Infections in multiple myeloma

Descriptive Characteristics of Multiple Myeloma Patients in King Abdulaziz Medical City National Guard

Background Multiple myeloma (MM) is a hematological malignancy characterized by the production of monoclonal immunoglobulin. It is the second-most common hematological malignancy. The survival rate varies depending on age at diagnosis, comorbidities, and treatment.This study aims to assess the prevalence of clinical and laboratory characteristics among multiple myeloma patients. Methods This is an observational study of multiple myeloma patients who were admitted to King Abdulaziz Medical City - National Guard between January 2015 and December 2020. Patient records were reviewed to derive clinical and laboratory characteristics. Descriptive data analysis and survival analysis were obtained using SPSS. Results Our study included 151 patients, 95 of whom were males and 56 were females, and the mean age of diagnosis with MM was 62.6 (SD = 13.4). Among 151 MM patients, the most common clinical signs were bone lesions and renal disease, with a percentage of 66.9% and 46.4%, respectively. Death rates throughout the time of study conduction were 19.2%, accounting for 29 patients, and the median overall survival was 5.1 years with a 95% confidence level. Testing the association between survival rates and gender showed that death rates in females were significantly higher than in males (p-value = 0.023). Patients with anemia had a significantly higher hazard ratio in both unadjusted and adjusted analyses (aHR = 2.61; 95% CI = 1.21-5.65). Conclusion There was a relationship between survival and gender, which suggests a protective factor favoring the male gender. Clinical and laboratory characteristics, including bone marrow lesions, anemia, and renal disease, were the initial presentation; thus, a detailed history focused on symptoms should be taken when any of these symptoms are reported.

BACTERIAL MENINGITIS IN PATIENTS WITH MULTIPLE MYELOMA: A PROSPECTIVE NATIONWIDE COHORT STUDY AND REVIEW OF THE LITERATURE

OBJECTIVE

To study the clinical features of bacterial meningitis in myeloma patients.

METHODS

We analyzed myeloma patients included in a nationwide cohort of patients >16 years old with community-acquired bacterial meningitis in the Netherlands between 2006 and 2018. Subsequently, we reviewed the literature for articles reporting myeloma patients with bacterial meningitis.

RESULTS

A total of 27 of 2306 (1.6%) episodes of bacterial meningitis occurred in myeloma patients. Six of 27 (22%) patients received stem cell transplantation. CSF showed a median leukocyte count of 172/µL and 12 (46%) of 26 patients had a CSF leukocyte count <100/µL. Streptococcus pneumoniae was the causative pathogen in 25 (93%) patients. Fourteen (52%) patients had unfavorable outcome of whom 10 (37%) died. Ninety-one myeloma patients with bacterial meningitis were described in the literature. The most common pathogen in these patients was S. pneumoniae (35 of 48; 73%) and four (20%) of 20 cases died.

CONCLUSION

Bacterial meningitis in patients with multiple myeloma is a severe disease with high rates of unfavorable outcome. Patients often present with a low CSF leukocyte count compared to bacterial meningitis in patients without multiple myeloma. Physicians should have a low threshold to perform a lumbar puncture in myeloma patients and start antibiotic treatment pending CSF chemistry and culture results.

Increased Length of Stay Associated With Antibiotic Use in Older Adults With Advanced Cancer Transitioned to Comfort Measures

BACKGROUND

Antibiotic use may increase hospital length of stay (LOS) among older patients with advanced cancer who are transitioned to comfort measures.

METHODS

We studied a cohort of patients with advanced cancer aged ≥65 years who were transitioned to comfort measures during admission from July 1, 2014, through November 30, 2016. We evaluated the association between antibiotic exposure and LOS using a Poisson regression model adjusted for age, gender, cancer type, comorbidities, infection, and intensive care unit admission.

RESULTS

Among 461 patients with advanced cancer, median age was 74 years (range: 65-99), 49.0% (n = 226) were female, and 20.6% (n = 95) had liquid tumors. Overall, 82.9% (n = 382) received ≥1 antibiotic and 64.6% (n = 298) had ≥1 infection diagnosis during hospitalization. Infection diagnoses commonly included sepsis (35%, n = 161/461), pneumonia (25%, n = 117/461), and urinary tract infection (14%, n = 66/461). Among those receiving antibiotics, the most common choices included vancomycin (79%, n = 300/382), cephalosporins (63%, n = 241/382), and penicillins (45%, n = 172/382). In a multivariable Poisson regression model, LOS was 34% longer (count ratio = 1.34, [95% confidence interval: 1.20-1.51]) among those exposed versus unexposed to antibiotics.

CONCLUSIONS

Antibiotic use among patients with advanced cancer who are transitioned to comfort measures is associated with longer LOS. These data illustrate the importance of tradeoffs associated with antibiotic use, such as unintended increased LOS, when striving for goal-concordant care near the end of life.

Changing treatment paradigms for patients with plasma cell myeloma: impact upon immune determinants of infection

Plasma cell myeloma (PCM) is increasing in prevalence in older age groups and infective complications are a leading cause of mortality. Patients with PCM are at increased risk of severe infections, having deficits in many arms of the immune system due to disease and treatment-related factors. Treatment of PCM has evolved over time with significant impacts on immune function resulting in changing rates and pattern of infection. Recently, there has been a paradigm shift in the treatment of PCM with the use of immunomodulatory drugs and proteasome inhibitors becoming the standard of care. These drugs have wide-ranging effects on the immune system but their impact on infection risk and aetiology remain unclear. The aims of this review are to discuss the impact of patient, disease and treatment factors on immune function over time for patients with PCM and to correlate immune deficits with the incidence and aetiology of infections seen clinically in these patients. Preventative measures and the need for clinically relevant tools to enable infective profiling of patients with PCM are discussed.

Epidemiology of infections in cancer patients

Although major advances in the care of cancer patients over the past several decades have resulted in improved survival, infectious complications remain a significant cause of morbidity and mortality. To successfully identify, treat, and prevent infections, a comprehensive understanding of risk factors that predispose to infection and of commonly encountered pathogens is necessary. In addition, clinicians must keep abreast of the changing epidemiology of infections in this population. As therapeutic modalities continue to evolve, as established pathogens become increasingly drug resistant, and as new pathogens are discovered, successful management of infections will continue to present challenges in the years to come.

Characterization of the Toll-like receptor expression profile in human multiple myeloma cells

Expression and function of Toll-like receptors (TLRs) in multiple myeloma (MM) has recently become the focus of several studies. Knowledge of expression and biology of these receptors in MM will provide us with a new insight into the role of an inflammatory environment in disease progression or pathogenesis of MM. However, to date a quite heterogeneous expression pattern of TLRs in MM particularly at gene level has been described while information on the TLR expression at the protein level is largely unavailable. In this study, we investigated the TLR expression in human myeloma cell lines (HMCLs) Fravel, L363, UM6, UM9, OPM1, OPM2, U266, RPMI 8226, XG1, and NCI H929 and primary cells from MM patients at both mRNA and protein level (western blot and flow cytometry). We found that all cell lines and primary cells expressed TLR1, TLR3, TLR4, TLR7, TLR8, and TLR9 mRNA and protein. TLR2 and TLR5 were expressed by the majority of HMCLs at mRNA but were not detectable at protein level, while primary samples showed a low level of TLR2, TLR3 and TLR5 protein expression. Our results indicate that MM cells express a broad range of TLRs with a degree of disparity between gene and protein expression pattern. The clear expression of TLRs in MM cells indicates a propensity for responding to tumor-induced inflammatory signals, which seem inevitable in the MM bone marrow environment.

Diagnosis and management of infectious complications in critically ill patients with cancer

Cancer and its treatments lead to profound suppression of innate and acquired immune function. In this population, bacterial infections are common and may rapidly lead to overwhelming sepsis and death. Furthermore, infections caused by viral and fungal pathogens should be considered in patients who have specific immune defects. As cancer therapies have become more aggressive the risk for infection has increased and many patients require intensive care support. Despite improvements in long-term survival, infections remain a common complication of cancer therapy and accounts for the majority of chemotherapy-associated deaths. By understanding the host defense impairments and likely pathogens clinicians will be better able to guide diagnosis and management of this unique population.

Multiple myeloma in 16 cats: a retrospective study

BACKGROUND

There is limited published information regarding feline multiple myeloma. Diagnostic criteria are derived from canine studies and to our knowledge, have not been critically reviewed for cats.

OBJECTIVE

To evaluate the clinical and laboratory findings in cats with multiple myeloma and appraise diagnostic criteria.

METHODS

Retrospective evaluation of medical records was performed. Inclusion required an antemortem diagnosis of multiple myeloma using 2 of 4 criteria: 1) >or=20% plasma cells in the bone marrow, or >or=10% if atypical plasma cells; 2) paraproteinemia; 3) radiographically-evident osteolysis; 4) light chain proteinuria. Alternatively, a postmortem diagnosis was based on the findings of multiple plasma cell neoplasms, with marrow involvement.

RESULTS

Sixteen cats were diagnosed with multiple myeloma between 1996 and 2004, with a median age of 14.0 years; 9 of 16 (56%) were castrated males, and 7 of 16 (44%) were spayed females. Laboratory abnormalities included hyperglobulinemia (14/16, 87.5%), with 11/14 (78.5%) monoclonal and 3/14 (21.4%) biclonal gammopathies; hypoalbuminemia (4/16, 25%); light chain proteinuria, (4/9, 44.4%); hypocholesterolemia (11/16, 68.7%); hypercalcemia, (3/15, 20%); nonregenerative anemia, (11/16, 68.7%); regenerative anemia, (1/16, 6.2%); neutropenia (5/15, 33.3%); thrombocytopenia (8/16, 50%); and marrow plasmacytosis (14/15, 93.3%). Plasma cells were markedly immature, atypical, or both in 10 of 12 (83.3%) cats. Focal or multifocal osteolysis was noted in 6 of 12 (50%) cats for which radiographs were available for review; generalized osteopenia was found in 1 (8.3%) cat. Noncutaneous, extramedullary tumors were found in all cats assessed, 7/7 (100%), including spleen (6), liver (3), and lymph nodes (4). The disease in 1 of 2 cats with cutaneous tumors progressed to plasmacytic leukemia.

CONCLUSIONS

Common findings in feline multiple myeloma include atypical plasma cell morphology, hypocholesterolemia, anemia, bone lesions, and multi-organ involvement. Based on the results of this study, we advocate modifying diagnostic criteria in cats to include consideration of plasma cell morphology and visceral organ infiltration.

Invasive fungal infections are responsible for one-fifth of the infectious deaths in children with ALL

The following report will discuss in detail all lethal invasive fungal infections (IFI) that occurred in a group of 2021 children with acute lymphoblasic leukaemia (ALL). The German ALL-Berlin-Frankfurt-Muenster (BFM) study group is one of the largest cooperation for the treatment of childhood ALL. Between 1995 and 2000, 2021 children with ALL received chemotherapy according to the German BFM 95 protocols (ALL-BFM 95). This population was retrospectively screened, whether a lethal fungal infection occurred: totally, in this group, 43 of 2021 (2.1%) children died because of infections. Nine of 43 (21%) patients died in the context of an IFI: six fatal Aspergillus infections and three fatal yeast infections were reported. The following report will focus on the nine children with ALL who died from IFI. The underlying risk factors (RF) included neutropenia (seven of nine patients) and steroid medication (nine of nine patients). Seven of nine children had additional medical complications (e.g. liver failure, haemolytic uraemic syndrome and acute renal failure). In six of nine children the fungal infection was progressive despite intravenous antimycotic therapy, three patients received no antifungal therapy, as IFI was not considered. The progression of IFI despite antimycotic therapy illustrates the inherent problems of diagnosis and the need for innovative therapeutic modalities. The high percentage (21%) of death from IFI among lethal infections in paediatric ALL patients illustrates the relevance of fungi in this group of patients. On the contrary, the total number of IFI in paediatric ALL patients remains to be determined, as only lethal infections were included in this report.

Immune suppression and considerations for dental care

Immunocompromised individuals present a challenge to oral health care providers. As the spectrum of patients with dysfunctional immune responses continues to broaden, practitioners should be able to identify these patients, understand the potential for complications, and manage their dental care safely and effectively. This article reviews various immune deficiencies, addresses complications that may result from an individual's immune status, and discusses dental considerations for these patients.