rather than cellular immunity predominates in the former because nerve roots and neuromuscular junctions lack blood-nerve barriers. Treatment for CIDP consists of intravenous immunoglobulin (IVIg) therapy, steroids, and plasma exchange, either alone or in combination. However, patients with anti-neurofascin 155 and contactin 1 antibodies are refractory to IVIg. It has been suggested that rituximab, a monoclonal antibody to CD20, could have efficacy in these patients. Further studies are needed to validate the CIDP subtypes defined by the EFNS/PNS from the viewpoint of pathogenesis and establish therapeutic strategies based on the pathophysiologies specific to each subtype.
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Affiliation(s)
- Haruki Koike
- Department of Neurology, Nagoya University Graduate School of Medicine, Nagoya, Japan.
| | - Masahisa Katsuno
- Department of Neurology, Nagoya University Graduate School of Medicine, Nagoya, Japan
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23
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Anagnostouli M, Vakrakou AG, Zambelis T, Boufidou F, Nikolaou C, Karandreas N, Kilidireas C. Myasthenia gravis, atypical polyneuropathy and multiple autoimmune phenomena in the same patient, with HLA-immunogenetic profile expectable for Greek chronic inflammatory demyelinating polyneuropathy: a case report. Int J Neurosci 2020; 132:593-600. [PMID: 32988257 DOI: 10.1080/00207454.2020.1829616] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
PURPOSE The comorbidity of myasthenia gravis (MG), with other autoimmune disorders like systemic lupus erythematosus (SLE), is relatively frequent but the co-occurrence with chronic inflammatory demyelinating polyneuropathy (CIDP) along with various autoimmune manifestations in the absence of thymoma is of extreme rarity. Our aim is to report a case of a woman who presented the concomitant appearance of MG, axonal sensory-motor polyneuropathy and hepatitis that may indicate an underlying pathogenetic link among the different autoimmune disorders. MATERIALS AND METHODS/RESULTS We present a case of a 54-year-old woman, with a generalized MG and a chronic sensory-motor polyneuropathy, hypothyroidism, anaemia, hepatitis, livedo reticularis and facial flush, of assumed autoimmune background, like SLE, although with persistent negative ANA antibodies, from the beginning and through the whole following years. The Human Leukocyte Antigen (HLA)-DRB1 genotyping showed a profile of alleles (DRB1*11:01/11:04) compatible with CIDP of mainly female gender in Greece and frequencies close to those of Sjogren's syndrome and scleroderma's in the Greek population. The diagnostic problems, the atypical clinical, electrophysiological and immunological features are discussed, along with the rarity of the case, with this exceptional combination of autoimmune manifestations, which could be truly associated under the clinical umbrella of a systemic disease, like SLE. However, our patient did not ever fulfil the SLE criteria. CONCLUSIONS To raise awareness among clinicians about the exceptional combination of autoimmune manifestations driven by a specific HLA background.
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Affiliation(s)
- Maria Anagnostouli
- 1st Department of Neurology, Medical School of Athens National and Kapodistrian University, NKUA, Aeginition Hospital, Athens, Greece.,Immunogenetics Laboratory, 1st Department of Neurology, Medical School of Athens National and Kapodistrian University, NKUA, Aeginition Hospital, Athens, Greece
| | - Aigli G Vakrakou
- 1st Department of Neurology, Medical School of Athens National and Kapodistrian University, NKUA, Aeginition Hospital, Athens, Greece
| | - Thomas Zambelis
- 1st Department of Neurology, Medical School of Athens National and Kapodistrian University, NKUA, Aeginition Hospital, Athens, Greece.,Laboratory of Electrophysiology, 1st Department of Neurology, Medical School of Athens National and Kapodistrian University, NKUA, Aeginition Hospital, Athens, Greece
| | - Fotini Boufidou
- Department of Biopathology and Immunology, Medical School of Athens National and Kapodistrian University, NKUA, Aeginition Hospital, Athens, Greece
| | - Chrysoula Nikolaou
- Department of Biopathology and Immunology, Medical School of Athens National and Kapodistrian University, NKUA, Aeginition Hospital, Athens, Greece
| | - Nikolaos Karandreas
- 1st Department of Neurology, Medical School of Athens National and Kapodistrian University, NKUA, Aeginition Hospital, Athens, Greece.,Laboratory of Electrophysiology, 1st Department of Neurology, Medical School of Athens National and Kapodistrian University, NKUA, Aeginition Hospital, Athens, Greece
| | - Constantinos Kilidireas
- 1st Department of Neurology, Medical School of Athens National and Kapodistrian University, NKUA, Aeginition Hospital, Athens, Greece.,Neuroimmunology Laboratory, 1st Department of Neurology of Medical School of Athens National and Kapodistrian University, NKUA, Aeginition Hospital, Athens, Greece
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24
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Takci Z, Guler Simsek G, Uzuner H, Akbayrak A, Yıldız Seckin H, Karadag AS. Dyshidrotic eczema and seborrheic dermatitis-like eczematous eruption following intravenous immunoglobulin therapy. Dermatol Ther 2020; 33:e14147. [PMID: 32767429 DOI: 10.1111/dth.14147] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Revised: 07/16/2020] [Accepted: 07/26/2020] [Indexed: 11/27/2022]
Abstract
Intravenous immunoglobulin (IVIg) is increasingly used for the treatment of inflammatory and autoimmune diseases. Although skin reactions to IVIg therapy are usually minor, rare, and not life-threatening, dermatologists need to recognize the nature of these adverse reactions. We describe a 33-year-old man suffering from demyelinating polyneuropathy who developed dyshidrotic eczema on the palms and flaky grayish-white scales on an erythematous base on his face after the administration of IVIg.
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Affiliation(s)
- Zennure Takci
- Department of Dermatology, Faculty of Medicine, Gaziosmanpasa University, Tokat, Turkey
| | - Gulcin Guler Simsek
- Department of Pathology, Kecioren Research and Training Hospital, Ankara, Turkey
| | - Hatice Uzuner
- Department of Pathology, Samsun Research and Training Hospital, Samsun, Turkey
| | - Atiye Akbayrak
- Department of Dermatology, Faculty of Medicine, Gaziosmanpasa University, Tokat, Turkey
| | - Havva Yıldız Seckin
- Department of Dermatology, Faculty of Medicine, Gaziosmanpasa University, Tokat, Turkey
| | - Ayse Serap Karadag
- Department of Dermatology, Medical Faculty, Istanbul Medeniyet University, Göztepe Research and Training Hospital, Istanbul, Turkey
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25
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Algahtani H, Shirah B, Alrefaei K, Albassam M, Abdelghaffar N. Are Repeated Cycles of Intravenous Immunoglobulin Justified in Patients With Poorly Responsive Guillain-Barré Syndrome? Neurohospitalist 2020; 10:224-228. [PMID: 32549948 DOI: 10.1177/1941874419893570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Guillain-Barré syndrome (GBS) is a life-threatening form of inflammatory polyneuropathy. Immunotherapy with intravenous immunoglobulin (IVIG) has been used successfully in the treatment of GBS. In this case report, we present a severe axonal form of GBS that showed improvement after 3 cycles of IVIG. Repeated cycles of IVIG may be an option for treating severe forms of GBS not responding to the first course of such treatment. The recent work suggests that patients who are severely affected and have severe gadolinium enhancement on the magnetic resonance imaging of the spine should be considered for retreatment with IVIG. Although the cost of management was high, the outcome was excellent, which is definitely considered a reasonable approach. This case report is an urgent call for performing large multicenter trials on the use of repeated cycles of IVIG in the management of severe cases of GBS.
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Affiliation(s)
- Hussein Algahtani
- King Abdulaziz Medical City, King Saud bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
| | - Bader Shirah
- King Abdullah International Medical Research Center, King Saud bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
| | - Khalid Alrefaei
- King Saud bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
| | - Mohammed Albassam
- King Saud bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
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26
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Abstract
No consensus has been reached on the ideal therapeutic algorithm for myasthenia gravis (MG). Most patients with MG require induction therapy with high doses of corticosteroids and maintenance with an immunosuppressant. Severe cases and acute worsening require intravenous immunoglobulin or plasmapheresis before oral immunosuppressants start having an effect. However, biologics are emerging as important therapeutic tools that promise to provide better corticosteroid sparing effects than standard treatments and can even induce remission. In particular, eculizumab, a monoclonal antibody against complement C5, has been approved by the FDA for refractory MG on the basis of a phase III trial. Rituximab, an anti-CD20 monoclonal antibody that depletes peripheral B cells, has also been effective in many large uncontrolled series, although was not in a small phase III trial. Whether the newer anti-CD20 agents ocrelizumab, ofatumumab, obinutuzumab, ublituximab or inebilizumab will be more effective remains unclear. Belimumab, an antibody against the B cell trophic factor BAFF, was ineffective in phase III trials, and efgartigimod, which depletes antibodies, was effective in a phase II study. Some anti-cytokine agents relevant to MG immunopathogenesis also seem promising. Checkpoint inhibitors can trigger MG in some patients, necessitating early intervention. Increased availability of new biologics provides targeted immunotherapies and the opportunities to develop more specific therapies.
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27
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Koike H, Nishi R, Ikeda S, Kawagashira Y, Iijima M, Katsuno M, Sobue G. Ultrastructural mechanisms of macrophage-induced demyelination in CIDP. Neurology 2018; 91:1051-1060. [PMID: 30429275 DOI: 10.1212/wnl.0000000000006625] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Accepted: 07/18/2018] [Indexed: 11/15/2022] Open
Abstract
Chronic inflammatory demyelinating polyneuropathy (CIDP) is a form of chronic neuropathy that is presumably caused by heterogeneous immune-mediated processes. Recent advances in the search for autoantibodies against components expressed at nodal regions, such as the nodes of Ranvier and paranodes, have substantially contributed to clarifying the pathogenesis of CIDP in a subpopulation of patients. In particular, immunoglobulin G4 (IgG4) antibodies to paranodal junction proteins, including neurofascin-155 and contactin-1, have attracted the attention of researchers. Paranodal dissection resulting from the attachment of IgG4 at paranodal junctions and the absence of macrophage-induced demyelination are characteristic pathologic features in patients who have these antibodies. By contrast, the mechanisms of neuropathy in cases with classical macrophage-induced demyelination remain unclear despite the long-standing recognition of this process in CIDP. In addition to complement-dependent damage provoked by autoantibodies, recent studies have shed light on antibody-dependent phagocytosis by macrophages without participation of complements. However, a direct association between specific autoantibodies and macrophage-induced demyelination has not been reported. Electron microscopic examination of longitudinal sections of sural nerve biopsy specimens suggested that macrophages recognize specific sites of myelinated fibers as the initial target of demyelination. The site that macrophages select to initiate myelin breakdown is located around the nodal regions in some patients and internode in others. Hence, it seems that the components that distinguish between the nodal regions and internode play a pivotal role in the behavior of macrophages that initiate phagocytosis of myelin. Further studies are needed to elucidate the mechanisms underlying macrophage-induced demyelination from this perspective.
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Affiliation(s)
- Haruki Koike
- From the Department of Neurology (H.K., R.N., S.I., Y.K., M.I., M.K., G.S.) and Research Division of Dementia and Neurodegenerative Disease (G.S.), Nagoya University Graduate School of Medicine, Japan.
| | - Ryoji Nishi
- From the Department of Neurology (H.K., R.N., S.I., Y.K., M.I., M.K., G.S.) and Research Division of Dementia and Neurodegenerative Disease (G.S.), Nagoya University Graduate School of Medicine, Japan
| | - Shohei Ikeda
- From the Department of Neurology (H.K., R.N., S.I., Y.K., M.I., M.K., G.S.) and Research Division of Dementia and Neurodegenerative Disease (G.S.), Nagoya University Graduate School of Medicine, Japan
| | - Yuichi Kawagashira
- From the Department of Neurology (H.K., R.N., S.I., Y.K., M.I., M.K., G.S.) and Research Division of Dementia and Neurodegenerative Disease (G.S.), Nagoya University Graduate School of Medicine, Japan
| | - Masahiro Iijima
- From the Department of Neurology (H.K., R.N., S.I., Y.K., M.I., M.K., G.S.) and Research Division of Dementia and Neurodegenerative Disease (G.S.), Nagoya University Graduate School of Medicine, Japan
| | - Masahisa Katsuno
- From the Department of Neurology (H.K., R.N., S.I., Y.K., M.I., M.K., G.S.) and Research Division of Dementia and Neurodegenerative Disease (G.S.), Nagoya University Graduate School of Medicine, Japan
| | - Gen Sobue
- From the Department of Neurology (H.K., R.N., S.I., Y.K., M.I., M.K., G.S.) and Research Division of Dementia and Neurodegenerative Disease (G.S.), Nagoya University Graduate School of Medicine, Japan
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28
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Liu S, Dong C, Ubogu EE. Immunotherapy of Guillain-Barré syndrome. Hum Vaccin Immunother 2018; 14:2568-2579. [PMID: 29953326 PMCID: PMC6314401 DOI: 10.1080/21645515.2018.1493415] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Revised: 06/05/2018] [Accepted: 06/21/2018] [Indexed: 12/14/2022] Open
Abstract
Guillain-Barré syndrome (GBS), the most common cause of acute neuromuscular weakness and paralysis worldwide, encompasses a group of acute immune-mediated disorders restricted to peripheral nerves and roots. Immune-mediated attack of peripheral nervous system myelin, axons or both is presumed to be triggered by molecular mimicry, with both cell- and humoral-dependent mechanisms implicated in disease pathogenesis. Good circumstantial evidence exists for a pathogenic role for molecular mimicry in GBS pathogenesis, especially with its axonal forms, providing insights that could guide future immunotherapy. Intravenous immunoglobulin (IVIg) and plasma exchange (PE) are the most commonly prescribed immunotherapies for GBS with variable efficacy dependent on GBS subtype, severity at initial presentation and other clinical and electrophysiologic prognostic factors. The mechanisms of action of IVIg and PE are not known definitely. Despite recent significant advances in molecular biology that provide insights into GBS pathogenesis, no advances in therapeutics or significant improvements in patient outcomes have occurred over the past three decades. We summarize the clinical aspects of GBS, its current pathogenesis and immunotherapy, and highlight the potential of leukocyte trafficking inhibitors as novel disease-specific immunotherapeutic drugs.
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Affiliation(s)
- Shuang Liu
- Neuromuscular Immunopathology Research Laboratory, Division of Neuromuscular Disease, Department of Neurology, University of Alabama at Birmingham, Birmingham, AL, USA
- Division of Neurology, The Second Affiliated Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin, Peoples’ Republic of China
| | - Chaoling Dong
- Neuromuscular Immunopathology Research Laboratory, Division of Neuromuscular Disease, Department of Neurology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Eroboghene Ekamereno Ubogu
- Neuromuscular Immunopathology Research Laboratory, Division of Neuromuscular Disease, Department of Neurology, University of Alabama at Birmingham, Birmingham, AL, USA
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29
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Tradtrantip L, Felix CM, Spirig R, Morelli AB, Verkman A. Recombinant IgG1 Fc hexamers block cytotoxicity and pathological changes in experimental in vitro and rat models of neuromyelitis optica. Neuropharmacology 2018; 133:345-353. [PMID: 29428821 PMCID: PMC6322534 DOI: 10.1016/j.neuropharm.2018.02.002] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2017] [Revised: 01/26/2018] [Accepted: 02/02/2018] [Indexed: 12/17/2022]
Abstract
Intravenous human immunoglobulin G (IVIG) may have therapeutic benefit in neuromyelitis optica spectrum disorders (herein called NMO), in part because of the anti-inflammatory properties of the IgG Fc region. Here, we evaluated recombinant Fc hexamers consisting of the IgM μ-tailpiece fused with the Fc region of human IgG1. In vitro, the Fc hexamers prevented cytotoxicity in aquaporin-4 (AQP4) expressing cells and in rat spinal cord slice cultures exposed to NMO anti-AQP4 autoantibody (AQP4-IgG) and complement, with >500-fold greater potency than IVIG or monomeric Fc fragments. Fc hexamers at low concentration also prevented antibody-dependent cellular cytotoxicity produced by AQP4-IgG and natural killer cells. Serum from rats administered a single intravenous dose of Fc hexamers at 50 mg/kg taken at 8 h did not produce complement-dependent cytotoxicity when added to AQP4-IgG-treated AQP4-expressing cell cultures. In an experimental rat model of NMO produced by intracerebral injection of AQP4-IgG, Fc hexamers at 50 mg/kg administered before and at 12 h after AQP4-IgG fully prevented astrocyte injury, complement activation, inflammation and demyelination. These results support the potential therapeutic utility of recombinant IgG1 Fc hexamers in AQP4-IgG seropositive NMO.
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Affiliation(s)
- Lukmanee Tradtrantip
- Departments of Medicine and Physiology, University of California, San Francisco, CA, USA
| | - Christian M. Felix
- Departments of Medicine and Physiology, University of California, San Francisco, CA, USA
| | | | | | - A.S. Verkman
- Departments of Medicine and Physiology, University of California, San Francisco, CA, USA
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Alexopoulos H, Akrivou S, Mastroyanni S, Antonopoulou M, Dinopoulos A, Giorgi M, Konstantinou K, Kouremenos E, Lariou M, Naoumis D, Pavlidou E, Pavlou E, Voudris K, Vlachoyiannopoulos P, Dalakas MC. Postherpes simplex encephalitis: a case series of viral-triggered autoimmunity, synaptic autoantibodies and response to therapy. Ther Adv Neurol Disord 2018; 11:1756286418768778. [PMID: 29774053 PMCID: PMC5949951 DOI: 10.1177/1756286418768778] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Accepted: 01/24/2018] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Recent evidence suggests that patients with herpes simplex virus (HSV) encephalitis may relapse because of autoimmunity against the N-methyl-D-aspartate receptor (NMDAR). We present a case series of post-HSV relapsing encephalopathy associated with antibodies to central nervous system (CNS) synaptic antigens. PATIENT/METHODS Sera and cerebrospinal fluid (CSF) from five patients with HSV encephalitis who relapsed after antiviral therapy were tested for anti-NMDAR, gamma-aminobutyric acid b receptor (GABAbR), α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid receptor (AMPAR), Leucine-rich, glioma inactivated 1 (LGI1), anti -contactin-associated protein-like 2 (CASPR2) and dipeptidyl-peptidase-like protein-6 (DDPX) antibodies using cell-based assays. RESULTS Five patients (two infants, one child and two adults) developed post-HSV autoimmune encephalitis. The infants, aged 9 months and 10 months, after prompt and seemingly successful anti-HSV therapy, were readmitted with typical signs of NMDAR-encephalitis evolving within days, with NMDAR antibodies detected in both serum and CSF. Although they were promptly treated with intravenous immunoglobulin (IVIg) and with IVIg followed by rituximab, respectively, they were both left with psychomotor deficits. A 14-year-old girl with seizures due to HSV encephalitis improved with anti-HSV therapy. Later, she manifested intractable seizures and she was found positive for anti-NMDAR antibodies which persist. The two adults were women, aged 58 and 33 years. The first recovered after anti-HSV therapy and remained asymptomatic for 6 months, until she developed generalized seizures with persisting CSF anti-NMDAR antibodies; the second, who continued to be encephalopathic after 2 weeks of anti-HSV therapy, tested positive for anti-NMDAR antibodies in the serum and anti-GABAbR antibodies in the serum and CSF. She recovered fully following IVIg therapy but her serum anti-GABAbR antibodies persist 34 months later. DISCUSSION Infection of the CNS with HSV can trigger CNS autoimmunity associated not only with anti-NMDAR but also with anti-GABAbR antibodies. These antibodies can persist in the serum, even without associated symptoms, but their presence in the CSF is firmly associated with disease development. In contrast to children and adults who responded well to therapies, the infants had an incomplete recovery with severe psychomotor deficits probably due to the interference of anti-NMDAR antibodies with neuro-developmental processes.
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Affiliation(s)
- Harry Alexopoulos
- Department of Pathophysiology, National and Kapodistrian University of Athens, Athens, Greece
| | - Sofia Akrivou
- Department of Pathophysiology, National and Kapodistrian University of Athens, Athens, Greece
| | - Sotiria Mastroyanni
- Department of Neurology, ‘P & A Kyriakou’ Children’s Hospital, Athens, Greece
| | - Maria Antonopoulou
- Department of Neurology, 251 Hellenic Air Force Military Hospital, Athens, Greece
| | - Argirios Dinopoulos
- Third Department of Pediatrics, National and Kapodistrian University of Athens, Athens, Greece
| | - Melpo Giorgi
- Third Department of Pediatrics, National and Kapodistrian University of Athens, Athens, Greece
| | - Kostas Konstantinou
- Department of Pathophysiology, National and Kapodistrian University of Athens, Athens, Greece
| | - Evangelos Kouremenos
- Department of Neurology, 251 Hellenic Air Force Military Hospital, Athens, Greece
| | - Maria Lariou
- Department of Neurology, ‘P & A Kyriakou’ Children’s Hospital, Athens, Greece
| | - Dimitrios Naoumis
- Department of Neurology, 251 Hellenic Air Force Military Hospital, Athens, Greece
| | - Efterpi Pavlidou
- Second Department of Pediatrics, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Evaggelos Pavlou
- Second Department of Pediatrics, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | | | | | - Marinos C. Dalakas
- Neuroimmunology Unit, Department of Pathophysiology, Faculty of Medicine, National and Kapodistrian University of Athens, Greece
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Melamed IR, Heffron M, Testori A, Lipe K. A pilot study of high-dose intravenous immunoglobulin 5% for autism: Impact on autism spectrum and markers of neuroinflammation. Autism Res 2018; 11:421-433. [PMID: 29427532 DOI: 10.1002/aur.1906] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Revised: 11/07/2017] [Accepted: 11/25/2017] [Indexed: 12/12/2022]
Abstract
Research has shown that a subset of the autism spectrum disorder (ASD) population presents with immune dysregulation. To explore this topic further, we investigated the efficacy and tolerability of intravenous immunoglobulin (IVIG) infusion in children with ASD. In this study, participants were recruited based on a diagnosis of autistic disorder, Asperger's disorder, or pervasive developmental disorder not otherwise specified. Participants also showed evidence of immune dysfunction based on abnormal levels of specific biomarkers, including CD40 ligand (CD154), lymphocyte stimulation, and T or B cell dysfunction. Of 17 screened patients, 14 completed the trial and received IVIG treatment (1 g/kg dose) for ten 21-day treatment cycles. The primary endpoint was disease improvement assessed using standardized cognitive and behavioral tests (Children's Communication Checklist [CCC-2], Social Responsiveness Scale [SRS], Aberrant Behavior Checklist [ABC], Clinical Global Impressions-Severity [CGI-S] and -Improvement [CGI-I], Autism Diagnostic Observation Schedule [ADOS], and Peabody Picture Vocabulary Test [PPVT]). Secondary endpoints included experimental biomarkers such as CD154, toll-like receptor-4, memory B cells, FOXP3, and lymphocyte stimulation. Significant improvements from baseline to study endpoint were observed in several subscales of the CCC-2, SRS, CGI-I, CGI-S, and ADOS, including Associated Maladaptive Behaviors (P ≤ .043), Reciprocal Social Interaction (P = .015), Communication (P < .001), and Stereotyped Behaviors and Repetitive Interests (P ≤ .013). Statistically significant reductions were also seen in numerous secondary outcomes of immunological biomarkers indicative of neuroinflammation. IVIG was well tolerated; no subjects withdrew due to an adverse event, and clinical data showed no evidence of thromboembolic events. Autism Res 2018, 11: 421-433. © 2018 International Society for Autism Research, Wiley Periodicals, Inc. LAY SUMMARY Since research has demonstrated a link between autism spectrum disorder (ASD) and immune dysfunction, this study investigated the efficacy and tolerability of intravenous immunoglobulin (IVIG) infusion in children with ASD. Fourteen patients received IVIG treatment and were assessed using standardized cognitive and behavioral tests. Following treatment with IVIG, significant improvement was observed across several subscales of the clinical tests and significant reductions were seen in the markers of neuroinflammation. These data suggest that inflammatory etiologies may play a role in select cases of autism, and IVIG treatment may exert a positive impact on behaviors and markers of inflammation in ASD.
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Affiliation(s)
| | | | | | - Kellie Lipe
- IMMUNOe Research Centers, Centennial, Colorado
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Dalakas MC. Advances in the diagnosis, immunopathogenesis and therapies of IgM-anti-MAG antibody-mediated neuropathies. Ther Adv Neurol Disord 2018; 11:1756285617746640. [PMID: 29403542 PMCID: PMC5791554 DOI: 10.1177/1756285617746640] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Accepted: 11/16/2017] [Indexed: 11/17/2022] Open
Abstract
Polyneuropathy with immunoglobulin M (IgM) monoclonal gammopathy is the most common paraproteinemic neuropathy, comprising a clinicopathologically and immunologically distinct entity. The clinical spectrum spans from distal paresthesias and mild gait imbalance to more severe sensory ataxia, with falls and a varying degree of distal sensorimotor deficits. In approximately 75% of patients, the monoclonal IgM immunoreacts with myelin-associated glycoprotein (MAG) and sulfoglucuronyl glycosphingolipid (SGPG), or other peripheral nerve glycolipids that serve as antigens. These antibodies are considered pathogenic because IgM and complement are deposited on the myelin sheath, splitting the myelin lamellae, while adoptive transfer of patients’ IgM into susceptible host animals causes sensory ataxia and reproduces the human pathology. In spite of the apparently convincing pathogenicity of these antibodies, the response to immunotherapies remains suboptimal. Clorambuscil, cladibrine, cyclophospamide and intravenous immunoglobulin may help some patients but the benefits are minimal and transient. Open-label studies in >200 patients indicate that rituximab is helpful in 30–50% of these patients, even with long-term benefits, probably by suppressing IgM anti-MAG antibodies or inducing immunoregulatory T cells. Two controlled studies with rituximab did not however meet the primary endpoint, mostly because of the poor sensitivity of the scales used; they did however show statistical improvement in secondary endpoints and improved clinical functions in several patients. This review provides an overview of the clinical phenotypes and immunoreactivity of IgM to glycolipids or glycoproteins of peripheral nerve myelin, summarizes the progress on treatment with rituximab as a promising therapy, discusses the pitfalls of scales used, identifies possible biomarkers of response to therapy and highlights the promising new anti-B cell or target-specific immunotherapies.
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Affiliation(s)
- Marinos C Dalakas
- Neuroimmunology Unit, Department of Pathophysiology, National and Kapodistrian University of Athens Medical School, Athens, Greece
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Liu X, Treister R, Lang M, Oaklander AL. IVIg for apparently autoimmune small-fiber polyneuropathy: first analysis of efficacy and safety. Ther Adv Neurol Disord 2018; 11:1756285617744484. [PMID: 29403541 PMCID: PMC5791555 DOI: 10.1177/1756285617744484] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2017] [Accepted: 11/03/2017] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVES Small-fiber polyneuropathy (SFPN) has various underlying causes, including associations with systemic autoimmune conditions. We have proposed a new cause; small-fiber-targeting autoimmune diseases akin to Guillain-Barré and chronic inflammatory demyelinating polyneuropathy (CIDP). There are no treatment studies yet for this 'apparently autoimmune SFPN' (aaSFPN), but intravenous immunoglobulin (IVIg), first-line for Guillain-Barré and CIDP, is prescribed off-label for aaSFPN despite very high cost. This project aimed to conduct the first systematic evaluation of IVIg's effectiveness for aaSFPN. METHODS With IRB approval, we extracted all available paper and electronic medical records of qualifying patients. Inclusion required having objectively confirmed SFPN, autoimmune attribution and other potential causes excluded. IVIg needed to have been dosed at ⩾1 g/kg/4 weeks for ⩾3 months. We chose two primary outcomes - changes in composite autonomic function testing (AFT) reports of SFPN and in ratings of pain severity - to capture objective as well as patient-prioritized outcomes. RESULTS Among all 55 eligible patients, SFPN had been confirmed by 3/3 nerve biopsies, 62% of skin biopsies, and 89% of composite AFT. Evidence of autoimmunity included 27% of patients having systemic autoimmune disorders, 20% having prior organ-specific autoimmune illnesses and 80% having ⩾1/5 abnormal blood-test markers associated with autoimmunity. A total of 73% had apparent small-fiber-restricted autoimmunity. IVIg treatment duration averaged 28 ± 25 months. The proportion of AFTs interpreted as indicating SFPN dropped from 89% at baseline to 55% (p ⩽ 0.001). Sweat production normalized (p = 0.039) and the other four domains all trended toward improvement. Among patients with pre-treatment pain ⩾3/10, severity averaging 6.3 ± 1.7 dropped to 5.2 ± 2.1 (p = 0.007). Overall, 74% of patients rated themselves 'improved' and their neurologists labeled 77% as 'IVIg responders'; 16% entered remissions that were sustained after IVIg withdrawal. All adverse events were expected; most were typical infusion reactions. The two moderate complications (3.6%) were vein thromboses not requiring discontinuation. The one severe event (1.8%), hemolytic anemia, remitted after IVIg discontinuation. CONCLUSION These results provide Class IV, real-world, proof-of-concept evidence suggesting that IVIg is safe and effective for rigorously selected SFPN patients with apparent autoimmune causality. They provide rationale for prospective trials, inform trial design and indirectly support the discovery of small-fiber-targeting autoimmune/inflammatory illnesses.
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Affiliation(s)
- Xiaolei Liu
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, USA
- Department of Neurology, Dayi Hospital of Shanxi Medical University, China
| | - Roi Treister
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, USA; Faculty of Social Welfare and Health Sciences, University of Haifa, Haifa, Israel
| | - Magdalena Lang
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, USA
| | - Anne Louise Oaklander
- Department of Neurology, Massachusetts General Hospital, 275 Charles Street/Warren Building 310, Boston, MA 02114, USA
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Subcutaneous IgG for chronic inflammatory demyelinating polyneuropathy. Lancet Neurol 2018; 17:20-21. [DOI: 10.1016/s1474-4422(17)30379-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2017] [Accepted: 10/23/2017] [Indexed: 11/20/2022]
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Iro MA, Martin NG, Absoud M, Pollard AJ. Intravenous immunoglobulin for the treatment of childhood encephalitis. Cochrane Database Syst Rev 2017; 10:CD011367. [PMID: 28967695 PMCID: PMC6485509 DOI: 10.1002/14651858.cd011367.pub2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Encephalitis is a syndrome of neurological dysfunction due to inflammation of the brain parenchyma, caused by an infection or an exaggerated host immune response, or both. Attenuation of brain inflammation through modulation of the immune response could improve patient outcomes. Biological agents such as immunoglobulin that have both anti-inflammatory and immunomodulatory properties may therefore be useful as adjunctive therapies for people with encephalitis. OBJECTIVES To assess the efficacy and safety of intravenous immunoglobulin (IVIG) as add-on treatment for children with encephalitis. SEARCH METHODS The Cochrane Multiple Sclerosis and Rare Diseases of the CNS group's Information Specialist searched the following databases up to 30 September 2016: CENTRAL, MEDLINE, Embase, CINAHL, ClinicalTrials.gov, and the WHO ICTRP Search Portal. In addition, two review authors searched Science Citation Index Expanded (SCI-EXPANDED) & Conference Proceedings Citation Index - Science (CPCI-S) (Web of Science Core Collection, Thomson Reuters) (1945 to January 2016), Global Health Library (Virtual Health Library), and Database of Abstracts of Reviews of Effects (DARE). SELECTION CRITERIA Randomised controlled trials (RCTs) comparing IVIG in addition to standard care versus standard care alone or placebo. DATA COLLECTION AND ANALYSIS Two review authors independently selected articles for inclusion, extracted relevant data, and assessed quality of trials. We resolved disagreements by discussion among the review authors. Where possible, we contacted authors of included studies for additional information. We presented results as risk ratios (RR) or mean differences (MD) with 95% confidence intervals (CI). MAIN RESULTS The search identified three RCTs with 138 participants. All three trials included only children with viral encephalitis, one of these included only children with Japanese encephalitis, a specific form of viral encephalitis. Only the trial of Japanese encephalitis (22 children) contributed to the primary outcome of this review and follow-up in that study was for three to six months after hospital discharge. There was no follow-up of participants in the other two studies. We identified one ongoing trial.For the primary outcomes, the results showed no significant difference between IVIG and placebo when used in the treatment of children with Japanese encephalitis: significant disability (RR 0.75, 95% CI 0.22 to 2.60; P = 0.65) and serious adverse events (RR 1.00, 95% CI 0.07 to 14.05; P = 1.00).For the secondary outcomes, the study of Japanese encephalitis showed no significant difference between IVIG and placebo when assessing significant disability at hospital discharge (RR 1.00, 95% CI 0.60 to 1.67). There was no significant difference (P = 0.53) in Glasgow Coma Score at discharge between IVIG (median score 14; range 3 to 15) and placebo (median 14 score; range 7 to 15) in the Japanese encephalitis study. The median length of hospital stay in the Japanese encephalitis study was similar for IVIG-treated (median 13 days; range 9 to 21) and placebo-treated (median 12 days; range 6 to 18) children (P = 0.59).Pooled analysis of the results of the other two studies resulted in a significantly lower mean length of hospital stay (MD -4.54 days, 95% CI -7.47 to -1.61; P = 0.002), time to resolution of fever (MD -0.97 days, 95% CI -1.25 to -0.69; P < 0.00001), time to stop spasms (MD -1.49 days, 95% CI -1.97 to -1.01; P < 0.00001), time to regain consciousness (MD -1.10 days, 95% CI -1.48 to -0.72; P < 0.00001), and time to resolution of neuropathic symptoms (MD -3.20 days, 95% CI -3.34 to -3.06; P < 0.00001) in favour of IVIG when compared with standard care.None of the included studies reported other outcomes of interest in this review including need for invasive ventilation, duration of invasive ventilation, cognitive impairment, poor adaptive functioning, quality of life, number of seizures, and new diagnosis of epilepsy.The quality of evidence was very low for all outcomes of this review. AUTHORS' CONCLUSIONS The findings suggest a clinical benefit of adjunctive IVIG treatment for children with viral encephalitis for some clinical measures (i.e. mean length of hospital stay, time (days) to stop spasms, time to regain consciousness, and time to resolution of neuropathic symptoms and fever. For children with Japanese encephalitis, IVIG had a similar effect to placebo when assessing significant disability and serious adverse events.Despite these findings, the risk of bias in the included studies and quality of the evidence make it impossible to reach any firm conclusions on the efficacy and safety of IVIG as add-on treatment for children with encephalitis. Furthermore, the included studies involved only children with viral encephalitis, therefore findings of this review cannot be generalised to all forms of encephalitis. Future well-designed RCTs are needed to assess the efficacy and safety of IVIG in the management of children with all forms of encephalitis. There is a need for internationally agreed core outcome measures for clinical trials in childhood encephalitis.
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Affiliation(s)
- Mildred A Iro
- University of Oxford and the NIHR Oxford Biomedical Research CentreDepartment of PaediatricsChurchill Hospital, Old Road, HeadingtonOxfordUK
| | - Natalie G Martin
- Christchurch School of Medicine, University of OtagoDepartment of PaediatricsChristchurchNew Zealand
| | - Michael Absoud
- Evelina London Children's Hospital, Guy's and St Thomas' Hospital, King's Health PartnersChildren's Neurosciences CentreWestminster Bridge RoadLondonUKSE1 7EH
| | - Andrew J Pollard
- Children's HospitalDepartment of Paediatrics, University of OxfordOxfordUKOX3 9DU
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Kuwabara S, Mori M, Misawa S, Suzuki M, Nishiyama K, Mutoh T, Doi S, Kokubun N, Kamijo M, Yoshikawa H, Abe K, Nishida Y, Okada K, Sekiguchi K, Sakamoto K, Kusunoki S, Sobue G, Kaji R. Intravenous immunoglobulin for maintenance treatment of chronic inflammatory demyelinating polyneuropathy: a multicentre, open-label, 52-week phase III trial. J Neurol Neurosurg Psychiatry 2017; 88:832-838. [PMID: 28768822 PMCID: PMC5629934 DOI: 10.1136/jnnp-2017-316427] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2017] [Revised: 06/14/2017] [Accepted: 06/19/2017] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Short-term efficacy of induction therapy with intravenous immunoglobulin (Ig) in patients with chronic inflammatory demyelinating polyneuropathy (CIDP) is well established. However, data of previous studies on maintenance therapy were limited up to 24-week treatment period. We aimed to investigate the efficacy and safety of longer-term intravenous Ig therapy for 52 weeks. METHODS This study was an open-label phase 3 clinical trial conducted in 49 Japanese tertiary centres. 49 patients with CIDP who fulfilled diagnostic criteria were included. After an induction intravenous Ig therapy (0.4 g/kg/day for five consecutive days), maintenance dose intravenous Ig (1.0 g/kg) was given every 3 weeks for up to 52 weeks. The primary outcome measures were the responder rate at week 28 and relapse rate at week 52. The response and relapse were defined with the adjusted Inflammatory Neuropathy Cause and Treatment scale. RESULTS At week 28, the responder rate was 77.6% (38/49 patients; 95% CI 63% to 88%), and the 38 responders continued the maintenance therapy. At week 52, 4 of the 38 (10.5%) had a relapse (95% CI 3% to 25%). During 52 weeks, 34 (69.4%) of the 49 enrolled patients had a maintained improvement. Adverse events were reported in 94% of the patients; two patients (66-year-old and 76-year-old men with hypertension or diabetes) developed cerebral infarction (lacunar infarct with good recovery), and the other adverse effects were mild and resolved by the end of the study period. CONCLUSIONS Maintenance treatment with 1.0 g/kg intravenous Ig every 3 weeks is an efficacious therapy for patients with CIDP, and approximately 70% of them had a sustained remission for 52 weeks. Thrombotic complications should be carefully monitored, particularly in elderly patients with vascular risk factors. TRIAL REGISTRATION NUMBER ClinicalTrials.gov (NCT01824251).
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Affiliation(s)
- Satoshi Kuwabara
- Department of Neurology, Chiba University Hospital, Chiba, Japan
| | - Masahiro Mori
- Department of Neurology, Chiba University Hospital, Chiba, Japan
| | - Sonoko Misawa
- Department of Neurology, Chiba University Hospital, Chiba, Japan
| | - Miki Suzuki
- Department of Neurology, Tokyo Women's Medical University, Tokyo, Japan
| | - Kazutoshi Nishiyama
- Department of Neurology, Kitasato University School of Medicine, Sagamihara, Japan
| | - Tatsuro Mutoh
- Department of Neurology, Fujita Health University School of Medicine, Toyoake, Japan
| | - Shizuki Doi
- Department of Neurology, National Hospital Organization Hokkaido Medical Center, Sapporo, Japan
| | - Norito Kokubun
- Department of Neurology, Dokkyo Medical University, Tochigi, Japan
| | - Mikiko Kamijo
- Department of Neurology, Chubu Rosai Hospital, Nagoya, Japan
| | - Hiroo Yoshikawa
- Division of Neurology, Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya, Japan
| | - Koji Abe
- Department of Neurology, Okayama University School of Medicine, Okayama, Japan
| | | | - Kazumasa Okada
- Department of Neurology, University of Occupational and Environmental Health School of Medicine, Kitakyushu, Japan
| | - Kenji Sekiguchi
- Division of Neurology, Kobe University Graduate School of Medicine, Kobe, Japan
| | | | - Susumu Kusunoki
- Department of Neurology, Kindai University Faculty of Medicine, Osaka, Japan
| | - Gen Sobue
- Department of Neurology, Nagoya University School of Medicine, Nagoya, Japan
| | - Ryuji Kaji
- Department of Neurology, Tokushima University School of Medicine, Tokushima, Japan
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Immune Gamma Globulin Therapeutic Indications in Immune Deficiency and Autoimmunity. Curr Allergy Asthma Rep 2017; 16:55. [PMID: 27401913 DOI: 10.1007/s11882-016-0632-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Immune gamma globulin (IgG) has a long history in the treatment of both primary immune deficiency and autoimmune disorders. Disease indications continue to expand and new-generation products increase the versatility of delivery. This review encompasses a historical perspective as well as current and future implications of human immune globulin for the treatment of immune-mediated illness.
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Verboon C, van Doorn PA, Jacobs BC. Treatment dilemmas in Guillain-Barré syndrome. J Neurol Neurosurg Psychiatry 2017; 88:346-352. [PMID: 27837102 DOI: 10.1136/jnnp-2016-314862] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Revised: 10/21/2016] [Accepted: 10/27/2016] [Indexed: 12/28/2022]
Abstract
Guillain-Barré syndrome (GBS) is an acute polyradiculoneuropathy with a highly variable clinical course and outcome. Intravenous immunoglobulin (IVIg) and plasma exchange are proven effective treatments, but the efficacy has been demonstrated mainly on motor improvement in adults with a typical and severe form of GBS. In clinical practice, treatment dilemmas may occur in patients with a relatively mild presentation, variant forms of GBS, or when the onset of weakness was more than 2 weeks ago. Other therapeutic dilemmas may arise in patients who do not improve or even progress after initial treatment. We provide an overview of the current literature about therapeutic options in these situations, and additionally give our personal view that may serve as a basis for therapeutic decision-making.
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Affiliation(s)
| | | | - Bart C Jacobs
- Department of Neurology, Erasmus MC, Rotterdam, The Netherlands.,Immunology, Erasmus MC, Rotterdam, The Netherlands
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Tolerability and safety of Octagam® (IVIG): a post-authorization safety analysis of four non-interventional phase IV trials
. Int J Clin Pharmacol Ther 2017; 54:847-855. [PMID: 27719744 PMCID: PMC5095453 DOI: 10.5414/cp202782] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/19/2016] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE To evaluate the tolerability and safety of Octagam<sup>®</sup> 5% and 10% across all indications, ages, and treatment regimens, using data from four non-interventional post-authorization safety studies (PASS); this analysis was performed following changes in the preparation of raw material used to manufacture Octagam. METHODS All four studies included in- and out-patients prescribed Octagam for treatment of their medical condition. Physicians used case report forms to document baseline demographics, Octagam treatment details, and data on the efficacy of Octagam, and recorded all adverse drug reactions (ADRs) and other safety data. RESULTS Altogether 21,780 infusions of Octagam in 2,397 patients were included in our analysis. The most frequent indication for Octagam was secondary immunodeficiencies (SID; n = 1,368, 11,348 infusions), followed by primary immunodeficiencies (PID; n = 363; 3,923 infusions). During the individual patient observation, 83% of SID and 67% of PID patients were free of any infection. In up to 85% of all investigator assessments, Octagam was rated to have a favorable effect. In autoimmune diseases, investigators assessed Octagam as being beneficial in 70% (immune thrombocytopenia) up to 100% (Guillain-Barré syndrome), depending on the indication. The majority of patients (92%) tolerated Octagam treatment without any ADR. The overall incidence of reported ADRs was 1.0% for all infusions. The majority of ADRs were considered non-serious (93%) and mild or moderate (87%) in severity. No unexpected ADR signal was detected. CONCLUSIONS This analysis demonstrates that the changes in the preparation of raw material used to manufacture Octagam did not affect the safety profile of Octagam<sup>®</sup> 5% and 10%.
*At the time of study realization.
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Perez EE, Orange JS, Bonilla F, Chinen J, Chinn IK, Dorsey M, El-Gamal Y, Harville TO, Hossny E, Mazer B, Nelson R, Secord E, Jordan SC, Stiehm ER, Vo AA, Ballow M. Update on the use of immunoglobulin in human disease: A review of evidence. J Allergy Clin Immunol 2016; 139:S1-S46. [PMID: 28041678 DOI: 10.1016/j.jaci.2016.09.023] [Citation(s) in RCA: 391] [Impact Index Per Article: 48.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2015] [Revised: 09/12/2016] [Accepted: 09/23/2016] [Indexed: 12/20/2022]
Abstract
Human immunoglobulin preparations for intravenous or subcutaneous administration are the cornerstone of treatment in patients with primary immunodeficiency diseases affecting the humoral immune system. Intravenous preparations have a number of important uses in the treatment of other diseases in humans as well, some for which acceptable treatment alternatives do not exist. We provide an update of the evidence-based guideline on immunoglobulin therapy, last published in 2006. Given the potential risks and inherent scarcity of human immunoglobulin, careful consideration of its indications and administration is warranted.
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Affiliation(s)
- Elena E Perez
- Allergy Associates of the Palm Beaches, North Palm Beach, Fla.
| | - Jordan S Orange
- Department of Pediatrics, Section of Immunology Allergy and Rheumatology, Center for Human Immunobiology, Texas Children's Hospital and Baylor College of Medicine, Houston, Tex
| | - Francisco Bonilla
- Department of Pediatrics, Clinical Immunology Program, Children's Hospital Boston and Harvard Medical School, Boston, Mass
| | - Javier Chinen
- Department of Pediatrics, Section of Immunology Allergy and Rheumatology, Center for Human Immunobiology, Texas Children's Hospital and Baylor College of Medicine, Houston, Tex
| | - Ivan K Chinn
- Department of Pediatrics, Section of Immunology Allergy and Rheumatology, Center for Human Immunobiology, Texas Children's Hospital and Baylor College of Medicine, Houston, Tex
| | - Morna Dorsey
- Department of Pediatrics, Allergy, Immunology and BMT Division, Benioff Children's Hospital and University of California, San Francisco, Calif
| | - Yehia El-Gamal
- Department of Pediatrics, Pediatric Allergy and Immunology Unit, Children's Hospital and Ain Shams University, Cairo, Egypt
| | - Terry O Harville
- Departments of Pathology and Laboratory Services and Pediatrics, University of Arkansas, Little Rock, Ark
| | - Elham Hossny
- Department of Pediatrics, Pediatric Allergy and Immunology Unit, Children's Hospital and Ain Shams University, Cairo, Egypt
| | - Bruce Mazer
- Department of Pediatrics, Allergy and Immunology, Montreal Children's Hospital and McGill University, Montreal, Quebec, Canada
| | - Robert Nelson
- Department of Medicine and Pediatrics, Division of Hematology and Oncology and Stem Cell Transplantation, Riley Hospital, Indiana University School of Medicine and the IU Melvin and Bren Simon Cancer Center, Indianapolis, Ind
| | - Elizabeth Secord
- Department of Pediatrics, Wayne State University, Children's Hospital of Michigan, Detroit, Mich
| | - Stanley C Jordan
- Nephrology & Transplant Immunology, Kidney Transplant Program, David Geffen School of Medicine at UCLA and Cedars-Sinai Medical Center, Los Angeles, Calif
| | - E Richard Stiehm
- Department of Pediatrics, David Geffen School of Medicine at UCLA, Los Angeles, Calif
| | - Ashley A Vo
- Transplant Immunotherapy Program, Comprehensive Transplant Center, Kidney Transplant Program, Cedars-Sinai Medical Center, Los Angeles, Calif
| | - Mark Ballow
- Department of Pediatrics, Division of Allergy & Immunology, University of South Florida, Morsani College of Medicine, Johns Hopkins All Children's Hospital, St Petersburg, Fla
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Gürcan HM, Ahmed AR. Efficacy of Various Intravenous Immunoglobulin Therapy Protocols in Autoimmune and Chronic Inflammatory Disorders. Ann Pharmacother 2016; 41:812-23. [PMID: 17440006 DOI: 10.1345/aph.1k037] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
Objective: To determine the efficacy of various intravenous immunoglobulin (IVIG) protocols used in the treatment of autoimmune and chronic inflammatory disorders. Data Sources: Literature retrieval was accessed through MEDLINE (November 1984–March 2007) and a search was conducted using the term intravenous immunoglobulin. References cited in the selected articles were also reviewed. Study Selection and Data Extraction: Inclusion criteria for studies were (1) English language, (2) randomized controlled trials, (3) defined protocols, (4) a minimum of 15 patients, and (5) objective criteria provided to assess clinical outcomes and course. Data Synthesis: The therapeutic efficacy of IVIG therapy is well established, and defined protocols exist for treatment of Kawasaki disease, immune thrombocytopenic purpura, Guillain–Barré syndrome, chronic inflammatory demyelinating polyneuropathy, multifocal motor neuropathy, and autoimmune mucocutaneous blistering diseases. In the absence of a defined protocol, studies have demonstrated that IVIG therapy is effective in the treatment of myasthenia gravis, dermatomyositis, stiff person syndrome, antineutrophil cytoplasmic antibody positive systemic vasculitides, Graves' ophthalmopathy, and certain forms of systemic lupus erythematosus. It might also be of benefit in some patients with relapsing–remitting multiple sclerosis. The outcomes are variable in these studies. In toxic epidermal necrolysis and Stevens–Johnson syndrome, use of IVIG has dramatically influenced clinical response and reduced mortality. Conclusions: The cumulative evidence suggests that the clinical outcomes observed are significantly influenced by the use of a defined protocol. There is a need for multicenter trials approved by the Food and Drug Administration to better define the role of IVIG in many disease states. Such studies would be able to establish the indications for use, optimal dose, frequency of infusions, duration of therapy, and need for gradual withdrawal versus sudden cessation. Defined protocols resulting from the study of a large cohort of patients often convince insurance companies to create policies that provide access to IVIG therapy.
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Affiliation(s)
- Hakan M Gürcan
- Department of Medicine, Center for Blistering Diseases, New England Baptist Hospital, Boston, MA 02120, USA
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Meyer zu Horste G, Cordes S, Pfaff J, Mathys C, Mausberg AK, Bendszus M, Pham M, Hartung HP, Kieseier BC. Predicting the Response to Intravenous Immunoglobulins in an Animal Model of Chronic Neuritis. PLoS One 2016; 11:e0164099. [PMID: 27711247 PMCID: PMC5053527 DOI: 10.1371/journal.pone.0164099] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Accepted: 09/20/2016] [Indexed: 11/19/2022] Open
Abstract
Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) is a disabling autoimmune disorder of the peripheral nervous system (PNS). Intravenous immunoglobulins (IVIg) are effective in CIDP, but the treatment response varies greatly between individual patients. Understanding this interindividual variability and predicting the response to IVIg constitute major clinical challenges in CIDP. We previously established intercellular adhesion molecule (ICAM)-1 deficient non-obese diabetic (NOD) mice as a novel animal model of CIDP. Here, we demonstrate that similar to human CIDP patients, ICAM-1 deficient NOD mice respond to IVIg treatment by clinical and histological measures. Nerve magnetic resonance imaging and histology demonstrated that IVIg ameliorates abnormalities preferentially in distal parts of the sciatic nerve branches. The IVIg treatment response also featured great heterogeneity allowing us to identify IVIg responders and non-responders. An increased production of interleukin (IL)-17 positively predicted IVIg treatment responses. In human sural nerve biopsy sections, high numbers of IL-17 producing cells were associated with younger age and shorter disease duration. Thus, our novel animal model can be utilized to identify prognostic markers of treatment responses in chronic inflammatory neuropathies and we identify IL-17 production as one potential such prognostic marker.
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Affiliation(s)
- Gerd Meyer zu Horste
- Department of Neurology, Heinrich-Heine-University, Medical Faculty, Düsseldorf, Germany
- Department of Neurology, University Hospital Münster, Münster, Germany
| | - Steffen Cordes
- Department of Neurology, Heinrich-Heine-University, Medical Faculty, Düsseldorf, Germany
| | - Johannes Pfaff
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Christian Mathys
- Institute of Neuroradiology, Heinrich-Heine-University, Medical Faculty, Düsseldorf, Germany
| | - Anne K. Mausberg
- Department of Neurology, Heinrich-Heine-University, Medical Faculty, Düsseldorf, Germany
| | - Martin Bendszus
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Mirko Pham
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Hans-Peter Hartung
- Department of Neurology, Heinrich-Heine-University, Medical Faculty, Düsseldorf, Germany
| | - Bernd C. Kieseier
- Department of Neurology, Heinrich-Heine-University, Medical Faculty, Düsseldorf, Germany
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González P, García X, Guerra A, Arango J, Delgado H, Uribe C, Sará J, López de Mesa J, Hernández O. Experience with Guillain-Barré syndrome in a neurological Intensive Care Unit. NEUROLOGÍA (ENGLISH EDITION) 2016. [DOI: 10.1016/j.nrleng.2014.09.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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Azizi G, Abolhassani H, Asgardoon MH, Shaghaghi S, Negahdari B, Mohammadi J, Rezaei N, Aghamohammadi A. Managing patients with side effects and adverse events to immunoglobulin therapy. Expert Rev Clin Pharmacol 2015; 9:91-102. [PMID: 26496172 DOI: 10.1586/17512433.2016.1105131] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Immunoglobulin therapy has not only served as a lifesaving approach for the prevention and treatment of infections in primary and secondary immunodeficiency diseases, but has also been used as an immunomodulatory agent for autoimmune and inflammatory disorders and to provide passive immunity for some infectious diseases. Most of the adverse effects associated with immunoglobulin therapy are mild, transient and self-limiting. However, serious side effects also occur. Therefore, to minimize the adverse events of immunoglobulin therapy, specialist review of patient clinical status and immunoglobulin products, in addition to selection of appropriate treatment strategy for the management of patients with associated side effects and adverse events, are crucial.
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Affiliation(s)
- Gholamreza Azizi
- a Imam Hassan Mojtaba Hospital , Alborz University of Medical Sciences , Karaj , Iran.,b Research Center for Immunodeficiencies, Pediatrics Center of Excellence, Children's Medical Center , Tehran University of Medical Sciences , Tehran , Iran
| | - Hassan Abolhassani
- b Research Center for Immunodeficiencies, Pediatrics Center of Excellence, Children's Medical Center , Tehran University of Medical Sciences , Tehran , Iran.,c Division of Clinical Immunology, Department of Laboratory Medicine , Karolinska Institute at Karolinska University Hospital Huddinge , Stockholm , Sweden
| | - Mohammad Hossein Asgardoon
- b Research Center for Immunodeficiencies, Pediatrics Center of Excellence, Children's Medical Center , Tehran University of Medical Sciences , Tehran , Iran
| | - Shiva Shaghaghi
- b Research Center for Immunodeficiencies, Pediatrics Center of Excellence, Children's Medical Center , Tehran University of Medical Sciences , Tehran , Iran.,d Faculty of Medicine , Guilan University of Medical Sciences , Rasht , Iran
| | - Babak Negahdari
- e School of Advanced Technologies in Medicine, Department of Medical Biotechnology, Tehran University of Medical Sciences , Tehran , Iran
| | - Javad Mohammadi
- f Department of Biomedical Engineering, Faculty of New Sciences and Technologies, University of Tehran , Tehran , Iran
| | - Nima Rezaei
- b Research Center for Immunodeficiencies, Pediatrics Center of Excellence, Children's Medical Center , Tehran University of Medical Sciences , Tehran , Iran
| | - Asghar Aghamohammadi
- b Research Center for Immunodeficiencies, Pediatrics Center of Excellence, Children's Medical Center , Tehran University of Medical Sciences , Tehran , Iran
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Biomarkers of Guillain-Barré Syndrome: Some Recent Progress, More Still to Be Explored. Mediators Inflamm 2015; 2015:564098. [PMID: 26451079 PMCID: PMC4588351 DOI: 10.1155/2015/564098] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2015] [Revised: 08/23/2015] [Accepted: 08/24/2015] [Indexed: 12/14/2022] Open
Abstract
Guillain-Barré syndrome (GBS), the axonal subtype of which is mainly triggered by C. jejuni with ganglioside-mimicking lipooligosaccharides (LOS), is an immune-mediated disorder in the peripheral nervous system (PNS) accompanied by the disruption of the blood-nerve barrier (BNB) and the blood-cerebrospinal fluid barrier (B-CSF-B). Biomarkers of GBS have been extensively explored and some of them are proved to assist in the clinical diagnosis and in monitoring disease progression as well as in assessing the efficacy of immunotherapy. Herein, we systemically review the literature on biomarkers of GBS, including infection-/immune-/BNB, B-CSF-B, and PNS damage-associated biomarkers, aiming at providing an overview of GBS biomarkers and guiding further investigations. Furthermore, we point out further directions for studies on GBS biomarkers.
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Management of adverse events in the treatment of patients with immunoglobulin therapy: A review of evidence. Autoimmun Rev 2015; 15:71-81. [PMID: 26384525 DOI: 10.1016/j.autrev.2015.09.002] [Citation(s) in RCA: 83] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Accepted: 09/08/2015] [Indexed: 12/12/2022]
Abstract
Immunoglobulin (IG) therapy is actually used for a broad range of diseases including primary and secondary immunodeficiency disorders, and autoimmune diseases. This therapy is available for intravenous (IV) and subcutaneous (SC) administration. The efficacy of the IG therapy has been demonstrated in numerous studies and across different diseases. Generally, IG infusions are well tolerated; however some well-known adverse reactions, ranging from mild to severe, are associated with the therapy. The most common adverse reactions including headache, nausea, myalgia, fever, chills, chest discomfort, skin and anaphylactic reactions, could arise immediately during or after the infusion. Delayed events could be more severe and include migraine headaches, aseptic meningitis, haemolysis renal impairment and thrombotic events. This paper reviews all the potential adverse events related to IG therapy and establishes a comprehensive guideline for the management of these events. Moreover it resumes the opinions and clinical experience of expert endorsers on the utilization of the treatment. Published data were classified into levels of evidence and the strength of the recommendation was given for each intervention according to the GRADE system.
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González P, García X, Guerra A, Arango JC, Delgado H, Uribe CS, Sará J, López de Mesa JC, Hernández O. Experience with Guillain-Barré syndrome in a neurological Intensive Care Unit. Neurologia 2014; 31:389-94. [PMID: 25542501 DOI: 10.1016/j.nrl.2014.09.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2014] [Revised: 05/05/2014] [Accepted: 09/06/2014] [Indexed: 10/24/2022] Open
Abstract
INTRODUCTION Guillain-Barré syndrome, an acute polyradiculoneuropathy that presents with weakness and areflexia, is the most common cause of acute flaccid paralysis. In certain patients, respiratory failure is secondary to this disorder, eventually causing patients to require mechanical ventilation and experience additional complications due to diminished respiratory support and related mobility limitations. Prognoses for most of these cases are positive; treatment consists of basic support combined with plasmapheresis or administration of immunoglobulins. OBJECTIVE This study sought to describe the socio-demographic, clinical, laboratory and neurophysiological characteristics of patients with Guillain-Barré syndrome who were hospitalised in the Intensive Care Unit of the Neurological Institute of Colombia between 2006 and 2012. METHODOLOGY This study presents a case series. RESULTS We surveyed 25 patients (32% female and 68% male) with Guillain-Barré syndrome and an average age of 54 years. Sixty per cent of these patients were admitted between days 3 and 7 after symptom onset; 64% had a history of respiratory infection and 20% had a history of intestinal infection. In addition, 84% of the patients presented with albuminocytological dissociation. We observed the following clinical subtypes of Guillain-Barré syndrome: inflammatory demyelinating polyneuropathy in 32%, acute motor-sensory axonal neuropathy in 28%, acute motor axonal neuropathy in 28%, and Miller Fisher syndrome in 12%. CONCLUSIONS In this descriptive study of a group of critical care patients with GBS, results depended on patients' clinical severity at time of admission. Our findings are similar to results published in the international literature.
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Affiliation(s)
- P González
- Servicio de Neurología, Universidad de Antioquia, Medellín, Antioquia, Colombia.
| | - X García
- Neuróloga, Universidad Nacional de Bogotá
| | - A Guerra
- Servicio de Neurología, Universidad de Antioquia, Medellín, Antioquia, Colombia; Neuróloga, Universidad Nacional de Bogotá; Profesor de Neurología, Universidad de Antioquia, Neurólogo UCI INDEC; Intensivistas, Unidad de Cuidados Intensivos, INDEC, Medellín, Antioquia, Colombia
| | - J C Arango
- Servicio de Neurología, Universidad de Antioquia, Medellín, Antioquia, Colombia; Neuróloga, Universidad Nacional de Bogotá; Profesor de Neurología, Universidad de Antioquia, Neurólogo UCI INDEC; Intensivistas, Unidad de Cuidados Intensivos, INDEC, Medellín, Antioquia, Colombia
| | - H Delgado
- Servicio de Neurología, Universidad de Antioquia, Medellín, Antioquia, Colombia; Neuróloga, Universidad Nacional de Bogotá; Profesor de Neurología, Universidad de Antioquia, Neurólogo UCI INDEC; Intensivistas, Unidad de Cuidados Intensivos, INDEC, Medellín, Antioquia, Colombia
| | - C S Uribe
- Profesor de Neurología, Universidad de Antioquia, Neurólogo UCI INDEC
| | - J Sará
- Servicio de Neurología, Universidad de Antioquia, Medellín, Antioquia, Colombia; Neuróloga, Universidad Nacional de Bogotá; Profesor de Neurología, Universidad de Antioquia, Neurólogo UCI INDEC; Intensivistas, Unidad de Cuidados Intensivos, INDEC, Medellín, Antioquia, Colombia
| | - J C López de Mesa
- Servicio de Neurología, Universidad de Antioquia, Medellín, Antioquia, Colombia; Neuróloga, Universidad Nacional de Bogotá; Profesor de Neurología, Universidad de Antioquia, Neurólogo UCI INDEC; Intensivistas, Unidad de Cuidados Intensivos, INDEC, Medellín, Antioquia, Colombia
| | - O Hernández
- Intensivistas, Unidad de Cuidados Intensivos, INDEC, Medellín, Antioquia, Colombia
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Severe periodontal disease associated with long-term treatment with intravenous immunoglobulin. Case Rep Dent 2014; 2014:860804. [PMID: 25379295 PMCID: PMC4213401 DOI: 10.1155/2014/860804] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2014] [Accepted: 09/18/2014] [Indexed: 02/02/2023] Open
Abstract
Intravenous immunoglobulin (IVIG) is used in the treatment of neuropathy. This case report presents, for the first time, a patient with severe periodontal destruction after chronic therapy with IVIG. The patient reported having extracted his maxillary anterior teeth himself due to high mobility. Clinical examination and radiographic images show a generalized and severe periodontitis. No significant alterations in genetic or microbiological features were observed. The present case suggests that periodontal disease aggravation could be considered a new adverse effect of IVIG therapy. Postulated mechanisms are immune complexes formation, complement activation, and a direct effect in osteoclasts. In conclusion, it is important that patients that will receive IVIG treatment underwent dental evaluation.
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Iro MA, Martin NG, Absoud M, Pollard AJ. Intravenous immunoglobulin for the treatment of childhood encephalitis. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2014. [DOI: 10.1002/14651858.cd011367] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Abstract
The advent of biologics in dermatologic treatment armentarium has added refreshing dimensions, for it is a major breakthrough. Several agents are now available for use. It is therefore imperative to succinctly comprehend their pharmacokinetics for their apt use. A concerted endeavor has been made to delve on this subject. The major groups of biologics have been covered and include: Drugs acting against TNF-α, Alefacept, Ustekinumab, Rituximab, IVIG and Omalizumab. The relevant pharmacokinetic characteristics have been detailed. Their respective label (approved) and off-label (unapproved) indications have been defined, highlighting their dosage protocol, availability and mode of administration. The evidence level of each indication has also been discussed to apprise the clinician of their current and prospective uses. Individual anti-TNF drugs are not identical in their actions and often one is superior to the other in a particular disease. Hence, the section on anti-TNF agents mentions the literature on each drug separately, and not as a group. The limitations for their use have also been clearly brought out.
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Affiliation(s)
- Virendra N Sehgal
- Dermato-Venereology (Skin/VD) Center, Sehgal Nursing Home, Delhi, India
| | - Deepika Pandhi
- Department of Dermatology and STD, University College of Medical Sciences and Associated Guru Teg Bahadur Hospital, Delhi, India
| | - Ananta Khurana
- Department of Dermatology and STD, University College of Medical Sciences and Associated Guru Teg Bahadur Hospital, Delhi, India
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