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Athni TS, Barmettler S. Hypogammaglobulinemia, late-onset neutropenia, and infections following rituximab. Ann Allergy Asthma Immunol 2023; 130:699-712. [PMID: 36706910 PMCID: PMC10247428 DOI: 10.1016/j.anai.2023.01.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 12/23/2022] [Accepted: 01/16/2023] [Indexed: 01/26/2023]
Abstract
Rituximab is a chimeric anti-CD20 monoclonal antibody that targets CD20-expressing B lymphocytes, has a well-defined efficacy and safety profile, and is broadly used to treat a wide array of diseases. In this review, we cover the mechanism of action of rituximab and focus on hypogammaglobulinemia and late-onset neutropenia-2 immune effects secondary to rituximab-and subsequent infection. We review risk factors and highlight key considerations for immunologic monitoring and clinical management of rituximab-induced secondary immune deficiencies. In patients treated with rituximab, monitoring for hypogammaglobulinemia and infections may help to identify the subset of patients at high risk for developing poor B cell reconstitution, subsequent infections, and adverse complications. These patients may benefit from early interventions such as vaccination, antibacterial prophylaxis, and immunoglobulin replacement therapy. Systematic evaluation of immunoglobulin levels and peripheral B cell counts by flow cytometry, both at baseline and periodically after therapy, is recommended for monitoring. In addition, in those patients with prolonged hypogammaglobulinemia and increased infections after rituximab use, immunologic evaluation for inborn errors of immunity may be warranted to further risk stratification, increase monitoring, and assist in therapeutic decision-making. As the immunologic effects of rituximab are further elucidated, personalized approaches to minimize the risk of adverse reactions while maximizing benefit will allow for improved care of patients with decreased morbidity and mortality.
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Affiliation(s)
| | - Sara Barmettler
- Allergy and Clinical Immunology Unit, Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Boston, Massachusetts.
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2
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Wagner JN, Leibetseder A, Troescher A, Panholzer J, von Oertzen TJ. Characteristics and therapy of enteroviral encephalitis: case report and systematic literature review. Int J Infect Dis 2021; 113:93-102. [PMID: 34628025 DOI: 10.1016/j.ijid.2021.10.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 09/24/2021] [Accepted: 10/02/2021] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVES Enterovirus (EV) is a frequent cause of encephalitis. The optimal therapeutic approach remains a matter of debate. We present the case of an immunosuppressed patient with EV encephalitis treated successfully with intravenous immunoglobulin (IVIG) and report the results of a systematic review on the characteristics of EV encephalitis, as well as the safety and efficacy of IVIG therapy. METHODS A systematic review was conducted using the PubMed, Cochrane Database, BIOSIS Previews, and ClinicalTrials.gov databases to identify all reports on patients with EV encephalitis as of December 31, 2020. The main outcomes assessed were the efficacy and safety of the respective therapeutic approach. RESULTS A total of 73 articles were included: one prospective trial, one retrospective and prospective case series, one purely retrospective case series, and 70 case reports. The case reports included a total of 101 patients. Immunosuppressed patients were at higher risk of contracting EV encephalitis and experiencing a fatal course. Hypogammaglobulinaemia particularly predisposes to EV disease, even with a moderate reduction in serum IgG levels. IVIG therapy in the immunosuppressed may confer a survival advantage. CONCLUSIONS IVIG therapy is rarely associated with severe adverse events and may be considered in immunosuppressed patients with EV encephalitis. Future trials should investigate the optimal IVIG dosing and route of application, the benefit of antibody-enriched IVIG preparations, and the serum immunoglobulin level that should trigger prophylactic replacement.
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Affiliation(s)
- Judith N Wagner
- Department of Neurology 1, Kepler University Hospital, Johannes Kepler University Linz, Wagner-Jauregg-Weg 15, 4020 Linz, Austria.
| | - Annette Leibetseder
- Department of Neurology 1, Kepler University Hospital, Johannes Kepler University Linz, Wagner-Jauregg-Weg 15, 4020 Linz, Austria
| | - Anna Troescher
- Department of Neurology 1, Kepler University Hospital, Johannes Kepler University Linz, Wagner-Jauregg-Weg 15, 4020 Linz, Austria
| | - Juergen Panholzer
- Department of Neurology 1, Kepler University Hospital, Johannes Kepler University Linz, Wagner-Jauregg-Weg 15, 4020 Linz, Austria
| | - Tim J von Oertzen
- Department of Neurology 1, Kepler University Hospital, Johannes Kepler University Linz, Wagner-Jauregg-Weg 15, 4020 Linz, Austria
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3
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Enterovirus A71 causing meningoencephalitis and acute flaccid myelitis in a patient receiving rituximab. J Neuroimmunol 2021; 358:577639. [PMID: 34214953 DOI: 10.1016/j.jneuroim.2021.577639] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 06/15/2021] [Accepted: 06/21/2021] [Indexed: 11/23/2022]
Abstract
We present the case of a young woman being treated with rituximab for rheumatoid arthritis who developed a severe enteroviral meningoencephalitis and acute flaccid myelitis (AFM). Cerebrospinal fluid (CSF) and stool reverse transcription-polymerase chain reaction (RT-PCR) testing confirmed the diagnosis and additional sequencing studies performed at the CDC further characterized the enterovirus as enterovirus A71 (EV-A71). After treatment with intravenous immunoglobulin (IVIg) and fluoxetine (based on previous reports of possible efficacy) the patient experienced a remarkable improvement over time. This case highlights the importance of considering enteroviral infection in patients treated with rituximab, depicts a possible clinical course of enteroviral meningoencephalitis and AFM, and illustrates the importance of testing multiple sites for enterovirus infection (CSF, stool, nasopharyngeal swab, blood). Here we present the case with a brief review of the literature pertaining to EV-A71.
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Higer M, Cana D, Podlech J, Schadmand-Fischer S, Schwarting A, Teschner D, Theobald M, Wölfel T, Hess G. Life-threatening disseminated enterovirus infection during combined rituximab and ibrutinib maintenance treatment for mantle cell lymphoma: a case report. J Med Case Rep 2020; 14:135. [PMID: 32859260 PMCID: PMC7456041 DOI: 10.1186/s13256-020-02457-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Accepted: 07/15/2020] [Indexed: 11/10/2022] Open
Abstract
Background Rituximab is a well-established component of treatment regimens for B-cell non-Hodgkin lymphoma. Rituximab binds the CD20 antigen on the surface of B lymphocytes, causing an enhanced clearance of malignant and benign B cells. Thus, rituximab leads to depletion of normal B lymphocytes as well, which can cause substantial immunodeficiency. Ibrutinib inhibits the Bruton tyrosine kinase and thereby B-cell activity. It is used for the treatment of different B-lymphocyte malignancies, such as mantle cell lymphoma. Recently, the combination of both drugs has been tested in various clinical scenarios. Case presentation We present a case of disseminated enterovirus infection resulting from combined rituximab and ibrutinib maintenance treatment in a 57-year-old Caucasian patient. with mantle cell lymphoma. Initially presenting with myositis symptoms, further diagnostic investigation revealed myocarditis, enteritis, myeloencephalitis, and hepatitis. These organ manifestations led to potentially life-threatening complications such as rhabdomyolysis, delirium, and heart rhythm disturbances. After treatment with high-dose intravenous immunoglobulins, virus clearance was achieved and organ functions could be restored. Conclusions This case emphasizes the risk of combined therapy with rituximab/ibrutinib for severe immune-related side effects with the necessity of continuous patient monitoring. High-dose intravenous therapy should be considered as treatment for severe enterovirus infection. In severe enterovirus infections, we recommend subtyping for the development of efficient preventive and therapeutic strategies.
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Affiliation(s)
- Maximilian Higer
- Department of Hematology, Medical Oncology & Pneumology, University Medical Center of the Johannes Gutenberg-University, Langenbeckstrasse 1, D-55131, Mainz, Germany.
| | - Denis Cana
- Division of Neuropathology, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Juergen Podlech
- Institute for Virology, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Simin Schadmand-Fischer
- Department of Diagnostic and Interventional Radiology, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Andreas Schwarting
- Department of Internal Medicine I (Gastroenterology, Hepatology, Nephrology, Rheumatology, Infectiology and Immunology), University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Daniel Teschner
- Department of Hematology, Medical Oncology & Pneumology, University Medical Center of the Johannes Gutenberg-University, Langenbeckstrasse 1, D-55131, Mainz, Germany
| | - Matthias Theobald
- Department of Hematology, Medical Oncology & Pneumology, University Medical Center of the Johannes Gutenberg-University, Langenbeckstrasse 1, D-55131, Mainz, Germany
| | - Thomas Wölfel
- Department of Hematology, Medical Oncology & Pneumology, University Medical Center of the Johannes Gutenberg-University, Langenbeckstrasse 1, D-55131, Mainz, Germany
| | - Georg Hess
- Department of Hematology, Medical Oncology & Pneumology, University Medical Center of the Johannes Gutenberg-University, Langenbeckstrasse 1, D-55131, Mainz, Germany
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Davis JS, Ferreira D, Paige E, Gedye C, Boyle M. Infectious Complications of Biological and Small Molecule Targeted Immunomodulatory Therapies. Clin Microbiol Rev 2020; 33:e00035-19. [PMID: 32522746 PMCID: PMC7289788 DOI: 10.1128/cmr.00035-19] [Citation(s) in RCA: 63] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
The past 2 decades have seen a revolution in our approach to therapeutic immunosuppression. We have moved from relying on broadly active traditional medications, such as prednisolone or methotrexate, toward more specific agents that often target a single receptor, cytokine, or cell type, using monoclonal antibodies, fusion proteins, or targeted small molecules. This change has transformed the treatment of many conditions, including rheumatoid arthritis, cancers, asthma, and inflammatory bowel disease, but along with the benefits have come risks. Contrary to the hope that these more specific agents would have minimal and predictable infectious sequelae, infectious complications have emerged as a major stumbling block for many of these agents. Furthermore, the growing number and complexity of available biologic agents makes it difficult for clinicians to maintain current knowledge, and most review articles focus on a particular target disease or class of agent. In this article, we review the current state of knowledge about infectious complications of biologic and small molecule immunomodulatory agents, aiming to create a single resource relevant to a broad range of clinicians and researchers. For each of 19 classes of agent, we discuss the mechanism of action, the risk and types of infectious complications, and recommendations for prevention of infection.
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Affiliation(s)
- Joshua S Davis
- Department of Infectious Diseases and Immunology, John Hunter Hospital, Newcastle, NSW, Australia
- Global and Tropical Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, NT, Australia
- School of Medicine and Public Health, University of Newcastle, Newcastle, NSW, Australia
| | - David Ferreira
- School of Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Emma Paige
- Department of Infectious Diseases, Alfred Hospital, Melbourne, VIC, Australia
| | - Craig Gedye
- School of Medicine, University of New South Wales, Sydney, NSW, Australia
- Department of Oncology, Calvary Mater Hospital, Newcastle, NSW, Australia
| | - Michael Boyle
- Department of Infectious Diseases and Immunology, John Hunter Hospital, Newcastle, NSW, Australia
- School of Medicine and Public Health, University of Newcastle, Newcastle, NSW, Australia
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6
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Maillet F, Pineton De Chambrun M, Monzani Q, Mercy G, Schuffenecker I, Mirand A, Deback C, Charlotte F, Fourniols E, Mathian A, Amoura Z. [Enteroviral infections in adults treated with rituximab: A new case of chronic meningitis and myofasciitis and literature review]. Rev Med Interne 2020; 41:200-205. [PMID: 31980187 DOI: 10.1016/j.revmed.2019.12.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Revised: 12/07/2019] [Accepted: 12/23/2019] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Chronic enterovirus infections can occur in primary immunodeficiency with hypogammaglobulinemia. They usually associate meningitis and myofasciitis. Such infections have also been described in adults with rituximab-induced hypogammaglobulinemia. CASE REPORT We report the case of a 33-year-old woman who was given rituximab for immune thrombocytopenia and developed rituximab-induced hypogammaglobulinemia (IgG 4.4g/L). One year after the last rituximab infusion, she developed lower limbs myofasciitis, followed two months later by a chronic lymphocytic meningitis. PCR in the serum and the cerebrospinal fluid at the time of the meningitis and the myofasciitis were positive to the same enterovirus (echovirus 11) while it was negative in the fascia biopsy. Under treatment with intravenous immunoglobulins, all symptoms and laboratory abnormalities improved and enterovirus PCR became negative. CONCLUSION We report a case of chronic enterovirus infection associating meningitis and myofasciitis in an adult with rituximab-induced hypogammaglobulinemia. Outcome was favorable under treatment with intravenous immunoglobulins.
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Affiliation(s)
- F Maillet
- Service de médecine interne 2, institut E3M, Sorbonne université, hôpital La Pitié-Salpêtrière, Assistance publique-hôpitaux de Paris (AP-HP), 47-83, boulevard de l'Hôpital, 75013 Paris, France
| | - M Pineton De Chambrun
- Service de médecine interne 2, institut E3M, Sorbonne université, hôpital La Pitié-Salpêtrière, Assistance publique-hôpitaux de Paris (AP-HP), 47-83, boulevard de l'Hôpital, 75013 Paris, France; Service de médecine intensive-réanimation, institut de cardiologie, Sorbonne université, hôpital La Pitié-Salpêtrière, AP-HP, 47-83, boulevard de l'Hôpital, 75013 Paris, France.
| | - Q Monzani
- Service de radiologie polyvalente et oncologique, Sorbonne université, hôpital La Pitié-Salpêtrière, AP-HP, 47-83, boulevard de l'Hôpital, 75013 Paris, France
| | - G Mercy
- Service de radiologie polyvalente et oncologique, Sorbonne université, hôpital La Pitié-Salpêtrière, AP-HP, 47-83, boulevard de l'Hôpital, 75013 Paris, France
| | - I Schuffenecker
- Laboratoire de virologie, centre national de référence des entérovirus, hospices civils de Lyon, 103, Grande-Rue-de-la-Croix-Rousse, 69004 Lyon, France
| | - A Mirand
- Laboratoire de virologie, centre national de référence des entérovirus, CHRU de Clermont-Ferrand, 58, rue Montalembert, 63000 Clermont-Ferrand, France
| | - C Deback
- Service de virologie, université Paris Sud, hôpital Paul Brousse, AP-HP, 12, avenue Paul-Vaillant-Couturier, 94800 Villejuif, France
| | - F Charlotte
- Service d'anatomopathologie, Sorbonne université, hôpital La Pitié-Salpêtrière, AP-HP, 47-83, boulevard de l'Hôpital, 75013 Paris, France
| | - E Fourniols
- Service de chirurgie orthopédique, Sorbonne université, hôpital La Pitié-Salpêtrière, AP-HP, 47-83, boulevard de l'Hôpital, 75013 Paris, France
| | - A Mathian
- Service de médecine interne 2, institut E3M, Sorbonne université, hôpital La Pitié-Salpêtrière, Assistance publique-hôpitaux de Paris (AP-HP), 47-83, boulevard de l'Hôpital, 75013 Paris, France
| | - Z Amoura
- Service de médecine interne 2, institut E3M, Sorbonne université, hôpital La Pitié-Salpêtrière, Assistance publique-hôpitaux de Paris (AP-HP), 47-83, boulevard de l'Hôpital, 75013 Paris, France
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Cameron Smail R, O'Neill JH, Andresen D. Brainstem encephalitis caused by Coxsackie A16 virus in a rituximab-immunosuppressed patient. BMJ Case Rep 2019; 12:12/8/e230177. [PMID: 31451462 DOI: 10.1136/bcr-2019-230177] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Rituximab and other B cell depleting agents are increasingly used for haematological, immunological and neurological diseases. In a small minority, immunosuppression leads to increased virulence of normally mild infections. Brainstem encephalitis has been described occurring after infection from enteroviruses, more commonly in the paediatric population, but also in immunosuppressed adults. In this paper, we describe an enteroviral brainstem encephalitis in a rituximab-immunosuppressed patient. The enterovirus identified was Coxsackie A16, which has never yet been reported to cause brainstem encephalitis in an adult.
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Affiliation(s)
| | - John H O'Neill
- Neurology, Saint Vincent's Hospital Sydney, Darlinghurst, New South Wales, Australia
| | - David Andresen
- Neurology, Saint Vincent's Hospital Sydney, Darlinghurst, New South Wales, Australia
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8
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Tellez R, Lastinger AM, Hogg JP. Chronic enteroviral meningoencephalitis in a patient on rituximab for the treatment of psoriatic arthritis: A case report and brief literature review. IDCases 2019; 17:e00558. [PMID: 31193253 PMCID: PMC6522838 DOI: 10.1016/j.idcr.2019.e00558] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Revised: 05/07/2019] [Accepted: 05/07/2019] [Indexed: 01/26/2023] Open
Abstract
Enteroviruses are RNA viruses within the Picornaviridae family. Enteroviruses derive their name from the way they are typically transmitted via the intestinal tract. They commonly infect millions of people every year and often do not cause severe disease in immunocompetent patients with few exceptions. Aseptic meningitis is a classic manifestation and is usually self-limited, however, can lead to severe neurological complications in an immunocompromised individual. It has been well-described that patients with hypogammaglobulinemia are predisposed to developing chronic enteroviral meningoencephalitis [1]. This is the first reported case of enteroviral meningoencephalitis in a patient being treated for psoriatic arthritis with rituximab. Here we describe a 46-year-old female who presented with altered mental status, fever, and myalgia. Polymerase chain reaction (PCR) of her cerebrospinal fluid (CSF) confirmed the presence of enterovirus. In the immunocompromised patient with encephalopathy, it is important to consider an enteroviral infection. This case adds to the present body of knowledge about enteroviral infections in immunocompromised hosts.
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Affiliation(s)
- Roberto Tellez
- West Virginia University School of Medicine, 1 Medical Center Drive, Morgantown, WV, 26505, United States
- Corresponding author.
| | - Allison M. Lastinger
- Section of Infectious Disease, West Virginia University, 1 Medical Center Drive, Morgantown, WV, 26505, United States
| | - Jeffery P. Hogg
- Department of Radiology, West Virginia University, 1 Medical Center Drive, Morgantown, WV, 26505, United States
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Sham L, Bitnun A, Branson H, Hazrati LN, Dell SD, Yeung RSM, Johnstone J, Yeh EA. Treatment of rituximab-associated chronic CNS enterovirus using IVIg and fluoxetine. Neurology 2019; 92:916-918. [PMID: 30944242 DOI: 10.1212/wnl.0000000000007468] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Accepted: 02/12/2019] [Indexed: 11/15/2022] Open
Affiliation(s)
- Lauren Sham
- From the Departments of Pediatrics (L.S., A.B., S.D.D., R.S.M.Y., E.A.Y.), Medical Imaging (H.B.), Laboratory Medicine and Pathobiology (L.-N.H.), Immunology (R.S.M.Y.), and Medical Science (R.S.M.Y.), and Lawrence Bloomberg School of Nursing (J.J.), University of Toronto; the Divisions of Neurology (L.S., J.J., E.A.Y.), Infectious Diseases (A.B.), Diagnostic Imaging (H.B.), Pathology (L.-N.H.), Respirology (S.D.D.), and Rheumatology (R.S.M.Y.), and the Division of Neuroscience and Mental Health, Research Institute (E.A.Y.), The Hospital for Sick Children, Toronto, Canada.
| | - Ari Bitnun
- From the Departments of Pediatrics (L.S., A.B., S.D.D., R.S.M.Y., E.A.Y.), Medical Imaging (H.B.), Laboratory Medicine and Pathobiology (L.-N.H.), Immunology (R.S.M.Y.), and Medical Science (R.S.M.Y.), and Lawrence Bloomberg School of Nursing (J.J.), University of Toronto; the Divisions of Neurology (L.S., J.J., E.A.Y.), Infectious Diseases (A.B.), Diagnostic Imaging (H.B.), Pathology (L.-N.H.), Respirology (S.D.D.), and Rheumatology (R.S.M.Y.), and the Division of Neuroscience and Mental Health, Research Institute (E.A.Y.), The Hospital for Sick Children, Toronto, Canada
| | - Helen Branson
- From the Departments of Pediatrics (L.S., A.B., S.D.D., R.S.M.Y., E.A.Y.), Medical Imaging (H.B.), Laboratory Medicine and Pathobiology (L.-N.H.), Immunology (R.S.M.Y.), and Medical Science (R.S.M.Y.), and Lawrence Bloomberg School of Nursing (J.J.), University of Toronto; the Divisions of Neurology (L.S., J.J., E.A.Y.), Infectious Diseases (A.B.), Diagnostic Imaging (H.B.), Pathology (L.-N.H.), Respirology (S.D.D.), and Rheumatology (R.S.M.Y.), and the Division of Neuroscience and Mental Health, Research Institute (E.A.Y.), The Hospital for Sick Children, Toronto, Canada
| | - Lili-Naz Hazrati
- From the Departments of Pediatrics (L.S., A.B., S.D.D., R.S.M.Y., E.A.Y.), Medical Imaging (H.B.), Laboratory Medicine and Pathobiology (L.-N.H.), Immunology (R.S.M.Y.), and Medical Science (R.S.M.Y.), and Lawrence Bloomberg School of Nursing (J.J.), University of Toronto; the Divisions of Neurology (L.S., J.J., E.A.Y.), Infectious Diseases (A.B.), Diagnostic Imaging (H.B.), Pathology (L.-N.H.), Respirology (S.D.D.), and Rheumatology (R.S.M.Y.), and the Division of Neuroscience and Mental Health, Research Institute (E.A.Y.), The Hospital for Sick Children, Toronto, Canada
| | - Sharon D Dell
- From the Departments of Pediatrics (L.S., A.B., S.D.D., R.S.M.Y., E.A.Y.), Medical Imaging (H.B.), Laboratory Medicine and Pathobiology (L.-N.H.), Immunology (R.S.M.Y.), and Medical Science (R.S.M.Y.), and Lawrence Bloomberg School of Nursing (J.J.), University of Toronto; the Divisions of Neurology (L.S., J.J., E.A.Y.), Infectious Diseases (A.B.), Diagnostic Imaging (H.B.), Pathology (L.-N.H.), Respirology (S.D.D.), and Rheumatology (R.S.M.Y.), and the Division of Neuroscience and Mental Health, Research Institute (E.A.Y.), The Hospital for Sick Children, Toronto, Canada
| | - Rae S M Yeung
- From the Departments of Pediatrics (L.S., A.B., S.D.D., R.S.M.Y., E.A.Y.), Medical Imaging (H.B.), Laboratory Medicine and Pathobiology (L.-N.H.), Immunology (R.S.M.Y.), and Medical Science (R.S.M.Y.), and Lawrence Bloomberg School of Nursing (J.J.), University of Toronto; the Divisions of Neurology (L.S., J.J., E.A.Y.), Infectious Diseases (A.B.), Diagnostic Imaging (H.B.), Pathology (L.-N.H.), Respirology (S.D.D.), and Rheumatology (R.S.M.Y.), and the Division of Neuroscience and Mental Health, Research Institute (E.A.Y.), The Hospital for Sick Children, Toronto, Canada
| | - Joley Johnstone
- From the Departments of Pediatrics (L.S., A.B., S.D.D., R.S.M.Y., E.A.Y.), Medical Imaging (H.B.), Laboratory Medicine and Pathobiology (L.-N.H.), Immunology (R.S.M.Y.), and Medical Science (R.S.M.Y.), and Lawrence Bloomberg School of Nursing (J.J.), University of Toronto; the Divisions of Neurology (L.S., J.J., E.A.Y.), Infectious Diseases (A.B.), Diagnostic Imaging (H.B.), Pathology (L.-N.H.), Respirology (S.D.D.), and Rheumatology (R.S.M.Y.), and the Division of Neuroscience and Mental Health, Research Institute (E.A.Y.), The Hospital for Sick Children, Toronto, Canada
| | - E Ann Yeh
- From the Departments of Pediatrics (L.S., A.B., S.D.D., R.S.M.Y., E.A.Y.), Medical Imaging (H.B.), Laboratory Medicine and Pathobiology (L.-N.H.), Immunology (R.S.M.Y.), and Medical Science (R.S.M.Y.), and Lawrence Bloomberg School of Nursing (J.J.), University of Toronto; the Divisions of Neurology (L.S., J.J., E.A.Y.), Infectious Diseases (A.B.), Diagnostic Imaging (H.B.), Pathology (L.-N.H.), Respirology (S.D.D.), and Rheumatology (R.S.M.Y.), and the Division of Neuroscience and Mental Health, Research Institute (E.A.Y.), The Hospital for Sick Children, Toronto, Canada
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Enteroviral Encephalitis in a Child With CNS Relapse of Burkitt Leukemia Treated With Rituximab. J Pediatr Hematol Oncol 2019; 41:e27-e29. [PMID: 29315142 PMCID: PMC5912504 DOI: 10.1097/mph.0000000000001077] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
A boy with central nervous system relapse of Burkitt leukemia developed fever and neurologic symptoms and cognitive impairment. He had received multi-drug chemotherapy including rituximab. Enterovirus (EV) was detected in cerebrospinal fluid by polymerase chain reaction, and magnetic resonance imaging findings were consistent with viral infection. The patient was treated with intravenous immunoglobulin and within 1 month cleared his EV. Rituximab can cause a profound B-cell deficiency predisposing patients to infections including EV encephalitis. This is the first report of enteroviral encephalitis in a child undergoing treatment for lymphoma with rituximab and suggests the need to watch for this complication of therapy.
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Holik H, Coha B, Šiško M, Tomić-Paradžik M. Leuconostoc sp. Meningitis in a Patient Treated with Rituximab for Mantle Cell Lymphoma. Turk J Haematol 2017; 32:271-4. [PMID: 26376594 PMCID: PMC4563205 DOI: 10.4274/tjh.2013.0149] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
We present a 64-year-old man who was treated with R-CHOP (rituximab plus cyclophosphamide, doxorubicin, vincristine, and prednisolone) chemoimmunotherapy for mantle cell lymphoma and developed purulent meningitis, probably caused by Leuconostoc sp. The patient had severe hypogammaglobulinemia, which is a possible complication of rituximab therapy. To our knowledge and after reviewing the available medical literature, this is the first described case of purulent meningitis caused by Leuconostoc sp. in a patient with mantle cell lymphoma that appeared after treatment with the R-CHOP protocol. The diagnosis of purulent meningitis was based on clinical, laboratory and cytological cerebrospinal fluid findings, in addition to blood culture results in which we isolated Leuconostoc sp. The patient was treated with meropenem with full recovery.
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Affiliation(s)
- Hrvoje Holik
- General Hospital Dr. Josip Benčević, Clinic of Internal Medicine, Slavonski Brod, Croatia Phone: 0038535201688 E-mail:
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Grisariu S, Vaxman I, Gatt M, Elias S, Avni B, Arad A, Pasvolsky O, Raanani P, Paltiel O. Enteroviral infection in patients treated with rituximab for non-Hodgkin lymphoma: a case series and review of the literature. Hematol Oncol 2016; 35:591-598. [DOI: 10.1002/hon.2365] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Revised: 08/23/2016] [Accepted: 09/08/2016] [Indexed: 11/11/2022]
Affiliation(s)
- S. Grisariu
- Department of Hematology; Hadassah-Hebrew University Medical Center; Jerusalem Israel
| | - I. Vaxman
- Hematology Division Davidoff Cancer Center; Beilinson Hospital; Rabin Medical Center; Israel
- Sackler School of Medicine; Tel-Aviv University; Tel-Aviv Israel
| | - M. Gatt
- Department of Hematology; Hadassah-Hebrew University Medical Center; Jerusalem Israel
| | - S. Elias
- Department of Hematology; Hadassah-Hebrew University Medical Center; Jerusalem Israel
| | - B. Avni
- Department of Hematology; Hadassah-Hebrew University Medical Center; Jerusalem Israel
| | - A. Arad
- Department of Hematology; Hadassah-Hebrew University Medical Center; Jerusalem Israel
| | - O. Pasvolsky
- Hematology Division Davidoff Cancer Center; Beilinson Hospital; Rabin Medical Center; Israel
- Sackler School of Medicine; Tel-Aviv University; Tel-Aviv Israel
| | - P. Raanani
- Hematology Division Davidoff Cancer Center; Beilinson Hospital; Rabin Medical Center; Israel
- Sackler School of Medicine; Tel-Aviv University; Tel-Aviv Israel
| | - O. Paltiel
- Department of Hematology; Hadassah-Hebrew University Medical Center; Jerusalem Israel
- School of Public Health; Hadassah-Hebrew University Medical Center; Jerusalem Israel
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Pruitt AA. Nervous system viral infections in immunocompromised hosts. HANDBOOK OF CLINICAL NEUROLOGY 2014; 123:685-704. [PMID: 25015512 DOI: 10.1016/b978-0-444-53488-0.00034-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- Amy A Pruitt
- Department of Neurology, University of Pennsylvania, Philadelphia, PA, USA.
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Abstract
Invasion of the central nervous system (CNS) by viral agents typically produces a meningoencephalitis in which either meningitis or encephalitis may predominate. Viruses may also infect cranial or spinal blood vessels to produce ischemic injury. Viral and other infections may also elicit a host immune response which is cross-reactive with components of the neural tissue, resulting in encephalomyelitis, transverse myelitis, injury to peripheral nerves, or optic neuritis. This chapter discusses the pathogenesis of CNS viral infections and reviews clinical features of these disorders, major agents responsible in immunocompromised and immunocompetent individuals, and treatment. Prion diseases and postinfectious viral CNS syndromes including postinfectious encephalomyelitis, acute hemorrhagic leukoencephalitis, cerebellar ataxia, and transverse myelitis are also discussed.
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[Central nervous system complications in patients undergoing cytotoxic chemotherapy and targeted therapies]. Bull Cancer 2012; 99:851-63. [PMID: 22961349 DOI: 10.1684/bdc.2012.1624] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Anti-cancer treatments (cytotoxic chemotherapies, targeted therapies and hormonotherapies) are known to induce early and delayed neurological toxicities. Acute encephalopathies and posterior reversible encephalopathies are better known and described, physiopathological hypotheses are emerging. It is difficult to discriminate what drug is causing the symptoms in patients treated with multiple cytotoxic drugs. Methotrexate and ifosfamide are responsible for acute encephalopathies. L-asparaginase and methotrexate or targeted therapies may induce cerebrovascular complications. As life expectancy increases and more complex regimen including innovative targeted therapies are developed, new toxicity profiles can be expected. To be able to provide an early diagnosis, prevention, and treatment (when existing) of these pathologies remains a tremendous challenge that would allow a good quality of life with social and professional life after their cancer is cured.
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Abstract
PURPOSE OF REVIEW This article provides a practical clinical approach to potential CNS infections in patients with cancer, discusses problematic presentations of posterior reversible encephalopathy syndrome and immune reconstitution inflammatory syndrome, and includes specific testing and treatment recommendations for bacterial meningitis, invasive fungal infections, and opportunistic viral infections. RECENT FINDINGS The major deficits predisposing patients with cancer to CNS infection are neutropenia, barrier disruption, B-lymphocyte or immunoglobulin deficiency, and impaired T lymphocyte-mediated immunity. Evolving patterns of drug resistance and prophylactic antimicrobial regimens have altered the timing and range of organisms causing infections. Increasingly intensive immunosuppression has made new groups of patients vulnerable to infections such as progressive multifocal leukoencephalopathy. New MRI sequences offer the potential to diagnose such infections earlier, at a stage when they are more treatable. SUMMARY Despite improved prophylactic and therapeutic antibiotic regimens, CNS infections remain an important source of morbidity and mortality among several cancer patient groups, particularly those patients undergoing craniotomy and those with hematologic malignancies receiving either hematopoietic cell transplantation or other intensive chemotherapy regimens.
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Affiliation(s)
- Amy A Pruitt
- University of Pennsylvania, 3400 Spruce St, Department of Neurology, Philadelphia, PA 19104, USA.
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Abstract
Nearly 70 years after the discovery of penicillin, neurologic infectious diseases (NIDs) remain an important worldwide source of morbidity and mortality. The clinician faced with a potential NID must urgently consider patient demographics, pace of illness and clinical syndrome, and laboratory data. In keeping with the topics of this issue, initial emergency diagnosis and management are emphasized, with appropriate references to relevant literature for subsequent longer-term interventions.
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Affiliation(s)
- Amy A Pruitt
- Department of Neurology, University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA.
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Enterovirus 71 meningoencephalitis complicating rituximab therapy. J Neurol Sci 2011; 305:149-51. [DOI: 10.1016/j.jns.2011.03.009] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2011] [Revised: 02/28/2011] [Accepted: 03/01/2011] [Indexed: 11/23/2022]
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Maródi L, Casanova JL. Primary immunodeficiencies may reveal potential infectious diseases associated with immune-targeting mAb treatments. J Allergy Clin Immunol 2010; 126:910-7. [DOI: 10.1016/j.jaci.2010.08.009] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2010] [Revised: 07/16/2010] [Accepted: 08/06/2010] [Indexed: 01/13/2023]
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Abstract
After more than 10 years of use, rituximab has proven to be remarkably safe. However, accumulated evidence now suggests that under some circumstances it may significantly increase the risk of infections. This risk is difficult to quantify because of confounding factors (namely, concomitant use of immunosuppressive or chemotherapeutic agents and underlying conditions), as well as under-reporting. Increased number of infections has been documented in patients treated with maintenance rituximab for low-grade lymphoma and in patients with concomitant severe immunodeficiency, whether caused by human immunodeficiency virus (HIV) infection or immunosuppressive agents like fludarabine. From the practical standpoint, the most important infection is hepatitis B reactivation, which may be delayed and result in fulminant liver failure and death. Special care should be placed on screening for hepatitis B virus (HBV) and preemptive antiviral treatment. Some investigators have reported an increase in Pneumocystis pneumonia. Finally, there is increasing evidence of a possible association with progressive multifocal leukoencephalopathy (PML), a lethal encephalitis caused by the polyomavirus JC. This review enumerates the described infectious complications, summarizes the possible underlying mechanisms of the increased risk, and makes recommendations regarding prevention, diagnosis and management.
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Affiliation(s)
- Juan C Gea-Banacloche
- Experimental Transplantation and Immunology Branch, National Cancer Institute, Bethesda, MD 20892, USA.
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Servais S, Caers J, Warling O, Frusch N, Baron F, De Prijck B, Beguin Y. Enteroviral meningoencephalitis as complication of Rituximab therapy in a patient treated for diffuse large B-cell lymphoma. Br J Haematol 2010; 150:379-81. [PMID: 20408837 DOI: 10.1111/j.1365-2141.2010.08202.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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