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Dasanu CA, Mann SK, Baidya M, Mdluli XP, Stapleton AE, Codreanu I. Evaluation of infectious morbidity due to BTK inhibitors in indolent B-cell lymphomas: latest research findings and systematic analysis. Expert Opin Pharmacother 2024; 25:1525-1540. [PMID: 39109526 DOI: 10.1080/14656566.2024.2390121] [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: 05/22/2024] [Accepted: 08/05/2024] [Indexed: 08/28/2024]
Abstract
INTRODUCTION Randomized clinical trials (RCTs) have suggested that BTK inhibitors (BTKis) might increase infectious disease (ID) risk. Systematic analysis of this topic as derived from RCTs and clinical practice is needed. AREAS COVERED An extensive Medline, Embase, and Cochrane search of peer-reviewed sources reporting on ID morbidity in patients on BTKis was performed (1 January 2014 - 31 December 2013). Contribution of intrinsic immune defects in indolent B-cell lymphomas to this morbidity was carefully considered. EXPERT OPINION Patients with indolent B-cell lymphomas display a wide range of innate and adaptive immune defects. In addition, BTKi use is linked with an increased signal of upper respiratory tract infections (URTIs) and pneumonias, mainly grade 1-2. These agents also increase the risk of rare invasive fungal infections (IFIs), mainly due to Cryptococcus and Aspergillus spp. with a peak within several months after the start of therapy. More than half of these IFIs are fatal. Research suggests a similar ID risk across 1st, 2nd and 3rd generations of BTKis, all causing B-cell dysfunction due to BTK inhibition, along with off-target functional neutrophil/macrophage alterations. Expanding the knowledge base on ID morbidity in patients on BTKis would facilitate timely diagnosis and treatment, and improve clinical outcomes.
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Affiliation(s)
- Constantin A Dasanu
- Lucy Curci Cancer Center, Eisenhower Health, Rancho Mirage, CA, USA
- Department of Medical Oncology and Hematology, UC San Diego Health System, San Diego, CA, USA
| | - Samar K Mann
- Department of Graduate Medical Education, Oakland William Beaumont School of Medicine, Rochester, MI, USA
| | - Melvin Baidya
- Lucy Curci Cancer Center, Eisenhower Health, Rancho Mirage, CA, USA
| | - Xolani P Mdluli
- Department of Infectious Diseases, Eisenhower Health, Rancho Mirage, CA, USA
| | - Ann E Stapleton
- Department of Infectious Diseases, Eisenhower Health, Rancho Mirage, CA, USA
| | - Ion Codreanu
- Translational Imaging Center, Houston Methodist Research Institute, Houston, TX, USA
- Department of Radiology, Nicolae Testemitanu State University of Medicine and Pharmacy, Chisinau, Republic of Moldova
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Arya S, Shahid Z. Overview of infectious complications among CAR T- cell therapy recipients. Front Oncol 2024; 14:1398078. [PMID: 39026972 PMCID: PMC11255439 DOI: 10.3389/fonc.2024.1398078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2024] [Accepted: 06/04/2024] [Indexed: 07/20/2024] Open
Abstract
Chimeric antigen receptor-modified T cell (CAR T-cell) therapy has revolutionized the management of hematological malignancies. In addition to impressive malignancy-related outcomes, CAR T-cell therapy has significant toxicity-related adverse events, including cytokine release syndrome (CRS), immune effector cell associated neurotoxicity syndrome (ICANS), immune effector cell-associated hematotoxicity (ICAHT), and opportunistic infections. Different CAR T-cell targets have different epidemiology and risk factors for infection, and these targets result in different long-term immunodeficiency states due to their distinct on-target and off- tumor effects. These effects are exacerbated by the use of multimodal immunosuppression in the management of CRS and ICANS. The most effective course of action for managing infectious complications involves determining screening, prophylactic, and monitoring strategies and understanding the role of immunoglobulin replacement and re-vaccination strategies. This involves considering the nature of prior immunomodulating therapies, underlying malignancy, the CAR T-cell target, and the development and management of related adverse events. In conclusion, we now have an increasing understanding of infection management for CAR T-cell recipients. As additional effector cells and CAR T-cell targets become available, infection management strategies will continue to evolve.
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Affiliation(s)
- Swarn Arya
- Infectious Disease Service, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Zainab Shahid
- Infectious Disease Service, Memorial Sloan Kettering Cancer Center, New York, NY, United States
- Department of Medicine, Weill Cornell School of Medicine, New York, NY, United States
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3
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Little J, Rauseo AM, Zuniga-Moya JC, Spec A, Pappas P, Perfect J, McCarthy T, Schwartz IS. Clinical Mycology Today: Emerging Challenges and Opportunities. Open Forum Infect Dis 2024; 11:ofae363. [PMID: 39045011 PMCID: PMC11263878 DOI: 10.1093/ofid/ofae363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2024] [Accepted: 06/25/2024] [Indexed: 07/25/2024] Open
Abstract
The Mycoses Study Group Education and Research Consortium is a collective of clinicians, researchers, and educators with the common goal to advance awareness, diagnosis, and management of invasive fungal diseases. Clinical Mycology Today, the Mycoses Study Group Education and Research Consortium's biennial meeting, is dedicated to discussing the most pressing contemporary issues facing the field of clinical mycology, promoting clinical, translational, and basic science collaborations, and mentoring the next generation of clinical mycologists. Here, we review the current opportunities and challenges facing the field of mycology that arose from discussions at the 2022 meeting, with emphasis on novel host risk factors, emerging resistant fungal pathogens, the evolving antifungal pipeline, and critical issues affecting the advancement of mycology research.
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Affiliation(s)
- Jessica Little
- Division of Infectious Diseases, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Stem Cell Transplant and Cellular Therapy, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts, USA
| | - Adriana M Rauseo
- Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Julio C Zuniga-Moya
- Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Andrej Spec
- Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Peter Pappas
- Division of Infectious Diseases, Department of Medicine, The University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - John Perfect
- Division of Infectious Diseases, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Todd McCarthy
- Division of Infectious Diseases, Department of Medicine, The University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Ilan S Schwartz
- Division of Infectious Diseases, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
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Li X, Paccoud O, Chan KH, Yuen KY, Manchon R, Lanternier F, Slavin MA, van de Veerdonk FL, Bicanic T, Lortholary O. Cryptococcosis Associated With Biologic Therapy: A Narrative Review. Open Forum Infect Dis 2024; 11:ofae316. [PMID: 38947739 PMCID: PMC11212009 DOI: 10.1093/ofid/ofae316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Accepted: 06/17/2024] [Indexed: 07/02/2024] Open
Abstract
Cryptococcus is an opportunistic fungal pathogen that can cause disseminated infection with predominant central nervous system involvement in patients with compromised immunity. Biologics are increasingly used in the treatment of neoplasms and autoimmune/inflammatory conditions and the prevention of transplant rejection, which may affect human defense mechanisms against cryptococcosis. In this review, we comprehensively investigate the association between cryptococcosis and various biologics, highlighting their risks of infection, clinical manifestations, and clinical outcomes. Clinicians should remain vigilant for the risk of cryptococcosis in patients receiving biologics that affect the Th1/macrophage activation pathways, such as tumor necrosis factor α antagonists, Bruton tyrosine kinase inhibitors, fingolimod, JAK/STAT inhibitors (Janus kinase/signal transducer and activator of transcription), and monoclonal antibody against CD52. Other risk factors-such as age, underlying condition, and concurrent immunosuppressants, especially corticosteroids-should also be taken into account during risk stratification.
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Affiliation(s)
- Xin Li
- Department of Infectious Diseases and Tropical Medicine, Université Paris Cité, Necker-Enfants Malades University Hospital, Assistance Publique–Hôpitaux de Paris, IHU Imagine, Paris, France
- Department of Microbiology, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Pokfulam, Hong Kong SAR, China
| | - Olivier Paccoud
- Department of Infectious Diseases and Tropical Medicine, Université Paris Cité, Necker-Enfants Malades University Hospital, Assistance Publique–Hôpitaux de Paris, IHU Imagine, Paris, France
| | - Koon-Ho Chan
- Department of Medicine, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Pokfulam, Hong Kong SAR, China
| | - Kwok-Yung Yuen
- Department of Microbiology, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Pokfulam, Hong Kong SAR, China
| | - Romain Manchon
- Department of Infectious Diseases and Tropical Medicine, Université Paris Cité, Necker-Enfants Malades University Hospital, Assistance Publique–Hôpitaux de Paris, IHU Imagine, Paris, France
| | - Fanny Lanternier
- Department of Infectious Diseases and Tropical Medicine, Université Paris Cité, Necker-Enfants Malades University Hospital, Assistance Publique–Hôpitaux de Paris, IHU Imagine, Paris, France
- Institut Pasteur, National Reference Center for Invasive Mycoses and Antifungals, Mycology Translational Research Group, Mycology Department, Université Paris Cité, Paris, France
| | - Monica A Slavin
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Australia
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Australia
- Victorian Infectious Diseases Service, Royal Melbourne Hospital, Melbourne, Australia
| | - Frank L van de Veerdonk
- Department of Internal Medicine, Radboud Center for Infectious Diseases, Radboudumc, Nijmegen, the Netherlands
| | - Tihana Bicanic
- Institute of Infection and Immunity, St George's University of London, London, UK
| | - Olivier Lortholary
- Department of Infectious Diseases and Tropical Medicine, Université Paris Cité, Necker-Enfants Malades University Hospital, Assistance Publique–Hôpitaux de Paris, IHU Imagine, Paris, France
- Institut Pasteur, National Reference Center for Invasive Mycoses and Antifungals, Mycology Translational Research Group, Mycology Department, Université Paris Cité, Paris, France
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Walker C, Horowitz A, Nooruddin Z, Frei CR. Incidence of invasive fungal infections in patients with chronic lymphocytic leukemia receiving ibrutinib within the veteran's healthcare administration. J Oncol Pharm Pract 2024; 30:673-677. [PMID: 37309168 DOI: 10.1177/10781552231181113] [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] [Indexed: 06/14/2023]
Abstract
PURPOSE Ibrutinib is a tyrosine kinase inhibitor that is increasingly prescribed in chronic lymphocytic leukemia (CLL). Invasive fungal infections (IFIs) have been reported early after ibrutinib initiation. Timing of IFIs is within 6 months and commonly reported fungal infections include Cryptococcus, Aspergillus, and Pneumocystis. Currently, there are no recommendations for routine prophylaxis against IFIs in patients receiving ibrutinib for CLL. OBJECTIVE The objective of this study was to evaluate the incidence of IFIs in patients receiving ibrutinib for CLL in first-line and relapsed/refractory (R/R) settings. METHODS This was a retrospective, cohort study of patients diagnosed with CLL and initiated on ibrutinib in the Veterans Health Administration (VHA) from October 1, 2013 to March 31, 2018. Patients were included if diagnosed with a proven or probable IFI from the start date of ibrutinib to 30 days after the last dose of ibrutinib. RESULTS Fourteen out of 1069 patients met inclusion criteria for IFI while on ibrutinib for CLL. All patients included were male with a median age of 78 years. Fifty percent of patients were initiated on ibrutinib within 3 months of last chemotherapy. IFIs occurred within 3 months (50%) and 6 months (71%) of ibrutinib initiation. Seventy-one percent of patients were continued on ibrutinib with concurrent IFI diagnosis. CONCLUSION The reported IFI incidence of 1.3% is comparable to current estimates of 1.2%. Future studies should examine the relationship of ibrutinib and incidence of IFIs in first-line and R/R settings in addition to identifying clinical risk factors predisposing patients to IFIs.
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Affiliation(s)
- Cassandra Walker
- Pharmacy Department, South Texas Veterans Health Care System, San Antonio, TX, USA
- Pharmacotherapy Division, College of Pharmacy, The University of Texas at Austin, TX, USA
- Pharmacotherapy Education and Research Center, School of Medicine, University of Texas Health, San Antonio, TX, USA
| | - Amy Horowitz
- Pharmacy Department, South Texas Veterans Health Care System, San Antonio, TX, USA
- Pharmacotherapy Division, College of Pharmacy, The University of Texas at Austin, TX, USA
- Pharmacotherapy Education and Research Center, School of Medicine, University of Texas Health, San Antonio, TX, USA
| | - Zohra Nooruddin
- Pharmacy Department, South Texas Veterans Health Care System, San Antonio, TX, USA
- Pharmacotherapy Division, College of Pharmacy, The University of Texas at Austin, TX, USA
- Pharmacotherapy Education and Research Center, School of Medicine, University of Texas Health, San Antonio, TX, USA
| | - Christopher R Frei
- Pharmacy Department, South Texas Veterans Health Care System, San Antonio, TX, USA
- Pharmacotherapy Division, College of Pharmacy, The University of Texas at Austin, TX, USA
- Pharmacotherapy Education and Research Center, School of Medicine, University of Texas Health, San Antonio, TX, USA
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Little JS, Kampouri E, Friedman DZ, McCarty T, Thompson GR, Kontoyiannis DP, Vazquez J, Baddley JW, Hammond SP. The Burden of Invasive Fungal Disease Following Chimeric Antigen Receptor T-Cell Therapy and Strategies for Prevention. Open Forum Infect Dis 2024; 11:ofae133. [PMID: 38887472 PMCID: PMC11181190 DOI: 10.1093/ofid/ofae133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Accepted: 03/05/2024] [Indexed: 06/20/2024] Open
Abstract
Chimeric antigen receptor (CAR) T-cell therapy is a novel immunotherapy approved for the treatment of hematologic malignancies. This therapy leads to a variety of immunologic deficits that could place patients at risk for invasive fungal disease (IFD). Studies assessing IFD in this setting are limited by inconsistent definitions and heterogeneity in prophylaxis use, although the incidence of IFD after CAR T-cell therapy, particularly for lymphoma and myeloma, appears to be low. This review evaluates the incidence of IFD after CAR T-cell therapy, and discusses optimal approaches to prevention, highlighting areas that require further study as well as future applications of cellular therapy that may impact IFD risk. As the use of CAR T-cell therapy continues to expand for hematologic malignancies, solid tumors, and most recently to include non-oncologic diseases, understanding the risk for IFD in this uniquely immunosuppressed population is imperative to prevent morbidity and mortality.
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Affiliation(s)
- Jessica S Little
- Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts, USA
- Division of Infectious Diseases, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Eleftheria Kampouri
- Infectious Diseases Service, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Daniel Z Friedman
- Section of Infectious Diseases and Global Health, The University of Chicago, Chicago, Illinois, USA
| | - Todd McCarty
- Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - George R Thompson
- Division of Infectious Diseases, University of California-Davis, Sacramento, California, USA
| | - Dimitrios P Kontoyiannis
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas, M.D. Anderson Cancer Center, Houston, Texas, USA
| | - Jose Vazquez
- Division of Infectious Diseases, Medical College of Georgia/Augusta University, Augusta, Georgia, USA
| | - John W Baddley
- Division of Infectious Diseases, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Sarah P Hammond
- Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts, USA
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Medical Oncology, Massachusetts General Hospital Cancer Center, Boston, Massachusetts, USA
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7
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Agudelo Higuita NI, Chastain DB, Scott B, Sahra S, Vargas Barahona L, Henao Cordero J, Lee ALH, Tuells J, Henao-Martínez AF. Risk of Invasive Fungal Infections in Patients With Chronic Lymphocytic Leukemia Treated With Bruton Tyrosine Kinase Inhibitors: A Case-Control Propensity Score-Matched Analysis. Open Forum Infect Dis 2024; 11:ofae115. [PMID: 38887474 PMCID: PMC11181183 DOI: 10.1093/ofid/ofae115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Accepted: 02/26/2024] [Indexed: 06/20/2024] Open
Abstract
Background Prior reports have suggested a possible increase in the frequency of invasive fungal infections (IFIs) with use of a Bruton tyrosine kinase inhibitor (BTKi) for treatment of chronic lymphoid malignancies such as chronic lymphocytic leukemia (CLL), but precise estimates are lacking. We aim to characterize the prevalence of IFIs among patients with CLL, for whom a BTKi is now the first-line recommended therapy. Methods We queried TriNetX, a global research network database, to identify adult patients with CLL using the International Classification of Diseases, Tenth Revision code (C91.1) and laboratory results. We performed a case-control propensity score-matched analysis to determine IFIs events by BTKi use. We adjusted for age, sex, ethnicity, and clinical risk factors associated with an increased risk of IFIs. Results Among 5358 matched patients with CLL, we found an incidence of 4.6% of IFIs in patients on a BTKi versus 3.5% among patients not on a BTKi at 5 years. Approximately 1% of patients with CLL developed an IFI while on a BTKi within this period. Our adjusted IFI event analysis found an elevated rate of Pneumocystis jirovecii pneumonia (PJP) (0.5% vs 0.3%, P = .02) and invasive candidiasis (3.5% vs 2.7%, P = .012) with the use of a BTKi. The number needed to harm for patients taking a BTKi was 120 and 358 for invasive candidiasis and PJP, respectively. Conclusions We found an adjusted elevated rate of PJP and invasive candidiasis with BTKi use. The rates are, however, low with a high number needed to harm. Additional studies stratifying other IFIs with specific BTKis are required to identify at-risk patients and preventive, cost-effective interventions.
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Affiliation(s)
- Nelson Iván Agudelo Higuita
- Department of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
- Instituto de Enfermedades Infecciosas y Parasitología Antonio Vidal, Tegucigalpa, Honduras
| | - Daniel B Chastain
- Department of Clinical and Administrative Pharmacy, University of Georgia College of Pharmacy, Albany, Georgia, USA
| | - Brian Scott
- Department of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Syeda Sahra
- Department of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | | | - José Henao Cordero
- Department of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Alfred L H Lee
- Department of Microbiology, Prince of Wales Hospital, Hong Kong Special Administration Region, China
| | - Jose Tuells
- Department of Community Nursing, Preventive Medicine and Public Health and History of Science, University of Alicante, San Vicente del Raspeig, Alicante, Spain
| | - Andrés F Henao-Martínez
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
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Shah M, El Chaer F, Ho DY, El Boghdadly Z. Managing infectious challenges in the age of molecular-targeted therapies for adult hematological malignancies. Transpl Infect Dis 2024; 26:e14283. [PMID: 38698640 DOI: 10.1111/tid.14283] [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: 11/15/2023] [Revised: 03/15/2024] [Accepted: 04/02/2024] [Indexed: 05/05/2024]
Abstract
Over the last decade, the therapeutic landscape for hematological malignancies (HMs) has witnessed a remarkable surge in the development of novel biological and small-molecule-targeted immunomodulatory agents. These therapies have drastically improved survival, but some come at the cost of increased risk of bacterial, viral, and/or fungal infections and on-target off-tumor immunological side effects. To mitigate such risks, physicians must be well informed about infectious complications and necessary preventive measures, such as screening, vaccinations, and antimicrobial prophylaxis. Furthermore, physicians should be vigilant about the noninfectious side effects of these agents that can mimic infections and understand their potential drug-drug interactions with antimicrobials. Strengthening and harmonizing the current surveillance and reporting system for drug-associated infections in real-world settings is essential to better ascertain the potential infections associated with these agents. In this review, we aimed to summarize the infection risks associated with novel agents used for specific HMs and outline recommended strategies for monitoring and prophylaxis.
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Affiliation(s)
- Manan Shah
- Division of Hematology and Medical Oncology, Department of Internal Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Firas El Chaer
- Division of Hematology and Oncology, Department of Medicine, The University of Virginia, Charlottesville, Virginia, USA
| | - Dora Y Ho
- Division of Infectious Diseases and Geographic Medicine, Department of Medicine, Stanford University, Stanford, Virginia, USA
| | - Zeinab El Boghdadly
- Division of Infectious Diseases, Department of Internal Medicine, The Ohio State University, Columbus, Ohio, USA
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Desai JV, Zarakas MA, Wishart AL, Roschewski M, Aufiero MA, Donkó Á, Wigerblad G, Shlezinger N, Plate M, James MR, Lim JK, Uzel G, Bergerson JR, Fuss I, Cramer RA, Franco LM, Clark ES, Khan WN, Yamanaka D, Chamilos G, El-Benna J, Kaplan MJ, Staudt LM, Leto TL, Holland SM, Wilson WH, Hohl TM, Lionakis MS. BTK drives neutrophil activation for sterilizing antifungal immunity. J Clin Invest 2024; 134:e176142. [PMID: 38696257 PMCID: PMC11178547 DOI: 10.1172/jci176142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 04/22/2024] [Indexed: 05/04/2024] Open
Abstract
We describe a previously-unappreciated role for Bruton's tyrosine kinase (BTK) in fungal immune surveillance against aspergillosis, an unforeseen complication of BTK inhibitors (BTKi) used for treating B-cell lymphoid malignancies. We studied BTK-dependent fungal responses in neutrophils from diverse populations, including healthy donors, BTKi-treated patients, and X-linked agammaglobulinemia patients. Upon fungal exposure, BTK was activated in human neutrophils in a TLR2-, Dectin-1-, and FcγR-dependent manner, triggering the oxidative burst. BTK inhibition selectively impeded neutrophil-mediated damage to Aspergillus hyphae, primary granule release, and the fungus-induced oxidative burst by abrogating NADPH oxidase subunit p40phox and GTPase RAC2 activation. Moreover, neutrophil-specific Btk deletion in mice enhanced aspergillosis susceptibility by impairing neutrophil function, not recruitment or lifespan. Conversely, GM-CSF partially mitigated these deficits by enhancing p47phox activation. Our findings underline the crucial role of BTK signaling in neutrophils for antifungal immunity and provide a rationale for GM-CSF use to offset these deficits in susceptible patients.
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Affiliation(s)
- Jigar V Desai
- Fungal Pathogenesis Section, LCIM, NIAID, NIH, Bethesda, United States of America
| | - Marissa A Zarakas
- Fungal Pathogenesis Section, LCIM, NIAID, NIH, Bethesda, United States of America
| | - Andrew L Wishart
- Fungal Pathogenesis Section, LCIM, NIAID, NIH, Bethesda, United States of America
| | - Mark Roschewski
- Lymphoid Malignancies Branch, National Cancer Institute, NIH, Bethesda, United States of America
| | - Mariano A Aufiero
- Louis V. Gerstner Jr. Graduate School of Biomedical Sciences, Memorial Sloan Kettering Cancer Center, New York, United States of America
| | - Ágnes Donkó
- Molecular Defenses Section, LCIM, NIAID, NIH, Bethesda, United States of America
| | - Gustaf Wigerblad
- Systemic Autoimmunity Branch, NIAMS, NIH, Bethesda, United States of America
| | - Neta Shlezinger
- Infectious Diseases, Memorial Sloan Kettering Cancer Center, New York, United States of America
| | - Markus Plate
- Infectious Diseases, Memorial Sloan Kettering Cancer Center, New York, United States of America
| | - Matthew R James
- Microbiology and Immunology, Geisel School of Medicine at Dartmouth, Hanover, United States of America
| | - Jean K Lim
- Department of Microbiology, Icahn School of Medicine at Mount Sinai, New York, United States of America
| | - Gulbu Uzel
- Immunopathogenesis Section, LCIM, NIAID, NIH, Bethesda, United States of America
| | - Jenna Re Bergerson
- Primary Immune Deficiency Clinic, LCIM, NIAID, NIH, Bethesda, United States of America
| | - Ivan Fuss
- Mucosal Immunity Section, LCIM, NIAID, NIH, Bethesda, United States of America
| | - Robert A Cramer
- Microbiology and Immunology, Geisel School of Medicine at Dartmouth, Hanover, United States of America
| | - Luis M Franco
- Functional Immunogenomics Section, NIAMS, NIH, Bethesda, United States of America
| | - Emily S Clark
- Microbiology and Immunology, Miller School of Medicine, University of Miami, Miami, United States of America
| | - Wasif N Khan
- Microbiology and Immunology, Miller School of Medicine, University of Miami, Miami, United States of America
| | - Daisuke Yamanaka
- Laboratory for Immunopharmacology of Microbial Products, School of Pharmacy, Tokyo University of Pharmacy and Life Sciences, Tokyo, Japan
| | - Georgios Chamilos
- Clinical Microbiology and Microbial Pathogenesis, University Hospital of Heraklion, Heraklion, Greece
| | - Jamel El-Benna
- Center for Research on Inflammation, City University of Paris, INSERM-U1149, CNRS-ERL8252, Paris, France
| | - Mariana J Kaplan
- Systemic Autoimmunity Branch, NIAMS, NIH, Bethesda, United States of America
| | - Louis M Staudt
- Lymphoid Malignancies Branch, National Cancer Institute, NIH, Bethesda, United States of America
| | - Thomas L Leto
- Molecular Defenses Section, LCIM, NIAID, NIH, Bethesda, United States of America
| | - Steven M Holland
- Immunopathogenesis Section, LCIM, NIAID, NIH, Bethesda, United States of America
| | - Wyndham H Wilson
- Lymphoid Malignancies Branch, National Cancer Institute, NIH, Bethesda, United States of America
| | - Tobias M Hohl
- Infectious Diseases, Memorial Sloan Kettering Cancer Center, New York, United States of America
| | - Michail S Lionakis
- Fungal Pathogenesis Section, LCIM, NIAID, NIH, Bethesda, United States of America
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Ledoux MP, Dicop E, Sabou M, Letscher-Bru V, Castelain V, Danion F, Herbrecht R. Fusarium, Scedosporium and Other Rare Mold Invasive Infections: Over Twenty-Five-Year Experience of a European Tertiary-Care Center. J Fungi (Basel) 2024; 10:289. [PMID: 38667960 PMCID: PMC11051493 DOI: 10.3390/jof10040289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2024] [Revised: 04/08/2024] [Accepted: 04/13/2024] [Indexed: 04/28/2024] Open
Abstract
Invasive mold infections (IMD) are an emerging concern due to the growing prevalence of patients at risk, encompassing but not limited to allogeneic hematopoietic stem cell transplant recipients, hematological malignancies patients, solid organ transplant recipients and intensive care unit patients. In contrast with invasive aspergillosis and mucormycosis, other hyalohyphomycoses and phaeohyphomycoses remain poorly known. We conducted a retrospective analysis of the clinical, biological, microbiological and evolutive features of 92 IMD having occurred in patients in our tertiary-care center over more than 25 years. A quarter of these infections were due to multiple molds. Molds involved were Fusarium spp. (36.2% of IMD with a single agent, 43.5% of IMD with multiple agents), followed by Scedosporium spp. (respectively 14.5% and 26.1%) and Alternaria spp. (respectively 13.0% and 8.7%). Mortality at day 84 was higher for Fusarium spp., Scedosporium spp. or multiple pathogens IMD compared with Alternaria or other pathogens (51.7% vs. 17.6%, p < 0.05). Mortality at day 84 was also influenced by host factor: higher among hematology and alloHSCT patients than in other patients (30.6% vs. 20.9% at day 42 and 50.0% vs. 27.9% at day 84, p = 0.041). Better awareness, understanding and treatments are awaited to improve patient prognosis.
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Affiliation(s)
- Marie-Pierre Ledoux
- Department of Hematology, Institut de Cancérologie de Strasbourg, 67033 Strasbourg, France
| | - Elise Dicop
- Clinics of Oncology, Elsan, 67000 Strasbourg, France
| | - Marcela Sabou
- Laboratoire de Parasitologie et Mycologie Médicale, Plateau Technique de Microbiologie, Hôpitaux Universitaires de Strasbourg, 67000 Strasbourg, France
- Institut de Parasitologie et de Pathologie Tropicale, UR 3073 Pathogens-Host-Arthropods-Vectors Interactions, Université de Strasbourg, 67000 Strasbourg, France
| | - Valérie Letscher-Bru
- Laboratoire de Parasitologie et Mycologie Médicale, Plateau Technique de Microbiologie, Hôpitaux Universitaires de Strasbourg, 67000 Strasbourg, France
- Institut de Parasitologie et de Pathologie Tropicale, UR 3073 Pathogens-Host-Arthropods-Vectors Interactions, Université de Strasbourg, 67000 Strasbourg, France
| | - Vincent Castelain
- Intensive Care Unit, Hôpitaux Universitaires de Strasbourg, 67000 Strasbourg, France
| | - François Danion
- Department of Infectious Diseases, Hôpitaux Universitaires de Strasbourg, 67000 Strasbourg, France
- INSERM UMR-S1109, 67000 Strasbourg, France
| | - Raoul Herbrecht
- Department of Hematology, Institut de Cancérologie de Strasbourg, 67033 Strasbourg, France
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11
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Chiu CY, John TM, Matsuo T, Wurster S, Hicklen RS, Khattak RR, Ariza-Heredia EJ, Bose P, Kontoyiannis DP. Disseminated Histoplasmosis in a Patient with Myelofibrosis on Ruxolitinib: A Case Report and Review of the Literature on Ruxolitinib-Associated Invasive Fungal Infections. J Fungi (Basel) 2024; 10:264. [PMID: 38667935 PMCID: PMC11051496 DOI: 10.3390/jof10040264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2024] [Revised: 03/24/2024] [Accepted: 03/29/2024] [Indexed: 04/28/2024] Open
Abstract
Ruxolitinib, a selective inhibitor of Janus kinases, is a standard treatment for intermediate/high-risk myelofibrosis (MF) but is associated with a predisposition to opportunistic infections, especially herpes zoster. However, the incidence and characteristics of invasive fungal infections (IFIs) in these patients remain uncertain. In this report, we present the case of a 59-year-old woman with MF who developed disseminated histoplasmosis after seven months of ruxolitinib use. The patient clinically improved after ten weeks of combined amphotericin B and azole therapy, and ruxolitinib was discontinued. Later, the patient received fedratinib, a relatively JAK2-selective inhibitor, without relapse of histoplasmosis. We also reviewed the literature on published cases of proven IFIs in patients with MF who received ruxolitinib. Including ours, we identified 28 such cases, most commonly due to Cryptococcus species (46%). IFIs were most commonly disseminated (39%), followed by localized lung (21%) infections. Although uncommon, a high index of suspicion for opportunistic IFIs is needed in patients receiving JAK inhibitors. Furthermore, the paucity of data regarding the optimal management of IFIs in patients treated with JAK inhibitors underscore the need for well-designed studies to evaluate the epidemiology, pathobiology, early diagnosis, and multimodal therapy of IFIs in patients with hematological malignancies receiving targeted therapies.
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Affiliation(s)
- Chia-Yu Chiu
- Department of Infectious Diseases, Infection Control, and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (C.-Y.C.); (T.M.J.); (T.M.); (S.W.); (R.R.K.); (E.J.A.-H.)
| | - Teny M. John
- Department of Infectious Diseases, Infection Control, and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (C.-Y.C.); (T.M.J.); (T.M.); (S.W.); (R.R.K.); (E.J.A.-H.)
| | - Takahiro Matsuo
- Department of Infectious Diseases, Infection Control, and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (C.-Y.C.); (T.M.J.); (T.M.); (S.W.); (R.R.K.); (E.J.A.-H.)
| | - Sebastian Wurster
- Department of Infectious Diseases, Infection Control, and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (C.-Y.C.); (T.M.J.); (T.M.); (S.W.); (R.R.K.); (E.J.A.-H.)
| | - Rachel S. Hicklen
- Research Medical Library, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA;
| | - Raihaan Riaz Khattak
- Department of Infectious Diseases, Infection Control, and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (C.-Y.C.); (T.M.J.); (T.M.); (S.W.); (R.R.K.); (E.J.A.-H.)
| | - Ella J. Ariza-Heredia
- Department of Infectious Diseases, Infection Control, and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (C.-Y.C.); (T.M.J.); (T.M.); (S.W.); (R.R.K.); (E.J.A.-H.)
| | - Prithviraj Bose
- Department of Leukemia, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA;
| | - Dimitrios P. Kontoyiannis
- Department of Infectious Diseases, Infection Control, and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (C.-Y.C.); (T.M.J.); (T.M.); (S.W.); (R.R.K.); (E.J.A.-H.)
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12
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Tham K, Prelewicz S, deHoll S, Stephens DM, Gomez CA. Infectious complications among patients receiving ibrutinib for the treatment of hematological malignancies. Am J Health Syst Pharm 2024; 81:112-119. [PMID: 37675967 DOI: 10.1093/ajhp/zxad210] [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: 08/31/2023] [Indexed: 09/08/2023] Open
Abstract
PURPOSE Ibrutinib is a Bruton's tyrosine kinase inhibitor used to treat multiple hematologic malignancies and graft-versus-host disease. Though less myelosuppressive than cytotoxic chemotherapy, increased infections, including invasive fungal infections (IFIs), have been reported with ibrutinib use. This study aimed to determine the characteristics and risk factors for infection associated with ibrutinib at our institution. METHODS Patients who received ibrutinib between June 2014 and August 2019 were included. Primary endpoints were the incidence of any infection and the incidence of serious infection (defined as hospitalization, parenteral antimicrobial therapy, or pneumonia regardless of hospitalization). Infection risk factors were assessed using logistic regression. RESULTS One hundred thirty-two patients were identified (78% male; median age, 71 years). The most common indications for ibrutinib were chronic lymphocytic leukemia (67%) and mantle cell lymphoma (12%). Infection and serious infection occurred in 94 (71%) and 47 (36%) patients, respectively; when pneumonia was excluded as a criterion for serious infection, the serious infection rate was 27%. The median time from ibrutinib initiation to first infection was 125 days. Prior allogeneic hematopoietic stem cell transplantation (allo-HSCT) (odds ratio [OR], 4.60; 95% CI, 1.22-17.4) and corticosteroid use (OR, 5.55; 95% CI, 1.52-20.3) were significant risk factors for serious infection. IFIs were diagnosed in 7 patients (5%): 5 had Pneumocystis jirovecii pneumonia and 2 were infected with invasive molds. CONCLUSION Serious infection and IFI rates are high but similar to those previously described. Risk factors for serious infection included allo-HSCT and corticosteroid use. Targeted antimicrobial prophylaxis should be evaluated in prospective studies in patients on ibrutinib to reduce serious infections and IFI.
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Affiliation(s)
- Kenneth Tham
- Department of Pharmacy, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Stacy Prelewicz
- Department of Pharmacy, Huntsman Cancer Institute at the University of Utah Health, Salt Lake City, UT, USA
| | - Sara deHoll
- Department of Pharmacy, Huntsman Cancer Institute at the University of Utah Health, Salt Lake City, UT, USA
| | - Deborah M Stephens
- Division of Hematology and Hematologic Malignancies, Department of Medicine, Huntsman Cancer Institute at the University of Utah Health, Salt Lake City, UT, USA
| | - Carlos A Gomez
- Division of Infectious Diseases, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, Nebraska, USA
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13
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Li Z, Shan Y, Dong J, Mei H, Kong Q, Li Y. Disseminated cryptococcosis presenting with generalized cutaneous involvement in a rheumatoid arthritis patient receiving tofacitinib: A case report. J Dermatol 2024; 51:e39-e41. [PMID: 37698047 DOI: 10.1111/1346-8138.16960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2023] [Revised: 08/15/2023] [Accepted: 08/26/2023] [Indexed: 09/13/2023]
Affiliation(s)
- Zonghui Li
- Department of Dermatology, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Yuxin Shan
- School of Medicine, Southeast University, Nanjing, China
| | - Jiazheng Dong
- Department of Dermatology, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Huan Mei
- Institute of Dermatology, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Qingtao Kong
- Department of Dermatology, Jinling Hospital, School of Medicine, Nanjing University, Nanjing, China
| | - Yan Li
- Department of Dermatology, The First Affiliated Hospital of Soochow University, Suzhou, China
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14
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Allouchery M, Brunet K, Tomowiak C, Singier A, Pambrun E, Pariente A, Bezin J, Pérault-Pochat MC, Salvo F. Invasive fungal infection incidence and risk factors in patients receiving ibrutinib in real-life settings: A nationwide population-based cohort study. Mycoses 2024; 67:e13676. [PMID: 37984556 DOI: 10.1111/myc.13676] [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: 08/17/2023] [Revised: 11/10/2023] [Accepted: 11/11/2023] [Indexed: 11/22/2023]
Abstract
BACKGROUND Data on the risk of invasive fungal infections (IFI) with ibrutinib treatment are scarce. OBJECTIVES This study aimed to determine IFI incidence and risk factors in ibrutinib-treated patients in real-life settings. METHODS We constituted a cohort of ibrutinib incident users in the French National Healthcare Database. All patients ≥18 years with a first dispensing of ibrutinib between 21 November 2014 and 31 December 2019 were included. Patients were followed from the cohort entry date until IFI, ibrutinib discontinuation, death, or 31 December 2020, whichever came first. The cumulative incidence function method was used to estimate the probability of IFI accounting for competing risk of death. A multivariate cause-specific Cox proportional hazards model was used to assess independent IFI risk factors. RESULTS Among 6937 ibrutinib-treated patients, 1-year IFI cumulative incidence was 1.3%, with invasive aspergillosis being the most frequent. Allogenic or autologous stem cell transplantation (ASCT) (hazard ratio [HR] 3.59, 95% confidence interval [1.74; 7.41]), previous anticancer treatment (HR 2.12, CI 95% [1.34; 3.35]) and chronic respiratory disease (HR 1.66, [1.03; 2.67]) were associated with higher risk of IFI. Besides neutropenia and corticosteroids, use of anti-CD20 agents was significantly more frequent in patients having experienced IFI (HR 3.68, [1.82; 7.45]). CONCLUSIONS In addition to patients with ASCT history, severe neutropenia or treated with corticosteroids, our findings support active surveillance of IFIs in those with chronic respiratory disease, previously treated, or treated with anti-CD20 agents in combination with ibrutinib. Further studies are needed to optimise IFI prophylaxis in these patient subgroups.
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Affiliation(s)
- Marion Allouchery
- Pharmacologie Clinique et Vigilances, CHU de Poitiers, Poitiers, France
- Faculté de Médecine et de Pharmacie, Université de Poitiers, Poitiers, France
- Univ. Bordeaux, INSERM, BPH, U1219, Team AHeaD, Bordeaux, France
| | - Kévin Brunet
- Faculté de Médecine et de Pharmacie, Université de Poitiers, Poitiers, France
- INSERM U1070 PHAR2, Université de Poitiers, Poitiers, France
- Laboratoire de Parasitologie et Mycologie Médicale, CHU de Poitiers, Poitiers, France
| | - Cécile Tomowiak
- Onco-Hématologie et Thérapie Cellulaire, CHU de Poitiers, Poitiers, France
- INSERM CIC 1402, CHU de Poitiers, Poitiers, France
| | - Allison Singier
- Univ. Bordeaux, INSERM, BPH, U1219, Team AHeaD, Bordeaux, France
| | - Elodie Pambrun
- Univ. Bordeaux, INSERM, BPH, U1219, Team AHeaD, Bordeaux, France
| | - Antoine Pariente
- Univ. Bordeaux, INSERM, BPH, U1219, Team AHeaD, Bordeaux, France
| | - Julien Bezin
- Univ. Bordeaux, INSERM, BPH, U1219, Team AHeaD, Bordeaux, France
- CHU de Bordeaux, Pôle de Santé Publique, Service de Pharmacologie médicale, Bordeaux, France
| | - Marie-Christine Pérault-Pochat
- Pharmacologie Clinique et Vigilances, CHU de Poitiers, Poitiers, France
- Laboratoire de Neurosciences Expérimentales et Cliniques, INSERM, UMR1084, Université de Poitiers, Poitiers, France
| | - Francesco Salvo
- Univ. Bordeaux, INSERM, BPH, U1219, Team AHeaD, Bordeaux, France
- CHU de Bordeaux, Pôle de Santé Publique, Service de Pharmacologie médicale, Bordeaux, France
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15
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Seiser S, Arzani H, Ayub T, Phan-Canh T, Staud C, Worda C, Kuchler K, Elbe-Bürger A. Native human and mouse skin infection models to study Candida auris-host interactions. Microbes Infect 2024; 26:105234. [PMID: 37813159 DOI: 10.1016/j.micinf.2023.105234] [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: 08/02/2023] [Revised: 09/29/2023] [Accepted: 09/30/2023] [Indexed: 10/11/2023]
Abstract
The World Health Organization (WHO) declared certain fungal pathogens as global health threats for the next decade. Candida auris (C. auris) is a newly emerging skin-tropic multidrug-resistant fungal pathogen that can cause life-threatening infections of high mortality in hospitals and healthcare settings. Here, we address an unmet need and present novel native ex vivo skin models, thus extending previous C. auris-host interaction studies. We exploit histology and immunofluorescence analysis of ex vivo skin biopsies of human adult and fetal, as well as mouse origin infected with C. auris via distinct routes. We demonstrate that an intact skin barrier efficiently protects from C. auris penetration and invasion. Although C. auris readily grows on native human skin, it can reach deeper layers only upon physical disruption of the barrier by needling or through otherwise damaged skin. By contrast, a barrier disruption is not necessary for C. auris penetration of native mouse skin. Importantly, we show that C. auris undergoes morphogenetic changes upon skin penetration, as it acquires pseudohyphal growth phenotypes in deeper human and mouse dermis. Taken together, this new human and mouse skin model toolset yields new insights into C. auris colonization, adhesion, growth and invasion properties of native versus damaged human skin. The results form a crucial basis for future studies on skin immune defense to colonizing pathogens, and offer new options for testing the action and efficacy of topical antimicrobial compound formulations.
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Affiliation(s)
- Saskia Seiser
- Medical University of Vienna, Department of Dermatology, Währinger Gürtel 18-20, 1090 Vienna, Austria
| | - Hossein Arzani
- Medical University of Vienna, Max Perutz Labs Vienna, Campus Vienna Biocenter, Dr. Bohr-Gasse 9/2, 1030 Vienna, Austria
| | - Tanya Ayub
- Medical University of Vienna, Department of Dermatology, Währinger Gürtel 18-20, 1090 Vienna, Austria
| | - Trinh Phan-Canh
- Medical University of Vienna, Max Perutz Labs Vienna, Campus Vienna Biocenter, Dr. Bohr-Gasse 9/2, 1030 Vienna, Austria
| | - Clement Staud
- Medical University of Vienna, Department of Plastic and Reconstructive Surgery, Währinger Gürtel 18-20, 1090 Vienna, Austria
| | - Christof Worda
- Medical University of Vienna, Department of Obstetrics and Gynecology, Währinger Gürtel 18-20, 1090 Vienna, Austria
| | - Karl Kuchler
- Medical University of Vienna, Max Perutz Labs Vienna, Campus Vienna Biocenter, Dr. Bohr-Gasse 9/2, 1030 Vienna, Austria.
| | - Adelheid Elbe-Bürger
- Medical University of Vienna, Department of Dermatology, Währinger Gürtel 18-20, 1090 Vienna, Austria.
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16
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Chastain DB, Zhang Q, Chen X, Young HN, Franco-Paredes C, Tuells J, Thompson GR, Henao-Martínez AF. Epidemiological trends and clinical outcomes of cryptococcosis in a medically insured population in the United States: a claims-based analysis from 2017 to 2019. Ther Adv Infect Dis 2024; 11:20499361241244967. [PMID: 38645299 PMCID: PMC11027593 DOI: 10.1177/20499361241244967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 03/19/2024] [Indexed: 04/23/2024] Open
Abstract
Background Emerging risk factors highlight the need for an updated understanding of cryptococcosis in the United States. Objective Describe the epidemiological trends and clinical outcomes of cryptococcosis in three patient groups: people with HIV (PWH), non-HIV-infected and non-transplant (NHNT) patients, and patients with a history of solid organ transplantation. Methods We utilized data from the Merative Medicaid Database to identify individuals aged 18 and above with cryptococcosis based on the International Classification of Diseases, Tenth Revision diagnosis codes from January 2017 to December 2019. Patients were stratified into PWH, NHNT patients, and transplant recipients according to Infectious Diseases Society of America guidelines. Baseline characteristics, types of cryptococcosis, hospitalization details, and in-hospital mortality rates were compared across groups. Results Among 703 patients, 59.7% were PWH, 35.6% were NHNT, and 4.7% were transplant recipients. PWH were more likely to be younger, male, identify as Black, and have fewer comorbidities than patients in the NHNT and transplant groups. Notably, 24% of NHNT patients lacked comorbidities. Central nervous system, pulmonary, and disseminated cryptococcosis were most common overall (60%, 14%, and 11%, respectively). The incidence of cryptococcosis fluctuated throughout the study period. PWH accounted for over 50% of cases from June 2017 to June 2019, but this proportion decreased to 47% from July to December 2019. Among the 52% of patients requiring hospitalization, 61% were PWH and 35% were NHNT patients. PWH had longer hospital stays. In-hospital mortality at 90 days was significantly higher in NHNT patients (22%) compared to PWH (7%) and transplant recipients (0%). One-year mortality remained lowest among PWH (8%) compared to NHNT patients (22%) and transplant recipients (13%). Conclusion In this study, most cases of cryptococcosis were PWH. Interestingly, while the incidence remained relatively stable in PWH, it slightly increased in those without HIV by the end of the study period. Mortality was highest in NHNT patients.
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Affiliation(s)
- Daniel B. Chastain
- Department of Clinical and Administrative Pharmacy, University of Georgia College of Pharmacy, 1000 Jefferson Street, Albany, GA 31701, USA
| | - Qian Zhang
- Department of Statistics, University of Georgia Franklin College of Arts and Sciences, Athens, GA, USA
| | - Xianyan Chen
- Department of Epidemiology & Biostatistics, University of Georgia College of Public Health, Athens, GA, USA
| | - Henry N. Young
- Department of Clinical and Administrative Pharmacy, University of Georgia College of Pharmacy, Athens, GA, USA
| | - Carlos Franco-Paredes
- Hospital Infantil de México, Federico Gómez, México City, México
- Department of Microbiology, Immunology, and Pathology, Colorado State University, Fort Collins, CO, USA
| | - Jose Tuells
- Department of Community Nursing, Preventive Medicine, Public Health and History of Science, University of Alicante, Alicante, Spain
| | - George R. Thompson
- Department of Medicine, Division of Infectious Diseases, and the Department of Medical Microbiology and Immunology, University of California, Davis Medical Center, Sacramento, CA, USA
| | - Andrés F. Henao-Martínez
- Division of Infectious Diseases, University of Colorado, Anschutz Medical Campus, Aurora, CO, USA
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17
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Teh BW, Mikulska M, Averbuch D, de la Camara R, Hirsch HH, Akova M, Ostrosky-Zeichner L, Baddley JW, Tan BH, Mularoni A, Subramanian AK, La Hoz RM, Marinelli T, Boan P, Aguado JM, Grossi PA, Maertens J, Mueller NJ, Slavin MA. Consensus position statement on advancing the standardised reporting of infection events in immunocompromised patients. THE LANCET. INFECTIOUS DISEASES 2024; 24:e59-e68. [PMID: 37683684 DOI: 10.1016/s1473-3099(23)00377-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/13/2023] [Revised: 06/07/2023] [Accepted: 06/09/2023] [Indexed: 09/10/2023]
Abstract
Patients can be immunocompromised from a diverse range of disease and treatment factors, including malignancies, autoimmune disorders and their treatments, and organ and stem-cell transplantation. Infections are a leading cause of morbidity and mortality in immunocompromised patients, and the disease treatment landscape is continually evolving. Despite being a critical but preventable and curable adverse event, the reporting of infection events in randomised trials lacks sufficient detail while inconsistency of categorisation and definition of infections in observational and registry studies limits comparability and future pooling of data. A core reporting dataset consisting of category, site, severity, organism, and endpoints was developed as a minimum standard for reporting of infection events in immunocompromised patients across study types. Further additional information is recommended depending on study type. The standardised reporting of infectious events and attributable complications in immunocompromised patients will improve diagnostic, treatment, and prevention approaches and facilitate future research in this patient group.
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Affiliation(s)
- Benjamin W Teh
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia; Sir Peter MacCallum Department of Oncology, University of Melbourne, VIC, Australia.
| | - Malgorzata Mikulska
- Division of Infectious Diseases, Department of Health Sciences, University of Genoa, Genoa, Italy; IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Dina Averbuch
- Pediatric Infectious Diseases, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel; Hadassah Medical Center, Jerusalem, Israel
| | | | - Hans H Hirsch
- Transplantation & Clinical Virology, Department of Biomedicine, University of Basel, Basel, Switzerland; Infectious Diseases & Hospital Epidemiology, University Hospital Basel, Basel, Switzerland
| | - Murat Akova
- Department of Infectious Diseases, Hacettepe University School of Medicine, Ankara, Turkey
| | - Luis Ostrosky-Zeichner
- Division of Infectious Diseases, McGovern Medical School, University of Texas, Houston, TX, USA
| | - John W Baddley
- Department of Medicine, Division of Infectious Diseases, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Ban Hock Tan
- Department of Infectious Diseases, Singapore General Hospital, Singapore
| | - Alessandra Mularoni
- Department of Infectious Diseases, Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione (IRCCS), Palermo, Italy
| | - Aruna K Subramanian
- Division of Infectious Diseases and Geographic Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Ricardo M La Hoz
- Division of Infectious Diseases and Geographic Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Tina Marinelli
- Department of Infectious Diseases, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Peter Boan
- Department of Infectious Diseases, Fiona Stanley Hospital, Murdoch, WA, Australia; Department of Microbiology, PathWest Laboratory Medicine WA, Fiona Stanley Hospital, Murdoch, WA, Australia
| | - Jose Maria Aguado
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Sanitaria Hospital "12 de Octubre" (imas12), CIBERINFEC, Universidad Complutense, Madrid, Spain
| | - Paolo A Grossi
- Infectious and Tropical Diseases Unit, Department of Medicine and Surgery, University of Insubria-ASST-Sette Laghi, Varese, Italy
| | - Johan Maertens
- Department of Haematology, Universitaire Ziekenhuizen Leuven, Leuven, Belgium
| | - Nicolas J Mueller
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, Zürich, Switzerland
| | - Monica A Slavin
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia; Sir Peter MacCallum Department of Oncology, University of Melbourne, VIC, Australia; Victorian Infectious Diseases Service, Royal Melbourne Hospital, Parkville, VIC, Australia
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18
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Baucher L, Lemiale V, Joseph A, Wallet F, Pineton de Chambrun M, Ferré A, Lombardi R, Platon L, Contejean A, Fuseau C, Calvet L, Pène F, Kouatchet A, Mokart D, Azoulay E, Lafarge A. Severe infections requiring intensive care unit admission in patients receiving ibrutinib for hematological malignancies: a groupe de recherche respiratoire en réanimation onco-hématologique (GRRR-OH) study. Ann Intensive Care 2023; 13:123. [PMID: 38055081 DOI: 10.1186/s13613-023-01219-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Accepted: 11/22/2023] [Indexed: 12/07/2023] Open
Abstract
BACKGROUND In the last decade, Ibrutinib has become the standard of care in the treatment of several lymphoproliferative diseases such as chronic lymphocytic leukemia (CLL) and several non-Hodgkin lymphoma. Beyond Bruton tyrosine kinase inhibition, Ibrutinib shows broad immunomodulatory effects that may promote the occurrence of infectious complications, including opportunistic infections. The infectious burden has been shown to vary by disease status, neutropenia, and prior therapy but data focusing on severe infections requiring intensive care unit (ICU) admission remain scarce. We sought to investigate features and outcomes of severe infections in a multicenter cohort of 69 patients receiving ibrutinib admitted to 10 French intensive care units (ICU) from 1 January 2015 to 31 December 2020. RESULTS Median time from ibrutinib initiation was 6.6 [3-18] months. Invasive fungal infections (IFI) accounted for 19% (n = 13/69) of severe infections, including 9 (69%; n = 9/13) invasive aspergillosis, 3 (23%; n = 3/13) Pneumocystis pneumonia, and 1 (8%; n = 1/13) cryptococcosis. Most common organ injury was acute respiratory failure (ARF) (71%; n = 49/69) and 41% (n = 28/69) of patients required mechanical ventilation. Twenty (29%; n = 20/69) patients died in the ICU while day-90 mortality reached 55% (n = 35/64). In comparison with survivors, decedents displayed more severe organ dysfunctions (SOFA 7 [5-11] vs. 4 [3-7], p = 0.004) and were more likely to undergo mechanical ventilation (68% vs. 31%, p = 0.010). Sixty-three ibrutinib-treated patients were matched based on age and underlying malignancy with 63 controls receiving conventional chemotherapy from an historic cohort. Despite a higher median number of prior chemotherapy lines (2 [1-2] vs. 0 [0-2]; p < 0.001) and higher rates of fungal [21% vs. 8%, p = 0.001] and viral [17% vs. 5%, p = 0.027] infections in patients receiving ibrutinib, ICU (27% vs. 38%, p = 0.254) and day-90 mortality (52% vs. 48%, p = 0.785) were similar between the two groups. CONCLUSION In ibrutinib-treated patients, severe infections requiring ICU admission were associated with a dismal prognosis, mostly impacted by initial organ failures. Opportunistic agents should be systematically screened by ICU clinicians in this immunocompromised population.
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Affiliation(s)
- Louise Baucher
- Médecine Intensive Réanimation, Hôpital Saint Louis, AP-HP, Université Paris Cité, Paris, France.
- Sorbonne Université, Paris, France.
| | - Virginie Lemiale
- Médecine Intensive Réanimation, Hôpital Saint Louis, AP-HP, Université Paris Cité, Paris, France
| | - Adrien Joseph
- Médecine Intensive Réanimation, Hôpital Saint Louis, AP-HP, Université Paris Cité, Paris, France
| | - Florent Wallet
- Médecine Intensive Réanimation, Hospices Civils de Lyon, Lyon, France
| | - Marc Pineton de Chambrun
- Service de Médecine Intensive-Réanimation, Sorbonne Université, Assistance Publique-Hôpitaux de Paris (APHP), Hôpital de La Pitié-Salpêtrière, Paris, France
- Sorbonne Université, INSERM, UMRS_1166-ICAN, Institut de Cardiométabolisme Et Nutrition (ICAN), 75013, Paris, France
| | - Alexis Ferré
- Réanimation Médico-Chirurgicale, Centre Hospitalier de Versailles, Le Chesnay, France
| | - Romain Lombardi
- Médecine Intensive Réanimation, Hôpital Pasteur, Nice, France
| | - Laura Platon
- Médecine Intensive Réanimation, Hôpital Lapeyronie, Montpellier, France
| | | | - Charline Fuseau
- Hématologie, Institut de Cancérologie (ICANS), Strasbourg, France
| | - Laure Calvet
- Médecine Intensive Réanimation, Hôpital Gabriel Montpied, Clermont-Ferrand, France
| | - Frédéric Pène
- Médecine Intensive Réanimation, Hôpital Cochin, Paris, France
| | | | - Djamel Mokart
- Anesthésie Réanimation, Institut Paoli Calmettes, Marseille, France
| | - Elie Azoulay
- Médecine Intensive Réanimation, Hôpital Saint Louis, AP-HP, Université Paris Cité, Paris, France
| | - Antoine Lafarge
- Médecine Intensive Réanimation, Hôpital Saint Louis, AP-HP, Université Paris Cité, Paris, France
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19
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Palmucci JR, Messina JA, Tenor JL, Perfect JR. New anticancer therapeutics impact fungal pathobiology, infection dynamics, and outcome. PLoS Pathog 2023; 19:e1011845. [PMID: 38127685 PMCID: PMC10735005 DOI: 10.1371/journal.ppat.1011845] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2023] Open
Affiliation(s)
- Julia R. Palmucci
- Division of Infectious Diseases, Department of Medicine, Duke University, Durham, North Carolina, United States of America
| | - Julia A. Messina
- Division of Infectious Diseases, Department of Medicine, Duke University, Durham, North Carolina, United States of America
| | - Jennifer L. Tenor
- Division of Infectious Diseases, Department of Medicine, Duke University, Durham, North Carolina, United States of America
| | - John R. Perfect
- Division of Infectious Diseases, Department of Medicine, Duke University, Durham, North Carolina, United States of America
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20
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Huang Y, Yi J, Song JJ, Du LJ, Li XM, Cheng LL, Yan SX, Li HL, Liu YM, Zhan HT, Dou YL, Li YZ. Negative serum (1,3) -β-D-glucan has a low power to exclude Pneumocystis jirovecii pneumonia (PJP) in HIV-uninfected patients with positive qPCR. Ann Clin Microbiol Antimicrob 2023; 22:102. [PMID: 37986091 PMCID: PMC10662630 DOI: 10.1186/s12941-023-00650-7] [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: 07/23/2023] [Accepted: 10/29/2023] [Indexed: 11/22/2023] Open
Abstract
OBJECTIVE The current study evaluated the diagnostic performance of serum (1,3)-beta-D Glucan (BDG) in differentiating PJP from P. jirovecii-colonization in HIV-uninfected patients with P. jirovecii PCR-positive results. METHODS This was a single-center retrospective study between 2019 and 2021. The diagnosis of PJP was based on the following criteria: detection of P. jirovecii in sputum or BAL specimen by qPCR or microscopy; Meet at least two of the three criteria: (1) have respiratory symptoms of cough and/or dyspnea, hypoxia; (2) typical radiological picture findings; (3) receiving a complete PJP treatment. After exclusion, the participants were divided into derivation and validation cohorts. The derivation cohort defined the cut-off value of serum BDG. Then, it was verified using the validation cohort. RESULTS Two hundred and thirteen HIV-uninfected patients were enrolled, with 159 PJP and 54 P. jirovecii-colonized patients. BDG had outstanding specificity, LR, and PPV for PJP in both the derivation (90.00%, 8.900, and 96.43%) and the validation (91.67%, 9.176, and 96.30%) cohorts at ≥ 117.7 pg/mL. However, it had lower sensitivity and NPV in the derivation cohort (89.01% and 72.97%), which was even lower in the validation cohort (76.47% and 57.89%). Of note, BDG ≥ 117.7 pg/mL has insufficient diagnostic efficacy for PJP in patients with lung cancer, interstitial lung disease (ILD) and nephrotic syndrome. And although lymphocytes, B cells, and CD4+ T cells in PJP patients were significantly lower than those in P. jirovecii-colonized patients, the number and proportion of peripheral blood lymphocytes did not affect the diagnostic efficacy of serum BDG. CONCLUSIONS Serum BDG ≥ 117.7 pg/mL could effectively distinguish P. jirovecii-colonization from infection in qPCR-positive HIV-uninfected patients with infectious diseases, solid tumors (excluding lung cancer), autoimmune or inflammatory disorders, and hematological malignancies. Of note, for patients with lung cancer, ILD, and nephrotic diseases, PJP should be cautiously excluded at BDG < 117.7 pg/mL.
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Affiliation(s)
- Yuan Huang
- Department of Clinical Laboratory, Peking Union Medical College Hospital, Dongcheng District, Beijing, 100730, China
| | - Jie Yi
- Department of Clinical Laboratory, Peking Union Medical College Hospital, Dongcheng District, Beijing, 100730, China
| | - Jing-Jing Song
- Department of Clinical Laboratory, The Maternal and Child Health Hospital Affiliated to Anhui Medical University, Hefei, Anhui, 230001, China
| | - Li-Jun Du
- Department of Clinical Laboratory, Nanchong Central Hospital, the Second Clinical Medical College, North Sichuan Medical College, Nanchong, Sichuan Province, 637000, China
| | - Xiao-Meng Li
- Department of Clinical Laboratory, Peking Union Medical College Hospital, Dongcheng District, Beijing, 100730, China
| | - Lin-Lin Cheng
- Department of Clinical Laboratory, Peking Union Medical College Hospital, Dongcheng District, Beijing, 100730, China
| | - Song-Xin Yan
- Department of Clinical Laboratory, Peking Union Medical College Hospital, Dongcheng District, Beijing, 100730, China
| | - Hao-Long Li
- Department of Clinical Laboratory, Peking Union Medical College Hospital, Dongcheng District, Beijing, 100730, China
| | - Yong-Mei Liu
- Department of Clinical Laboratory, Peking Union Medical College Hospital, Dongcheng District, Beijing, 100730, China
| | - Hao-Ting Zhan
- Department of Clinical Laboratory, Peking Union Medical College Hospital, Dongcheng District, Beijing, 100730, China
| | - Ya-Ling Dou
- Department of Clinical Laboratory, Peking Union Medical College Hospital, Dongcheng District, Beijing, 100730, China.
| | - Yong-Zhe Li
- Department of Clinical Laboratory, Peking Union Medical College Hospital, Dongcheng District, Beijing, 100730, China.
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21
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Kampouri E, Little JS, Rejeski K, Manuel O, Hammond SP, Hill JA. Infections after chimeric antigen receptor (CAR)-T-cell therapy for hematologic malignancies. Transpl Infect Dis 2023; 25 Suppl 1:e14157. [PMID: 37787373 DOI: 10.1111/tid.14157] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 08/30/2023] [Accepted: 09/10/2023] [Indexed: 10/04/2023]
Abstract
BACKGROUND Chimeric antigen receptor (CAR)-T-cell therapies have revolutionized the management of acute lymphoblastic leukemia, non-Hodgkin lymphoma, and multiple myeloma but come at the price of unique toxicities, including cytokine release syndrome, immune effector cell-associated neurotoxicity syndrome, and long-term "on-target off-tumor" effects. METHODS All of these factors increase infection risk in an already highly immunocompromised patient population. Indeed, infectious complications represent the key determinant of non-relapse mortality after CAR-T cells. The temporal distribution of these risk factors shapes different infection patterns early versus late post-CAR-T-cell infusion. Furthermore, due to the expression of their targets on B lineage cells at different stages of differentiation, CD19, and B-cell maturation antigen (BCMA) CAR-T cells induce distinct immune deficits that could require different prevention strategies. Infection incidence is the highest during the first month post-infusion and subsequently decreases thereafter. However, infections remain relatively common even a year after infusion. RESULTS Bacterial infections predominate early after CD19, while a more equal distribution between bacterial and viral causes is seen after BCMA CAR-T-cell therapy, and fungal infections are universally rare. Cytomegalovirus (CMV) and other herpesviruses are increasingly breported, but whether routine monitoring is warranted for all, or a subgroup of patients, remains to be determined. Clinical practices vary substantially between centers, and many areas of uncertainty remain, including CMV monitoring, antibacterial and antifungal prophylaxis and duration, use of immunoglobulin replacement therapy, and timing of vaccination. CONCLUSION Risk stratification tools are available and may help distinguish between infectious and non-infectious causes of fever post-infusion and predict severe infections. These tools need prospective validation, and their integration in clinical practice needs to be systematically studied.
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Affiliation(s)
- Eleftheria Kampouri
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, Washington, USA
- Infectious Diseases Service, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Jessica S Little
- Division of Infectious Diseases, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Division of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts, USA
| | - Kai Rejeski
- Department of Medicine III-Hematology/Oncology, LMU University Hospital, LMU Munich, Munich, Germany
- German Cancer Consortium (DKTK), Munich site, and German Cancer Research Center, Heidelberg, Germany
| | - Oriol Manuel
- Infectious Diseases Service, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Sarah P Hammond
- Division of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts, USA
- Divisions of Hematology/Oncology and Infectious Diseases, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Joshua A Hill
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, Washington, USA
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington, USA
- Department of Medicine, University of Washington, Seattle, Washington, USA
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22
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Casutt A, Lamoth F, Lortholary O, Prior JO, Tonglet A, Manuel O, Bergeron A, Beigelman-Aubry C. Atypical imaging patterns during lung invasive mould diseases: lessons for clinicians. Eur Respir Rev 2023; 32:230086. [PMID: 37758271 PMCID: PMC10523149 DOI: 10.1183/16000617.0086-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2023] [Accepted: 07/13/2023] [Indexed: 09/30/2023] Open
Abstract
Imaging of pulmonary invasive mould diseases (IMDs), which represents a cornerstone in their work-up, is mainly based on computed tomography (CT). The purpose of this review is to discuss their CT features, mainly those related to aspergillosis and mucormycosis. We will especially focus on atypical radiological presentations that are increasingly observed among non-neutropenic emerging populations of patients at risk, such as those receiving novel anticancer therapies or those in the intensive care unit. We will also discuss the interest of other available imaging techniques, mainly positron emission tomography/CT, that may play a role in the diagnosis as well as evaluation of disease extent and follow-up. We will show that any new airway-centred abnormality or caveated lesion should evoke IMDs in mildly immunocompromised hosts. Limitations in their recognition may be due to potential underlying abnormalities that increase the complexity of interpretation of lung imaging, as well as the non-specificity of imaging features. In this way, the differentials of all morphological/metabolic aspects must be kept in mind for the optimal management of patients, as well as the benefit of evaluation of the vascular status.
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Affiliation(s)
- Alessio Casutt
- Division of Pulmonology, Lausanne University Hospital (CHUV) and University of Lausanne (UNIL), Lausanne, Switzerland
- Division of Pulmonology, Ospedale Regionale di Lugano, Ente Ospedaliero Cantonale (EOC), Lugano, Switzerland
| | - Frédéric Lamoth
- Infectious Diseases Service, Department of Medicine, Lausanne University Hospital (CHUV) and University of Lausanne (UNIL), Lausanne, Switzerland
- Institute of Microbiology, Department of Laboratories, Lausanne University Hospital (CHUV) and University of Lausanne (UNIL), Lausanne, Switzerland
| | - Olivier Lortholary
- University Paris Cité, Necker Enfants Malades University Hospital, AP-HP, IHU Imagine, Paris, France
- Institut Pasteur, National Reference Center for Invasive Mycoses and Antifungals, Paris, France
| | - John O Prior
- Department of Nuclear Medicine and Molecular Imaging, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Andrea Tonglet
- Department of Diagnostic and Interventional Radiology, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Oriol Manuel
- Infectious Diseases Service, Department of Medicine, Lausanne University Hospital (CHUV) and University of Lausanne (UNIL), Lausanne, Switzerland
- Transplantation Center, Lausanne University Hospital (CHUV) and University of Lausanne (UNIL), Lausanne, Switzerland
| | - Anne Bergeron
- Department of Pulmonology, Geneva University Hospital, University of Geneva, Geneva, Switzerland
- A. Bergeron and C. Beigelman-Aubry contributed equally to this work
| | - Catherine Beigelman-Aubry
- Department of Diagnostic and Interventional Radiology, Lausanne University Hospital (CHUV), Lausanne, Switzerland
- A. Bergeron and C. Beigelman-Aubry contributed equally to this work
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23
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Desai JV, Lionakis MS. C5-C5aR1-mediated immune responses during fungal infection: Clinical and translational implications. Clin Transl Med 2023; 13:e1424. [PMID: 37723621 PMCID: PMC10507165 DOI: 10.1002/ctm2.1424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Accepted: 09/09/2023] [Indexed: 09/20/2023] Open
Affiliation(s)
- Jigar V. Desai
- Fungal Pathogenesis Section, Laboratory of Clinical Immunology and Microbiology (LCIM)National Institute of Allergy and Infectious Diseases (NIAID)National Institutes of Health (NIH)BethesdaMarylandUSA
- Present address:
Center for Discovery and Innovation, Hackensack Meridian Health, Nutley, NJ, USA
| | - Michail S. Lionakis
- Fungal Pathogenesis Section, Laboratory of Clinical Immunology and Microbiology (LCIM)National Institute of Allergy and Infectious Diseases (NIAID)National Institutes of Health (NIH)BethesdaMarylandUSA
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24
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Kajeekul R, Mekawichai P, Chayakulkeeree M. Clinical Features of Cryptococcal Meningoencephalitis in HIV-Positive and -Negative Patients in a Resource-Limited Setting. J Fungi (Basel) 2023; 9:869. [PMID: 37754977 PMCID: PMC10532421 DOI: 10.3390/jof9090869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 08/17/2023] [Accepted: 08/21/2023] [Indexed: 09/28/2023] Open
Abstract
Cryptococcal meningoencephalitis is a systemic fungal infection in immunocompromised and immunocompetent individuals. This study investigated the clinical characteristics and factors associated with mortality in HIV-associated and non-HIV-associated cryptococcal meningoencephalitis in a resource-limited setting. This was a retrospective cohort study of patients with cryptococcal meningoencephalitis between January 2009 and December 2019 at a tertiary teaching hospital in Thailand. Overall, 1019 patients with cryptococcal meningoencephalitis were enrolled, and 923 (90.6%) were HIV-positive. The patients with HIV-associated cryptococcal meningoencephalitis were younger than the HIV-negative patients (37 versus 56 years, p < 0.01). The HIV-negative patients were more likely to have underlying conditions (52.1% versus 7.5%; p < 0.01), had a longer median duration of headaches prior to admission (14 days versus 6 days, p < 0.01), and were more likely to have an altered mental status at presentation (36.5% versus 18.6%, p < 0.01) and pulmonary involvement (15.6% versus 0.8%, p < 0.01). The HIV-positive patients had lower cerebrospinal fluid (CSF) white blood cell counts (4 versus 94 cells/mm3; p < 0.01), lower CSF protein (69 versus 157 mg/dL; p < 0.01), higher CSF glucose (38.8 versus 21 mg/dL; p < 0.01), and more frequent cryptococcemia (44.1% versus 20.5%; p < 0.01). The mortality rate was high but not significantly different between the two groups (30.2% versus 33.2%; p = 0.53). The HIV-positive patients with comorbidities, fever, an altered mental status at presentation, a CSF white blood cell count below 20 cell/mm3, fungemia, and positive CSF India ink were independently associated with 30-day mortality. In comparison, an altered mental status at presentation and fungemia were associated with 30-day mortality in HIV-negative patients. In conclusion, HIV-negative patients with cryptococcal meningoencephalitis had more extensive central nervous system inflammation, although the two groups' mortality rates were similar. Unfavorable prognostic factors included comorbidities, fever, an altered mental status at presentation, a low CSF white blood cell count, fungemia, and positive CSF India ink.
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Affiliation(s)
- Rattagan Kajeekul
- Department of Internal Medicine, Maharat Nakhon Ratchasima Hospital, Nakhon Ratchasima 30000, Thailand;
| | - Pawut Mekawichai
- Department of Internal Medicine, Maharat Nakhon Ratchasima Hospital, Nakhon Ratchasima 30000, Thailand;
| | - Methee Chayakulkeeree
- Division of Infectious Diseases and Tropical Medicine, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand
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25
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Messina JA, Giamberardino CD, Tenor JL, Toffaletti DL, Schell WA, Asfaw YG, Palmucci JR, Lionakis MS, Perfect JR. Susceptibility to Cryptococcus neoformans Infection with Bruton's Tyrosine Kinase Inhibition. Infect Immun 2023; 91:e0004223. [PMID: 37404186 PMCID: PMC10429641 DOI: 10.1128/iai.00042-23] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Accepted: 05/01/2023] [Indexed: 07/06/2023] Open
Abstract
Patients receiving the Bruton's tyrosine kinase (BTK) inhibitor ibrutinib have an increased likelihood of fungal infections. The objectives of this study were to determine if Cryptococcus neoformans infection severity was isolate dependent with BTK inhibition and whether blocking BTK impacted infection severity in a mouse model. We compared four clinical isolates from patients on ibrutinib to virulent (H99) and avirulent (A1-35-8) reference strains. BTK knockout (KO) and wild-type (WT) C57 mice and WT CD1 mice were infected by intranasal (i.n.), oropharyngeal aspiration (OPA), and intravenous (i.v.) routes. Infection severity was assessed by survival and fungal burden (CFU per gram of tissue). Ibrutinib (25 mg/kg) or vehicle was administered daily through intraperitoneal injections. In the BTK KO model, no isolate-dependent effect on fungal burden was observed, and infection severity was not significantly different from that of the WT with i.n., OPA, and i.v. routes. Ibrutinib treatment did not impact infection severity. However, when the four clinical isolates were compared to H99, two of these isolates were less virulent, with significantly longer survival and reduced rates of brain infection. In conclusion, C. neoformans infection severity in the BTK KO model does not appear to be isolate dependent. BTK KO and ibrutinib treatment did not result in significantly different infection severities. However, based on repeated clinical observations of increased susceptibility to fungal infections with BTK inhibitor therapy, further work is needed to optimize a mouse model with BTK inhibition to better understand the role that this pathway plays in susceptibility to C. neoformans infection.
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Affiliation(s)
- Julia A. Messina
- Duke University School of Medicine, Department of Medicine, Division of Infectious Diseases, Durham, North Carolina, USA
| | - Charles D. Giamberardino
- Duke University School of Medicine, Department of Medicine, Division of Infectious Diseases, Durham, North Carolina, USA
| | - Jennifer L. Tenor
- Duke University School of Medicine, Department of Medicine, Division of Infectious Diseases, Durham, North Carolina, USA
| | - Dena L. Toffaletti
- Duke University School of Medicine, Department of Medicine, Division of Infectious Diseases, Durham, North Carolina, USA
| | - Wiley A. Schell
- Duke University School of Medicine, Department of Medicine, Division of Infectious Diseases, Durham, North Carolina, USA
| | - Yohannes G. Asfaw
- Duke University School of Medicine, Department of Medicine, Division of Infectious Diseases, Durham, North Carolina, USA
| | - Julia R. Palmucci
- Duke University School of Medicine, Department of Medicine, Division of Infectious Diseases, Durham, North Carolina, USA
| | - Michail S. Lionakis
- National Institutes of Health, Fungal Pathogenesis Section, Laboratory of Clinical Immunology and Microbiology, National Institutes of Allergy and Infectious Diseases, Bethesda, Maryland, USA
| | - John R. Perfect
- Duke University School of Medicine, Department of Medicine, Division of Infectious Diseases, Durham, North Carolina, USA
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26
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Damaraju V, Agarwal R, Singh Sehgal I, Khadwal A, Bal A, Rudramurthy SM, Muthu V. Ibrutinib and tracheal mucormycosis: A case report and systematic review of literature. J Mycol Med 2023; 33:101414. [PMID: 37523991 DOI: 10.1016/j.mycmed.2023.101414] [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: 12/12/2022] [Revised: 05/13/2023] [Accepted: 07/19/2023] [Indexed: 08/02/2023]
Abstract
Ibrutinib, a Bruton tyrosine kinase (BTK) inhibitor, has been approved for various hematological malignancies. Invasive aspergillosis is a known complication of ibrutinib, but mucormycosis is rare. We describe the case of a 70-year-old man with mantle cell lymphoma infiltrating the trachea, managed with a tracheobronchial stent and ibrutinib. He had improved one month after treatment, and we removed the airway stent. Four months later, he developed tracheal nodules confirmed to be tracheal mucormycosis and responded to liposomal amphotericin B (3.5 g) followed by posaconazole. After transient improvement, the tracheal lesions recurred, the biopsy showed lymphoma (with no evidence of mucormycosis), and he died. A systematic review of the literature identified 20 additional cases of ibrutinib-associated mucormycosis. Most of the 21 patients included were men (95%), and ibrutinib was the only risk factor in 15.7%. The reported mortality was 31.6% (6/19), attributable to mucormycosis in half the cases.
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Affiliation(s)
- Vikram Damaraju
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Ritesh Agarwal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Inderpaul Singh Sehgal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Alka Khadwal
- Department of Clinical Hematology and Oncology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Amanjit Bal
- Department of Histopathology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | | | - Valliappan Muthu
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India.
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27
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Apostolidi EA, Gamaletsou MN, Arapaki M, Asimakopoulos JV, Diamantopoulos P, Zafeiratou S, Kofteridis D, Pagoni M, Kotsopoulou M, Voulgarelis M, Sipsas NV. Bone Marrow Iron Stores Are Not Associated with Increased Risk for Invasive Fungal Infections in Patients with Newly Diagnosed Acute Leukemia or Myelodysplastic Syndrome in Transformation: Is There a Relationship? J Fungi (Basel) 2023; 9:748. [PMID: 37504736 PMCID: PMC10381291 DOI: 10.3390/jof9070748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 07/02/2023] [Accepted: 07/12/2023] [Indexed: 07/29/2023] Open
Abstract
Iron plays an important role in the pathogenesis of infections, including invasive fungal infections (IFIs). Studies suggested that iron overload might represent an additional risk factor for IFIs among patients with hematological malignancies. We conducted a prospective, multi-center study amongst adult patients with newly diagnosed acute myeloid leukemia (AML) or myelodysplastic syndrome (MDS) in transformation to determine whether baseline iron overload as measured using the bone marrow iron store (BMIS) score is an independent risk factor for the development of IFIs. We also measured baseline serum iron and ferritin levels. A total of 98 patients were enrolled (76 with AML) and were followed for 12 months. Twenty-two patients developed IFI during the follow-up period (invasive aspergillosis n = 16, candidemia n = 5, mucormycosis n = 1). A baseline BMIS score ≥ 3 indicated that iron overload was relatively common (38/98 patients, 38%), and its frequency was comparable between patients with no IFIs (31/76, 40.7%) and in those with IFIs (8/22, 36.4%). Univariate analysis showed that only the presence of AML was associated with increased risk for IFIs [OR (95% CI) 7.40 (1.05-325.42)]. Both univariate and multivariate analyses showed that an increased BMIS score (≥3) at baseline was not an independent risk factor for IFIs. Similarly, there was no difference in serum iron and ferritin between the two groups that had similar demographic characteristics. Indices of iron overload were not independent risk factors for IFIs in our cohort of Greek patients with newly diagnosed AML/MDS in transformation.
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Affiliation(s)
- Eirini A Apostolidi
- Pathophysiology Department, General Hospital of Athens Laiko, Medical School, National and Kapodistrian University of Athens, 11527 Athens, Greece
| | - Maria N Gamaletsou
- Pathophysiology Department, General Hospital of Athens Laiko, Medical School, National and Kapodistrian University of Athens, 11527 Athens, Greece
| | - Maria Arapaki
- Hematology Department, General Hospital of Athens Laiko, 11527 Athens, Greece
| | | | - Panagiotis Diamantopoulos
- First Department of Internal Medicine, General Hospital of Athens Laiko, Medical School, National and Kapodistrian University of Athens, 11527 Athens, Greece
| | - Sofia Zafeiratou
- Department of Hygiene, Epidemiology and Medical Statistics, Medical School, National and Kapodistrian University of Athens, 11527 Athens, Greece
| | - Diamantis Kofteridis
- Medicine Department, Medical School, University of Crete, 71003 Heraklion, Greece
| | - Maria Pagoni
- Hematology Department, General Hospital of Athens Evangelismos, 10676 Athens, Greece
| | | | - Michael Voulgarelis
- Pathophysiology Department, General Hospital of Athens Laiko, Medical School, National and Kapodistrian University of Athens, 11527 Athens, Greece
| | - Nikolaos V Sipsas
- Pathophysiology Department, General Hospital of Athens Laiko, Medical School, National and Kapodistrian University of Athens, 11527 Athens, Greece
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Wang CM, Liu H, Li LJ, Song J, Wang HQ, Wu YH, Guan J, Xing LM, Wang GJ, Liu H, Qu W, Wang XM, Shao ZH, Fu R. [Analysis of infection in B-cell lymphoma patients treated with BTK inhibitors]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2023; 44:582-586. [PMID: 37749040 PMCID: PMC10509625 DOI: 10.3760/cma.j.issn.0253-2727.2023.07.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Indexed: 09/27/2023]
Affiliation(s)
- C M Wang
- Department of Hematology, Tianjin Medical University General Hospital, Tianjin 300052, China
| | - H Liu
- Department of Hematology, Tianjin Medical University General Hospital, Tianjin 300052, China
| | - L J Li
- Department of Hematology, Tianjin Medical University General Hospital, Tianjin 300052, China
| | - J Song
- Department of Hematology, Tianjin Medical University General Hospital, Tianjin 300052, China
| | - H Q Wang
- Department of Hematology, Tianjin Medical University General Hospital, Tianjin 300052, China
| | - Y H Wu
- Department of Hematology, Tianjin Medical University General Hospital, Tianjin 300052, China
| | - J Guan
- Department of Hematology, Tianjin Medical University General Hospital, Tianjin 300052, China
| | - L M Xing
- Department of Hematology, Tianjin Medical University General Hospital, Tianjin 300052, China
| | - G J Wang
- Department of Hematology, Tianjin Medical University General Hospital, Tianjin 300052, China
| | - H Liu
- Department of Hematology, Tianjin Medical University General Hospital, Tianjin 300052, China
| | - W Qu
- Department of Hematology, Tianjin Medical University General Hospital, Tianjin 300052, China
| | - X M Wang
- Department of Hematology, Tianjin Medical University General Hospital, Tianjin 300052, China
| | - Z H Shao
- Department of Hematology, Tianjin Medical University General Hospital, Tianjin 300052, China
| | - R Fu
- Department of Hematology, Tianjin Medical University General Hospital, Tianjin 300052, China
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Criscuolo M, Fracchiolla N, Farina F, Verga L, Pagano L, Busca A. A review of prophylactic regimens to prevent invasive fungal infections in hematology patients undergoing chemotherapy or stem cell transplantation. Expert Rev Hematol 2023; 16:963-980. [PMID: 38044878 DOI: 10.1080/17474086.2023.2290639] [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: 09/07/2023] [Accepted: 11/29/2023] [Indexed: 12/05/2023]
Abstract
INTRODUCTION The recent introduction of targeted therapies, including monoclonal antibodies, tyrosine-kinase inhibitors, and immunotherapies has improved the cure rate of hematologic patients. The implication of personalized treatment on primary antifungal prophylaxis will be discussed. AREAS COVERED We reviewed the literature for clinical trials reporting the rate of invasive fungal infections during targeted and cellular therapies and stem cell transplant, and the most recent international guidelines for primary antifungal prophylaxis. EXPERT OPINION As the use of personalized therapies is growing, the risk of invasive fungal infection has emerged in various clinical settings. Therefore, it is possible that the use of mold-active antifungal prophylaxis would spread in the next years and the risk of breakthrough infections would increase. The introduction of new antifungal agents in the clinical armamentarium is expected to reduce clinical unmet needs concerning the management of primary antifungal prophylaxis and improve outcome of patients.
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Affiliation(s)
- Marianna Criscuolo
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
| | - Nicola Fracchiolla
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico Milano, Milan, Italy
| | | | | | - Livio Pagano
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
- Sezione di Ematologia, Dipartimento di Scienze Radiologiche ed Ematologiche, Università Cattolica del Sacro Cuore, Roma, Italy
| | - Alessandro Busca
- Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Department of Oncology, SSCVD Trapianto di Cellule Staminali Torino, Torino, Italy
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Walsh M, Xu A, Ballas Z, Sanchez R. Disseminated fungal infection in a patient receiving zanubrutinib. Clin Case Rep 2023; 11:e7564. [PMID: 37323284 PMCID: PMC10264913 DOI: 10.1002/ccr3.7564] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 05/25/2023] [Accepted: 06/01/2023] [Indexed: 06/17/2023] Open
Abstract
We report a case of fatal disseminated aspergillosis in the setting of administration of zanubrutinib, a second-generation Bruton's tyrosine kinase inhibitor thought to have a lower rate of immunosuppression-related side effects.
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Affiliation(s)
- Madalyn Walsh
- Department of Internal MedicineUniversity of Iowa Hospitals & ClinicsIowa CityIowaUSA
| | - Alice Xu
- Department of Internal MedicineUniversity of Iowa Hospitals & ClinicsIowa CityIowaUSA
| | - Zuhair Ballas
- Division of ImmunologyUniversity of Iowa Hospitals & ClinicsIowa CityIowaUSA
| | - Rolando Sanchez
- Division of Pulmonary, Critical Care and Occupational MedicineUniversity of Iowa Hospitals & ClinicsIowa CityIowaUSA
- Pulmonary Medicine, VA Iowa City Health CareVirginia Medical CenterIowa CityIowaUSA
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Tey A, Schwarer J, Raffa R, Shi E, Paul E, Opat S, Dendle C, Shortt J. High risk of infection in 'real-world' patients receiving ibrutinib, idelalisib or venetoclax for mature B-cell leukaemia/lymphoma. Eur J Haematol 2023; 110:540-547. [PMID: 36656100 PMCID: PMC10952205 DOI: 10.1111/ejh.13928] [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: 11/20/2022] [Revised: 01/11/2023] [Accepted: 01/13/2023] [Indexed: 01/20/2023]
Abstract
OBJECTIVE The infection risk in patients receiving ibrutinib, idelalisib or venetoclax for chronic lymphocytic leukaemia (CLL) or B-cell lymphoma treated outside of clinical trials is incompletely defined. We sought to identify the severe infection rate and associated risk factors in a 'real-world' cohort. METHODS We conducted a retrospective cohort study of adult patients with CLL or lymphoma treated with ibrutinib, idelalisib or venetoclax. RESULTS Of 67 patients identified (ibrutinib n = 53, idelalisib n = 8 and venetoclax n = 6), 32 (48%) experienced severe infection. Severe infection occurred at a rate of 65 infections per 100 person-years, with a median of 17.8 months of therapy. Median time to first infection (IQR) was 5.4 months (1.4-15.9). Poor baseline Eastern Cooperative Oncology Group (ECOG) performance status and high Charlson Comorbidity Index (CCI) score associated with increased risk of severe infection [hazard ratios (95% CI) 1.57 (1.07-2.31, p = .018) and 1.3 (1.05-1.62, p = .016) respectively]. CONCLUSION The severe infection rate for patients receiving ibrutinib, idelalisib or venetoclax for lymphoma and CLL exceeded those reported in clinical trials. Patients with poor ECOG or high CCI should be closely monitored for early signs of infection and prevention strategies actively pursued. Further prospective research is required to define optimal antimicrobial prophylaxis recommendations.
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MESH Headings
- Adult
- Humans
- Leukemia, Lymphocytic, Chronic, B-Cell/complications
- Leukemia, Lymphocytic, Chronic, B-Cell/diagnosis
- Leukemia, Lymphocytic, Chronic, B-Cell/drug therapy
- Retrospective Studies
- Lymphoma, B-Cell/drug therapy
- Antineoplastic Combined Chemotherapy Protocols/adverse effects
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Affiliation(s)
- Amanda Tey
- Pharmacy DepartmentMonash HealthClaytonVictoriaAustralia
| | - James Schwarer
- Monash Infectious DiseasesMonash HealthClaytonVictoriaAustralia
| | - Robert Raffa
- Pharmacy DepartmentMonash HealthClaytonVictoriaAustralia
| | - Emily Shi
- Pharmacy DepartmentMonash HealthClaytonVictoriaAustralia
| | - Eldho Paul
- Monash Centre for Health Research and Implementation, School of Public Health and Preventive MedicineMonash UniversityClaytonVictoriaAustralia
| | - Stephen Opat
- Department of Medicine, School of Clinical Sciences at Monash HealthMonash UniversityClaytonVictoriaAustralia
- Monash HaematologyMonash HealthClaytonVictoriaAustralia
| | - Claire Dendle
- Monash Infectious DiseasesMonash HealthClaytonVictoriaAustralia
- Department of Medicine, School of Clinical Sciences at Monash HealthMonash UniversityClaytonVictoriaAustralia
| | - Jake Shortt
- Department of Medicine, School of Clinical Sciences at Monash HealthMonash UniversityClaytonVictoriaAustralia
- Monash HaematologyMonash HealthClaytonVictoriaAustralia
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Lionakis MS. Exploiting antifungal immunity in the clinical context. Semin Immunol 2023; 67:101752. [PMID: 37001464 PMCID: PMC10192293 DOI: 10.1016/j.smim.2023.101752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2022] [Indexed: 03/31/2023]
Abstract
The continuous expansion of immunocompromised patient populations at-risk for developing life-threatening opportunistic fungal infections in recent decades has helped develop a deeper understanding of antifungal host defenses, which has provided the foundation for eventually devising immune-based targeted interventions in the clinic. This review outlines how genetic variation in certain immune pathway-related genes may contribute to the observed clinical variability in the risk of acquisition and/or severity of fungal infections and how immunogenetic-based patient stratification may enable the eventual development of personalized strategies for antifungal prophylaxis and/or vaccination. Moreover, this review synthesizes the emerging cytokine-based, cell-based, and other immunotherapeutic strategies that have shown promise as adjunctive therapies for boosting or modulating tissue-specific antifungal immune responses in the context of opportunistic fungal infections.
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Affiliation(s)
- Michail S Lionakis
- From the Fungal Pathogenesis Section, Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy & Infectious Diseases, National Institutes of Health, Bethesda, MD, USA.
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Pilmis B, Kherabi Y, Huriez P, Zahar JR, Mokart D. Infectious Complications of Targeted Therapies for Solid Cancers or Leukemias/Lymphomas. Cancers (Basel) 2023; 15:cancers15071989. [PMID: 37046650 PMCID: PMC10093532 DOI: 10.3390/cancers15071989] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 03/20/2023] [Accepted: 03/23/2023] [Indexed: 03/29/2023] Open
Abstract
Background: Infections are well known complications of some targeted drugs used to treat solid organ cancer and hematological malignancies. Furthermore, Individual patient risk factors are associated with underlying pathologies, concomitant immunosuppressive treatment, prior treatment and use of anti-infective prophylaxis. Immune-related adverse events (irAEs) are frequent among patients treated with new targeted drugs. Objectives: In this narrative review, we present the current state of knowledge concerning the infectious complications occurring in patients treated with immune checkpoint inhibitors (ICIs), Bruton’s tyrosine kinase (BTK) inhibitors, phosphatidylinositol 3-kinase (PI3K) inhibitors, antiapoptotic protein BCL-2 inhibitors, Janus kinase inhibitors or CAR-T cell infusion. Sources: We searched for studies treating infectious complications of ICIs, BTK inhibitors, PI3K inhibitors, antiapoptotic protein BCL-2 inhibitors and CAR-T cell therapy. We included randomized, observational studies and case reports. Content: Immune-related adverse events (irAEs) are frequent among patients treated with new targeted drugs. Treatment of irAEs with corticosteroids and other immunosuppressive agents can lead to opportunistic infections. Bruton’s tyrosine kinase (BTK) inhibitors are associated with higher rate of infections, including invasive fungal infections. Implications: Infections, particularly fungal ones, are common in patients treated with BTK inhibitors even though most of the complications occurring among patients treated by ICIs or CART-cells infusion are associated with the treatment of side effects related to the use of these new treatments. The diagnosis of these infectious complications can be difficult and may require extensive investigations.
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Affiliation(s)
- Benoît Pilmis
- Equipe Mobile de Microbiologie Clinique, Groupe Hospitalier Paris Saint-Joseph, 75014 Paris, France
- UMR 1319, Institut Micalis, Université Paris-Saclay, INRAeChâtenay Malabry, AgroParisTech, 92290 Chatenay Malabry, France
- Correspondence: ; Tel.: +33-1-44-12-78-20; Fax: +33-1-44-12-35-13
| | - Yousra Kherabi
- Equipe Mobile de Microbiologie Clinique, Groupe Hospitalier Paris Saint-Joseph, 75014 Paris, France
| | - Pauline Huriez
- Equipe Mobile de Microbiologie Clinique, Groupe Hospitalier Paris Saint-Joseph, 75014 Paris, France
| | - Jean-Ralph Zahar
- Infection Control Unit, AP-HP Hôpital Avicenne, Université Sorbonne Paris Nord, 93000 Bobigny, France
| | - Djamel Mokart
- Medical Surgical Intensive Care Unit, Institut Paoli Calmettes, 13009 Marseille, France
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Approach to the diagnosis of invasive fungal infections of the respiratory tract in the immunocompromised host. Curr Opin Pulm Med 2023; 29:149-159. [PMID: 36917216 DOI: 10.1097/mcp.0000000000000955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/15/2023]
Abstract
PURPOSE OF REVIEW The burden of invasive fungal infection is increasing worldwide, largely due to a growing population at-risk. Most serious human fungal pathogens enter the host via the respiratory tract. Early identification and treatment of invasive fungal respiratory infections (IFRIs) in the immunocompromised host saves lives. However, their accurate diagnosis is a difficult challenge for clinicians and mortality remains high. RECENT FINDINGS This article reviews IFRIs, focussing on host susceptibility factors, clinical presentation, and mycological diagnosis. Several new diagnostic tools are coming of age including molecular diagnostics and point-of-care antigen tests. As diagnosis of IFRI relies heavily on invasive procedures like bronchoalveolar lavage and lung biopsy, several novel noninvasive diagnostic techniques are in development, such as metagenomics, 'volatilomics' and advanced imaging technologies. SUMMARY Where IFRI cannot be proven, clinicians must employ a 'weights-of-evidence' approach to evaluate host factors, clinical and mycological data. Implementation studies are needed to understand how new diagnostic tools can be best applied within clinical pathways. Differentiating invasive infection from colonization and identifying antifungal resistance remain key challenges. As our diagnostic arsenal expands, centralized clinical mycology laboratories and efforts to ensure access to new diagnostics in low-resource settings will become increasingly important.
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Abstract
The respiratory tree maintains sterilizing immunity against human fungal pathogens. Humans inhale ubiquitous filamentous molds and geographically restricted dimorphic fungal pathogens that form small airborne conidia. In addition, pathogenic yeasts, exemplified by encapsulated Cryptococcus species, and Pneumocystis pose significant fungal threats to the lung. Classically, fungal pneumonia occurs in immune compromised individuals, specifically in patients with HIV/AIDS, in patients with hematologic malignancies, in organ transplant recipients, and in patients treated with corticosteroids and targeted biologics that impair fungal immune surveillance in the lung. The emergence of fungal co-infections during severe influenza and COVID-19 underscores the impairment of fungus-specific host defense pathways in the lung by respiratory viruses and by medical therapies to treat viral infections. Beyond life-threatening invasive syndromes, fungal antigen exposure can exacerbate allergenic disease in the lung. In this review, we discuss emerging principles of lung-specific antifungal immunity, integrate the contributions and cooperation of lung epithelial, innate immune, and adaptive immune cells to mucosal barrier immunity, and highlight the pathogenesis of fungal-associated allergenic disease. Improved understanding of fungus-specific immunity in the respiratory tree has paved the way to develop improved diagnostic, pre-emptive, therapeutic, and vaccine approaches for fungal diseases of the lung.
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Affiliation(s)
- Lena J Heung
- Division of Infectious Diseases, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA; Research Division of Immunology, Department of Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA, USA; Women's Guild Lung Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Darin L Wiesner
- Center for Immunity and Inflammation, New Jersey Medical School, Rutgers Biomedical and Health Sciences, Newark, NJ, USA
| | - Keyi Wang
- Center for Immunity and Inflammation, New Jersey Medical School, Rutgers Biomedical and Health Sciences, Newark, NJ, USA
| | - Amariliz Rivera
- Center for Immunity and Inflammation, New Jersey Medical School, Rutgers Biomedical and Health Sciences, Newark, NJ, USA
| | - Tobias M Hohl
- Infectious Disease Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Human Oncology and Pathogenesis Program, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
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36
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Ledoux MP, Herbrecht R. Invasive Pulmonary Aspergillosis. J Fungi (Basel) 2023; 9:jof9020131. [PMID: 36836246 PMCID: PMC9962768 DOI: 10.3390/jof9020131] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 01/12/2023] [Accepted: 01/15/2023] [Indexed: 01/19/2023] Open
Abstract
Invasive pulmonary aspergillosis is growing in incidence, as patients at risk are growing in diversity. Outside the classical context of neutropenia, new risk factors are emerging or newly identified, such as new anticancer drugs, viral pneumonias and hepatic dysfunctions. Clinical signs remain unspecific in these populations and the diagnostic work-up has considerably expanded. Computed tomography is key to assess the pulmonary lesions of aspergillosis, whose various features must be acknowledged. Positron-emission tomography can bring additional information for diagnosis and follow-up. The mycological argument for diagnosis is rarely fully conclusive, as biopsy from a sterile site is challenging in most clinical contexts. In patients with a risk and suggestive radiological findings, probable invasive aspergillosis is diagnosed through blood and bronchoalveolar lavage fluid samples by detecting galactomannan or DNA, or by direct microscopy and culture for the latter. Diagnosis is considered possible with mold infection in lack of mycological criterion. Nevertheless, the therapeutic decision should not be hindered by these research-oriented categories, that have been completed by better adapted ones in specific settings. Survival has been improved over the past decades with the development of relevant antifungals, including lipid formulations of amphotericin B and new azoles. New antifungals, including first-in-class molecules, are awaited.
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Lamoth F, Calandra T. Pulmonary aspergillosis: diagnosis and treatment. Eur Respir Rev 2022; 31:31/166/220114. [DOI: 10.1183/16000617.0114-2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 09/18/2022] [Indexed: 12/05/2022] Open
Abstract
Aspergillusspecies are the most frequent cause of fungal infections of the lungs with a broad spectrum of clinical presentations including invasive pulmonary aspergillosis (IPA) and chronic pulmonary aspergillosis (CPA). IPA affects immunocompromised populations, which are increasing in number and diversity with the advent of novel anti-cancer therapies. Moreover, IPA has emerged as a complication of severe influenza and coronavirus disease 2019 in apparently immunocompetent hosts. CPA mainly affects patients with pre-existing lung lesions and is recognised increasingly frequently among patients with long-term survival following cure of tuberculosis or lung cancer. The diagnosis of pulmonary aspergillosis is complex as it relies on the presence of clinical, radiological and microbiological criteria, which differ according to the type of pulmonary aspergillosis (IPA or CPA) and the type of patient population. The management of pulmonary aspergillosis is complicated by the limited number of treatment options, drug interactions, adverse events and the emergence of antifungal resistance.
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An L, Chen P, Wang J, Qin X, Liu T, Gao Y, Wang P, Zhang D, Fang X, Zhang Z. Case report: Recurrent lung infections following treatment with pralsetinib for an elderly patient with RET-fusion positive NSCLC. Front Oncol 2022; 12:1024365. [PMID: 36568233 PMCID: PMC9773986 DOI: 10.3389/fonc.2022.1024365] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2022] [Accepted: 11/10/2022] [Indexed: 12/13/2022] Open
Abstract
Patients with RET fusions represent 1-2% of all cases of non-small cell lung cancer (NSCLC), the majority of whom are younger, and are extremely rare in the elderly. As a selective RET inhibitor, pralsetinib has been shown to be efficacious and well-tolerated in patients with RET-fusion NSCLC. Nevertheless, there are currently insufficient data available for assessing the activity and safety of pralsetinib in elderly patients with NSCLC. Herein, we report an 81-year-old NSCLC patient with KIF5B-RET fusion, who achieved stable disease for more than 9 months at a low-dose of pralsetinib as second-line therapy. Of particular note, during pralsetinb therapy, his clinical course was complicated by cryptococcal pneumonia and staphylococcus aureus lung abscess. Our study demonstrates that pralsetinib is an effective therapeutic option that provides survival benefits for elderly NSCLC patients harboring RET fusion. However, during pralsetinb therapy, treating physicians should maintain particular vigilance for the increased risk of infection, especially in elderly patients.
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Affiliation(s)
- Li An
- Department of Respiratory and Critical Care Medicine, The Second Medical Center&National Clinical Research Center for Geriatric Disease, Chinese PLA General Hospital, Beijing, China
| | - Pengzhi Chen
- Department of Respiratory and Critical Care Medicine, The Second Medical Center&National Clinical Research Center for Geriatric Disease, Chinese PLA General Hospital, Beijing, China
| | - Junfeng Wang
- Department of Respiratory and Critical Care Medicine, The Second Medical Center&National Clinical Research Center for Geriatric Disease, Chinese PLA General Hospital, Beijing, China
| | - Xuebing Qin
- Department of Respiratory and Critical Care Medicine, The Second Medical Center&National Clinical Research Center for Geriatric Disease, Chinese PLA General Hospital, Beijing, China
| | - Tingting Liu
- Department of Respiratory and Critical Care Medicine, The Second Medical Center&National Clinical Research Center for Geriatric Disease, Chinese PLA General Hospital, Beijing, China
| | - Yanhong Gao
- Department of Respiratory and Critical Care Medicine, The Second Medical Center&National Clinical Research Center for Geriatric Disease, Chinese PLA General Hospital, Beijing, China
| | - Peng Wang
- Department of Oncology, The Second Medical Center&National Clinical Research Center for Geriatric Disease, Chinese PLA General Hospital, Beijing, China
| | - Dong Zhang
- Department of Oncology, The Second Medical Center&National Clinical Research Center for Geriatric Disease, Chinese PLA General Hospital, Beijing, China
| | - Xiangqun Fang
- Department of Respiratory and Critical Care Medicine, The Second Medical Center&National Clinical Research Center for Geriatric Disease, Chinese PLA General Hospital, Beijing, China,*Correspondence: Zhijian Zhang, ; Xiangqun Fang,
| | - Zhijian Zhang
- Department of Respiratory and Critical Care Medicine, The Second Medical Center&National Clinical Research Center for Geriatric Disease, Chinese PLA General Hospital, Beijing, China,*Correspondence: Zhijian Zhang, ; Xiangqun Fang,
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de Carvalho Patricio BF, da Silva Lopes Pereira JO, Sarcinelli MA, de Moraes BPT, Rocha HVA, Gonçalves-de-Albuquerque CF. Could the Lung Be a Gateway for Amphotericin B to Attack the Army of Fungi? Pharmaceutics 2022; 14:2707. [PMID: 36559201 PMCID: PMC9784761 DOI: 10.3390/pharmaceutics14122707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 11/27/2022] [Accepted: 11/28/2022] [Indexed: 12/07/2022] Open
Abstract
Fungal diseases are a significant cause of morbidity and mortality worldwide, primarily affecting immunocompromised patients. Aspergillus, Pneumocystis, and Cryptococcus are opportunistic fungi and may cause severe lung disease. They can develop mechanisms to evade the host immune system and colonize or cause lung disease. Current fungal infection treatments constitute a few classes of antifungal drugs with significant fungi resistance development. Amphotericin B (AmB) has a broad-spectrum antifungal effect with a low incidence of resistance. However, AmB is a highly lipophilic antifungal with low solubility and permeability and is unstable in light, heat, and oxygen. Due to the difficulty of achieving adequate concentrations of AmB in the lung by intravenous administration and seeking to minimize adverse effects, nebulized AmB has been used. The pulmonary pathway has advantages such as its rapid onset of action, low metabolic activity at the site of action, ability to avoid first-pass hepatic metabolism, lower risk of adverse effects, and thin thickness of the alveolar epithelium. This paper presented different strategies for pulmonary AmB delivery, detailing the potential of nanoformulation and hoping to foster research in the field. Our finds indicate that despite an optimistic scenario for the pulmonary formulation of AmB based on the encouraging results discussed here, there is still no product registration on the FDA nor any clinical trial undergoing ClinicalTrial.gov.
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Affiliation(s)
- Beatriz Ferreira de Carvalho Patricio
- Pharmacology Laboratory, Biomedical Institute, Federal University of State of Rio de Janeiro, 94 Frei Caneca Street, Rio de Janeiro 20211-010, Brazil
- Postgraduate Program in Molecular and Cell Biology, Biomedical Institute, Federal University of State of Rio de Janeiro, 94 Frei Caneca Street, Rio de Janeiro 20211-010, Brazil
| | | | - Michelle Alvares Sarcinelli
- Laboratory of Micro and Nanotechnology, Institute of Technology of Drugs, Oswaldo Cruz Foundation, Brazil Av., 4036, Rio de Janeiro 213040-361, Brazil
| | - Bianca Portugal Tavares de Moraes
- Postgraduate Program in Biotechnology, Biology Institute, Federal Fluminense University, Rua Prof. Marcos Waldemar de Freitas Reis, Niterói 24210-201, Brazil
- Immunopharmacology Laboratory, Biomedical Institute, Federal University of State of Rio de Janeiro, 94 Frei Caneca Street, Rio de Janeiro 20211-010, Brazil
| | - Helvécio Vinicius Antunes Rocha
- Laboratory of Micro and Nanotechnology, Institute of Technology of Drugs, Oswaldo Cruz Foundation, Brazil Av., 4036, Rio de Janeiro 213040-361, Brazil
| | - Cassiano Felippe Gonçalves-de-Albuquerque
- Postgraduate Program in Molecular and Cell Biology, Biomedical Institute, Federal University of State of Rio de Janeiro, 94 Frei Caneca Street, Rio de Janeiro 20211-010, Brazil
- Postgraduate Program in Biotechnology, Biology Institute, Federal Fluminense University, Rua Prof. Marcos Waldemar de Freitas Reis, Niterói 24210-201, Brazil
- Immunopharmacology Laboratory, Biomedical Institute, Federal University of State of Rio de Janeiro, 94 Frei Caneca Street, Rio de Janeiro 20211-010, Brazil
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40
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Punia A, Choudhary P, Sharma N, Dahiya S, Gulia P, Chhillar AK. Therapeutic Approaches for Combating Aspergillus Associated Infection. Curr Drug Targets 2022; 23:1465-1488. [PMID: 35748549 DOI: 10.2174/1389450123666220623164548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 02/12/2022] [Accepted: 02/16/2022] [Indexed: 01/25/2023]
Abstract
Now-a-days fungal infection emerges as a significant problem to healthcare management systems due to high frequency of associated morbidity, mortality toxicity, drug-drug interactions, and resistance of the antifungal agents. Aspergillus is the most common mold that cause infection in immunocompromised hosts. It's a hyaline mold that is cosmopolitan and ubiquitous in nature. Aspergillus infects around 10 million population each year with a mortality rate of 30-90%. Clinically available antifungal formulations are restricted to four classes (i.e., polyene, triazole, echinocandin, and allylamine), and each of them have their own limitations associated with the activity spectrum, the emergence of resistance, and toxicity. Consequently, novel antifungal agents with modified and altered chemical structures are required to combat these invasive fungal infections. To overcome these limitations, there is an urgent need for new antifungal agents that can act as potent drugs in near future. Currently, some compounds have shown effective antifungal activity. In this review article, we have discussed all potential antifungal therapies that contain old antifungal drugs, combination therapies, and recent novel antifungal formulations, with a focus on the Aspergillus associated infections.
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Affiliation(s)
- Aruna Punia
- Department of Biotechnology, Maharishi Dayanand University, Rohtak, Haryana 124001, India
| | - Pooja Choudhary
- Department of Biotechnology, Maharishi Dayanand University, Rohtak, Haryana 124001, India
| | - Namita Sharma
- Department of Biotechnology, Maharishi Dayanand University, Rohtak, Haryana 124001, India
| | - Sweety Dahiya
- Department of Biotechnology, Maharishi Dayanand University, Rohtak, Haryana 124001, India
| | - Prity Gulia
- Department of Biotechnology, Maharishi Dayanand University, Rohtak, Haryana 124001, India
| | - Anil K Chhillar
- Department of Biotechnology, Maharishi Dayanand University, Rohtak, Haryana 124001, India
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41
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Hoenigl M, Lewis R, van de Veerdonk FL, Verweij PE, Cornely OA. Liposomal amphotericin B—the future. J Antimicrob Chemother 2022; 77:ii21-ii34. [PMID: 36426674 PMCID: PMC9693803 DOI: 10.1093/jac/dkac353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Accepted: 09/26/2022] [Indexed: 11/26/2022] Open
Abstract
Advances in medicine have led to a growing number of people with compromised or suppressed immune systems who are susceptible to invasive fungal infections. In particular, severe fungal infections are becoming increasingly common in ICUs, affecting people within and outside of traditional risk groups alike. This is exemplified by the emergence of severe viral pneumonia as a significant risk factor for invasive pulmonary aspergillosis, and the recognition of influenza-associated pulmonary aspergillosis and, more recently, COVID-19-associated pulmonary aspergillosis. The treatment landscape for haematological malignancies has changed considerably in recent years, and some recently introduced targeted agents, such as ibrutinib, are increasing the risk of invasive fungal infections. Consideration must also be given to the risk of drug–drug interactions between mould-active azoles and small-molecule kinase inhibitors. At the same time, infections caused by rare moulds and yeasts are increasing, and diagnosis continues to be challenging. There is growing concern about azole resistance among both moulds and yeasts, mandating continuous surveillance and personalized treatment strategies. It is anticipated that the epidemiology of fungal infections will continue to change and that new populations will be at risk. Early diagnosis and appropriate treatment remain the most important predictors of survival, and broad-spectrum antifungal agents will become increasingly important. Liposomal amphotericin B will remain an essential therapeutic agent in the armamentarium needed to manage future challenges, given its broad antifungal spectrum, low level of acquired resistance and limited potential for drug–drug interactions.
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Affiliation(s)
- M Hoenigl
- Division of Infectious Diseases, Department of Internal Medicine, Medical University of Graz , Graz , Austria
- BioTechMed-Graz , Graz , Austria
- European Confederation of Medical Mycology (ECMM) Excellence Center, Medical University of Graz , Graz , Austria
| | - R Lewis
- Department of Medical and Surgical Sciences, Infectious Diseases Hospital, IRCSS S’Orsola-Malpighi, University of Bologna , Bologna , Italy
| | - F L van de Veerdonk
- Department of Internal Medicine, Radboud Center for Infectious Diseases, Radboud University Medical Center , Nijmegen , The Netherlands
| | - P E Verweij
- Department of Medical Microbiology, Radboud University Medical Center—CWZ Center of Expertise for Mycology , Nijmegen , The Netherlands
- Center for Infectious Disease Research, Diagnostics and Laboratory Surveillance, National Institute for Public Health and the Environment (RIVM) , Bilthoven , The Netherlands
| | - O A Cornely
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Translational Research, Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD) , Cologne , Germany
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD) and Excellence Center for Medical Mycology (ECMM) , Cologne , Germany
- German Centre for Infection Research (DZIF), Partner Site Bonn-Cologne , Cologne , Germany
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Clinical Trials Centre Cologne (ZKS Köln) , Cologne , Germany
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42
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Idol RA, Bhattacharya S, Huang G, Song Z, Huttenlocher A, Keller NP, Dinauer MC. Neutrophil and Macrophage NADPH Oxidase 2 Differentially Control Responses to Inflammation and to Aspergillus fumigatus in Mice. JOURNAL OF IMMUNOLOGY (BALTIMORE, MD. : 1950) 2022; 209:1960-1972. [PMID: 36426951 PMCID: PMC9643661 DOI: 10.4049/jimmunol.2200543] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 09/08/2022] [Indexed: 12/30/2022]
Abstract
Aspergillus fumigatus is an important opportunistic fungal pathogen and causes invasive pulmonary aspergillosis in conditions with compromised innate antifungal immunity, including chronic granulomatous disease, which results from inherited deficiency of the superoxide-generating leukocyte NADPH oxidase 2 (NOX2). Derivative oxidants have both antimicrobial and immunoregulatory activity and, in the context of A. fumigatus, contribute to both fungal killing and dampening inflammation induced by fungal cell walls. As the relative roles of macrophage versus neutrophil NOX2 in the host response to A. fumigatus are incompletely understood, we studied mice with conditional deletion of NOX2. When NOX2 was absent in alveolar macrophages as a result of LysM-Cre-mediated deletion, germination of inhaled A. fumigatus conidia was increased. Reducing NOX2 activity specifically in neutrophils via S100a8 (MRP8)-Cre also increased fungal burden, which was inversely proportional to the level of neutrophil NOX2 activity. Moreover, diminished NOX2 in neutrophils synergized with corticosteroid immunosuppression to impair lung clearance of A. fumigatus. Neutrophil-specific reduction in NOX2 activity also enhanced acute inflammation induced by inhaled sterile fungal cell walls. These results advance understanding into cell-specific roles of NOX2 in the host response to A. fumigatus. We show that alveolar macrophage NOX2 is a nonredundant effector that limits germination of inhaled A. fumigatus conidia. In contrast, reducing NOX2 activity only in neutrophils is sufficient to enhance inflammation to fungal cell walls as well as to promote invasive A. fumigatus. This may be relevant in clinical settings with acquired defects in NOX2 activity due to underlying conditions, which overlap risk factors for invasive aspergillosis.
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Affiliation(s)
- Rachel A. Idol
- Department of Pediatrics, Washington University School of Medicine in St. Louis, St. Louis, MO 63110, USA
| | - Sourav Bhattacharya
- Department of Pediatrics, Washington University School of Medicine in St. Louis, St. Louis, MO 63110, USA
| | - Guangming Huang
- Department of Pediatrics, Washington University School of Medicine in St. Louis, St. Louis, MO 63110, USA
| | - Zhimin Song
- Department of Pediatrics, Washington University School of Medicine in St. Louis, St. Louis, MO 63110, USA
| | - Anna Huttenlocher
- Department of Medical Microbiology and Immunology and Department of Pediatrics, University of Wisconsin, Madison, WI 53706, USA
| | - Nancy P. Keller
- Department of Medical Microbiology and Immunology and Department of Bacteriology, University of Wisconsin, Madison, WI 53706
| | - Mary C. Dinauer
- Department of Pediatrics and Department of Pathology and Immunology, Washington University School of Medicine in St. Louis, St. Louis, MO 63110, USA
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43
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Conte HA, Biondi MC, Janket SJ, Ackerson LK, Diamandis EP. Babesia microti-induced fulminant sepsis in an immunocompromised host: A case report and the case-specific literature review. Open Life Sci 2022; 17:1200-1207. [PMID: 36185407 PMCID: PMC9483830 DOI: 10.1515/biol-2022-0448] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Revised: 03/30/2022] [Accepted: 05/09/2022] [Indexed: 11/21/2022] Open
Abstract
Babesia microti is an obligate intra-erythrocytic parasite transmitted by infected ticks. B. microti is a eukaryote much larger than prokaryotic microbes and more similar to human hosts in their biochemistry and metabolism. Moreover, Babesia spp. possess various immune evasion mechanisms leading to persistent and sometimes life-threatening diseases in immunocompromised hosts. Chronic lymphocytic leukemia (CLL) is the most prevalent adult B-cell malignancy, and a small percentage of CLL transforms into aggressive lymphomas. CLL also causes immune dysfunction due to the over-expansion of immature and ineffective B-cells. When our patient with indolent CLL presented with anemia, pancytopenia, and splenomegaly, all his healthcare providers presumptively assumed a malignant transformation of CLL. However, these are also the signs and symptoms of babesiosis. Herein, we report a case where B. microti infection was presumed as a malignant transformation of CLL and narrowly avoided a devastating outcome. Although the patient developed fulminant sepsis, he finally received the correct diagnosis and treatment. Unfortunately, the disease recrudesced twice. Each time, it became more difficult to control the infection. We describe the clinical course of the case and discuss the case-specific literature review. This report highlights the importance of differential diagnoses ruling out infections which include babesiosis, prior to initiating the treatment of B-cell malignancy.
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Affiliation(s)
- Harry A Conte
- Department of Infectious Diseases, Saint Francis Hospital, Hartford, CT, USA.,Department of Infectious Diseases, Johnson Memorial Hospital, Stafford Springs, CT, USA
| | - Michael C Biondi
- Department of Radiology, Saint Francis Hospital, Hartford, CT, USA
| | - Sok-Ja Janket
- Center for Clinical and Translational Research, The Forsyth Institute, Cambridge, MA, USA
| | - Leland K Ackerson
- Department of Public Health, University of Massachusetts at Lowell, Lowell, MA, USA
| | - Eleftherios P Diamandis
- Department of Pathology and Laboratory Medicine, Mount Sinai Hospital, 60 Murray St. Box 32, Floor 6, Rm L6-201. Toronto, ON, M5T 3L9, Canada
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Colombo AL, De Almeida JN, Lewis RE, Kontoyiannis DP. Quandaries of deciding when to change first-line therapy in invasive pulmonary aspergillosis. J Antimicrob Chemother 2022; 77:2897-2900. [PMID: 36059133 DOI: 10.1093/jac/dkac301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
We read the excellent viewpoint by Slavin et al. (J Antimicrob Chemother 2022; 77: 16-23) that draws upon the experience of an advisory board of notable experts to comprehensively address many of the clinical factors that drive the need for changes in antifungal therapy for invasive aspergillosis (IA). As noted by the authors, there remains a paucity of quality data to support many of the decisions faced by clinicians managing patients with IA. However, we would like to highlight several other important issues, not fully addressed in that viewpoint, that play an important role in deciding when to change antifungal therapy for IA.
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Affiliation(s)
- Arnaldo L Colombo
- Department of Medicine, Division of Infectious Diseases, Special Mycology Laboratory-LEMI, Federal University of São Paulo, São Paulo, Brazil
| | - João N De Almeida
- Department of Medicine, Division of Infectious Diseases, Special Mycology Laboratory-LEMI, Federal University of São Paulo, São Paulo, Brazil
| | - Russell E Lewis
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Dimitrios P Kontoyiannis
- Department of Infectious Diseases Infection Control and Employee Health, MD Anderson Cancer Center, Houston, TX, USA
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Egger M, Gornicec M, Wölfler A, Lembeck AL, Tinchon C, Maderdonner M, Prattes J. Incidence of invasive fungal infections in patients with hematological malignancies receiving ibrutinib therapy in south-east Austria. Med Mycol 2022; 60:6677974. [PMID: 36029283 DOI: 10.1093/mmy/myac061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 06/09/2022] [Accepted: 08/26/2022] [Indexed: 11/14/2022] Open
Abstract
Since the broad implementation of ibrutinib therapy, an increasing number of studies have been reporting on invasive fungal infections (IFI) associated with ibrutinib administration. We conducted a retrospective cohort study in three hospitals in south-east Austria in order to assess the local epidemiology of ibrutinib associated IFIs. One-hundred-thirteen patients with underlying hematological malignancy were included in the study. During the study period, a single IFI episode was observed, which corresponds to an IFI incidence of 2.3 cases per 100 person years (95% CI: 0.12-11.47). IFIs during ibrutinib therapy seem to be a rare event in case of absent additional risk factors for IFIs.
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Affiliation(s)
- Matthias Egger
- Division of Infectious Diseases, Medical University of Graz, Graz, Austria
| | - Max Gornicec
- Division of Infectious Diseases, Medical University of Graz, Graz, Austria
| | - Albert Wölfler
- Division of Hematology, Medical University of Graz, Graz, Austria
| | - Anna Lena Lembeck
- Division of Internal Medicine, Hospital of the Brothers of St. John of God, Graz, Austria
| | | | | | - Juergen Prattes
- Division of Infectious Diseases, Medical University of Graz, Graz, Austria
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46
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Role of Iron and Iron Overload in the Pathogenesis of Invasive Fungal Infections in Patients with Hematological Malignancies. J Clin Med 2022; 11:jcm11154457. [PMID: 35956074 PMCID: PMC9369168 DOI: 10.3390/jcm11154457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 07/28/2022] [Accepted: 07/28/2022] [Indexed: 02/04/2023] Open
Abstract
Iron is an essential trace metal necessary for the reproduction and survival of fungal pathogens. The latter have developed various mechanisms to acquire iron from their mammalian hosts, with whom they participate in a continuous struggle for dominance over iron. Invasive fungal infections are an important problem in the treatment of patients with hematological malignancies, and they are associated with significant morbidity and mortality. The diagnosis of invasive clinical infections in these patients is complex, and the treatment, which must occur as early as possible, is difficult. There are several studies that have shown a possible link between iron overload and an increased susceptibility to infections. This link is also relevant for patients with hematological malignancies and for those treated with allogeneic hematopoietic stem cell transplantation. The role of iron and its metabolism in the virulence and pathogenesis of various invasive fungal infections is intriguing, and so far, there is some evidence linking invasive fungal infections to iron or iron overload. Clarifying the possible association of iron and iron overload with susceptibility to invasive fungal infections could be important for a better prevention and treatment of these infections in patients with hematological malignancies.
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47
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Low Incidence of Invasive Fungal Disease Following CD19 Chimeric Antigen Receptor T-Cell (CAR-T) Therapy for Non-Hodgkin Lymphoma. Blood Adv 2022; 6:4821-4830. [PMID: 35802461 DOI: 10.1182/bloodadvances.2022007474] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 06/18/2022] [Indexed: 11/20/2022] Open
Abstract
CAR T-cell (CAR-T) therapy has revolutionized the treatment of hematologic malignancies, though its use may be complicated by toxicities including cytokine release syndrome (CRS), immune effector cell-associated neurotoxicity syndrome (ICANS), and infections. Invasive fungal disease (IFD) has been reported following CAR-T therapy, but the incidence in the absence of antifungal prophylaxis is unknown. Optimal screening, prophylaxis, and preemptive treatment strategies are widely debated. We performed a single-center retrospective study of 280 adults receiving CD19 CAR-T therapy for Non-Hodgkin's lymphoma (NHL) between December 2017 and September 2021 (n=280). Patients did not receive routine anti-yeast or mold prophylaxis. Proven and probable IFD was identified between day of cell infusion and last follow up. Cumulative Incidence Functions were calculated at 100 days and 18 months based on time to IFD using dates of IFD-free death, initiation of salvage treatment following relapse, and hematopoietic cell transplantation as competing risks. Eight patients (2.9%) developed IFD, including 3 Pneumocystis jirovecii pneumonia (PJP), 3 invasive mold infections (IMIs), and 2 invasive yeast infections (IYIs). Five infections (3 IMI; 2 IYI) occurred prior to day 100 and the 100-day cumulative incidence of IFD accounting for competing risks was 1.8% (95% CI 0.8 - 4.4%). Amongst the 280 patients, many developed early toxicity including CRS (85%) and ICANS (55%). Late toxicities after day 30 including grade 3/4 neutropenia (41%), hypogammaglobulinemia (35%), and low CD4 T-cell count (20%) were common. IFD was rare amongst patients who received CD19 CAR-T therapy for NHL in the absence of routine antifungal prophylaxis despite frequent toxicities including CRS, ICANS, and late neutropenia. This study suggests that in settings with low institutional rates of IFD, routine antifungal prophylaxis may not be indicated.
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48
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Prevel R, Guillotin V, Imbert S, Blanco P, Delhaes L, Duffau P. Central Nervous System Cryptococcosis in Patients With Sarcoidosis: Comparison With Non-sarcoidosis Patients and Review of Potential Pathophysiological Mechanisms. Front Med (Lausanne) 2022; 9:836886. [PMID: 35425769 PMCID: PMC9002233 DOI: 10.3389/fmed.2022.836886] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 03/02/2022] [Indexed: 11/13/2022] Open
Abstract
Introduction Cryptococcus spp. infection of the central nervous system (CINS) is a devastating opportunistic infection that was historically described in patients with acquired immunodeficiency syndrome (AIDS). Cryptococcus spp. infections are also associated with sarcoidosis; the impairment of cell-mediated immunity and long-term corticosteroid therapy being evoked to explain this association. Nevertheless, this assertion is debated and the underlying pathophysiological mechanisms are still unknown. The aims of this study were (i) to describe the clinical and biological presentation, treatments, and outcomes of CINS patients with and without sarcoidosis and (ii) to review the pathophysiological evidence underlying this clinical association. Patients and Methods Every patient with positive cerebrospinal fluid (CSF) cryptococcal antigen testing, India ink preparation, and/or culture from January 2015 to December 2020 at a tertiary university hospital were included, and patients with sarcoidosis were compared with non-sarcoidosis patients. Quantitative variables are presented as mean ± SD and are compared using the Mann-Whitney Wilcoxon rank-sum test. Categorical variables are expressed as the number of patients (percentage) and compared using the χ2 or Fisher's tests. Results During the study period, 16 patients experienced CINS, of whom 5 (31%) were associated with sarcoidosis. CINS symptoms, biological, and CSF features were similar between CINS patients with and without sarcoidosis except regarding CD4 cells percentages and CD4/CD8 ratio that was higher in those with sarcoidosis (47 ± 12 vs. 22 ± 18, p = 0.02 and 2.24 ± 1.42 vs. 0.83 ± 1.10, p = 0.03, respectively). CINS patients with sarcoidosis had less often positive blood antigen testing than those without sarcoidosis (2/5 vs. 11/11, p = 0.02). CINS patients with and without sarcoidosis were treated with similar drugs, but patients with sarcoidosis had a shorter length of treatment. CD4 cell levels do not seem to explain the association between sarcoidosis and cryptococcosis. Conclusion Sarcoidosis was the most frequently associated condition with CINS in this study. CINS patients associated with sarcoidosis had overall similar clinical and biological presentation than CINS patients associated with other conditions but exhibited a lower rate of positive blood cryptococcal antigen testing and higher CD4/CD8 T cells ratio. Pathophysiological mechanisms underlying this association remain poorly understood but B-1 cell deficiency or lack of IgM could be a part of the explanation. Another plausible mechanism is the presence of anti-granulocyte-macrophage colony-stimulating factor (GM-CSF) antibodies in a subset of patients with sarcoidosis, which could impair macrophage phagocytic function. Further studies are strongly needed to better understand those mechanisms and to identify at-risk patients.
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Affiliation(s)
- Renaud Prevel
- CHU Bordeaux, Internal Medicine Department, Bordeaux, France.,Univ Bordeaux, Centre de Recherche Cardio-Thoracique de Bordeaux, Inserm UMR 1045, Bordeaux, France
| | | | - Sébastien Imbert
- Univ Bordeaux, Centre de Recherche Cardio-Thoracique de Bordeaux, Inserm UMR 1045, Bordeaux, France.,CHU Bordeaux, Mycology-Parasitology Department, CIC 1401, Bordeaux, France
| | - Patrick Blanco
- CHU Bordeaux, Immunology Department, Bordeaux, France.,Univ Bordeaux, CNRS ImmunoConcEpT UMR 5164, Bordeaux, France
| | - Laurence Delhaes
- Univ Bordeaux, Centre de Recherche Cardio-Thoracique de Bordeaux, Inserm UMR 1045, Bordeaux, France.,CHU Bordeaux, Mycology-Parasitology Department, CIC 1401, Bordeaux, France
| | - Pierre Duffau
- CHU Bordeaux, Internal Medicine Department, Bordeaux, France.,Univ Bordeaux, CNRS ImmunoConcEpT UMR 5164, Bordeaux, France
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49
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Viens AL, Timmer KD, Alexander NJ, Barghout R, Milosevic J, Hopke A, Atallah NJ, Scherer AK, Sykes DB, Irimia D, Mansour MK. TLR Signaling Rescues Fungicidal Activity in Syk-Deficient Neutrophils. JOURNAL OF IMMUNOLOGY (BALTIMORE, MD. : 1950) 2022; 208:1664-1674. [PMID: 35277418 PMCID: PMC8976732 DOI: 10.4049/jimmunol.2100599] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 01/14/2022] [Indexed: 06/14/2023]
Abstract
An impaired neutrophil response to pathogenic fungi puts patients at risk for fungal infections with a high risk of morbidity and mortality. Acquired neutrophil dysfunction in the setting of iatrogenic immune modulators can include the inhibition of critical kinases such as spleen tyrosine kinase (Syk). In this study, we used an established system of conditionally immortalized mouse neutrophil progenitors to investigate the ability to augment Syk-deficient neutrophil function against Candida albicans with TLR agonist signaling. LPS, a known immunomodulatory molecule derived from Gram-negative bacteria, was capable of rescuing effector functions of Syk-deficient neutrophils, which are known to have poor fungicidal activity against Candida species. LPS priming of Syk-deficient mouse neutrophils demonstrates partial rescue of fungicidal activity, including phagocytosis, degranulation, and neutrophil swarming, but not reactive oxygen species production against C. albicans, in part due to c-Fos activation. Similarly, LPS priming of human neutrophils rescues fungicidal activity in the presence of pharmacologic inhibition of Syk and Bruton's tyrosine kinase (Btk), both critical kinases in the innate immune response to fungi. In vivo, neutropenic mice were reconstituted with wild-type or Syk-deficient neutrophils and challenged i.p. with C. albicans. In this model, LPS improved wild-type neutrophil homing to the fungal challenge, although Syk-deficient neutrophils did not persist in vivo, speaking to its crucial role on in vivo persistence. Taken together, we identify TLR signaling as an alternate activation pathway capable of partially restoring neutrophil effector function against Candida in a Syk-independent manner.
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Affiliation(s)
- Adam L Viens
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA;
| | - Kyle D Timmer
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA
| | | | - Rana Barghout
- Center for Regenerative Medicine, Massachusetts General Hospital, Boston, MA
- Harvard Stem Cell Institute, Boston, MA
| | - Jelena Milosevic
- Center for Regenerative Medicine, Massachusetts General Hospital, Boston, MA
- Harvard Stem Cell Institute, Boston, MA
- Harvard Medical School, Boston, MA
| | - Alex Hopke
- Harvard Medical School, Boston, MA
- Shriners Burns Hospital, Boston, MA; and
- Center for Engineering in Medicine and Surgery, Department of Surgery, Harvard Medical School, Boston, MA
| | - Natalie J Atallah
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Allison K Scherer
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - David B Sykes
- Center for Regenerative Medicine, Massachusetts General Hospital, Boston, MA
- Harvard Stem Cell Institute, Boston, MA
- Harvard Medical School, Boston, MA
| | - Daniel Irimia
- Harvard Medical School, Boston, MA
- Shriners Burns Hospital, Boston, MA; and
- Center for Engineering in Medicine and Surgery, Department of Surgery, Harvard Medical School, Boston, MA
| | - Michael K Mansour
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA;
- Harvard Medical School, Boston, MA
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50
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Ferreras-Antolín L, Irwin A, Atra A, Chapelle F, Drysdale SB, Emonts M, McMaster P, Paulus S, Patel S, Rompola M, Vergnano S, Whittaker E, Warris A. Pediatric Antifungal Prescribing Patterns Identify Significant Opportunities to Rationalize Antifungal Use in Children. Pediatr Infect Dis J 2022; 41:e69-e74. [PMID: 34784303 PMCID: PMC8826618 DOI: 10.1097/inf.0000000000003402] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/27/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The need for pediatric antifungal stewardship programs has been driven by an increasing consumption of antifungals for prophylactic and empirical use. Drivers and rational of antifungal prescribing need to be identified to optimize prescription behaviors. METHODS A prospective modified weekly Point Prevalence Survey capturing antifungal prescriptions for children (> 90 days to < 18 years of age) in 12 centers in England during 26 consecutive weeks was performed. Demographic, diagnostic and treatment information was collected for each patient. Data were entered into an online REDCap database. RESULTS One thousand two hundred fifty-eight prescriptions were included for 656 pediatric patients, 44.9% were girls, with a median age of 6.4 years (interquartile range, 2.5-11.3). Most common underlying condition was malignancy (55.5%). Four hundred nineteen (63.9%) received antifungals for prophylaxis, and 237 (36.1%) for treatment. Among patients receiving antifungal prophylaxis, 40.2% did not belong to a high-risk group. In those receiving antifungal treatment, 45.9%, 29.4%, 5.1% and 19.6% had a diagnosis of suspected, possible, probable of proven invasive fungal disease (IFD), respectively. Proven IFD was diagnosed in 78 patients, 84.6% (n = 66) suffered from invasive candidiasis and 15.4% (n = 12) from an invasive mold infection. Liposomal amphotericin B was the most commonly prescribed antifungal for both prophylaxis (36.6%) and empiric and preemptive treatment (47.9%). Throughout the duration of the study, 72 (11.0%) patients received combination antifungal therapy. CONCLUSIONS Antifungal use in pediatric patients is dominated by liposomal amphotericin B and often without evidence for the presence of IFD. A significant proportion of prophylactic and empiric antifungal use was seen in pediatric patients not at high-risk for IFD.
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Affiliation(s)
- Laura Ferreras-Antolín
- From the Medical Research Council Centre for Medical Mycology, University of Exeter, United Kingdom
- St George’s University Hospitals NHS Foundation Trust, London, United Kingdom
| | - Adam Irwin
- Department of Paediatric Infectious Diseases, Great Ormond Street Hospital for Children, London, United Kingdom
- The University of Queensland Centre for Clinical Research, Brisbane, Australia
| | - Ayad Atra
- Department of Paediatric Oncology, Royal Marsden Hospital, Downs Road, Sutton, London, United Kingdom
| | - Faye Chapelle
- Department of Infectious Diseases and Immunology, Evelina Children Hospital, London, United Kingdom
| | - Simon B. Drysdale
- St George’s University Hospitals NHS Foundation Trust, London, United Kingdom
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, United Kingdom
| | - Marieke Emonts
- Department of Paediatric Immunology, Infectious Diseases and Allergy, Great North Children’s Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Paddy McMaster
- Department of Paediatric Infectious Diseases, Royal Manchester Childrens´ Hospital, Manchester, United Kingdom
| | - Stephane Paulus
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, United Kingdom
- Institute of Infection and Global Health, University of Liverpool, Liverpool, United Kingdom
| | - Sanjay Patel
- Department of Paediatric Infectious Diseases, University Hospital Southampton NHS Foundation Trust, United Kingdom
| | - Menie Rompola
- Dept. of Paediatric Haematology and Oncology, Leeds General Infirmary, Leeds, United Kingdom
| | - Stefania Vergnano
- Department of Paediatric Infectious Diseases, Bristol Royal Hospital for Children, Bristol, United Kingdom
| | - Elizabeth Whittaker
- Paediatric Infectious Diseases, Imperial College Healthcare NHS Trust and Section of Paediatrics, Department of Infectious Diseases, Imperial College, London, United Kingdom
| | - Adilia Warris
- From the Medical Research Council Centre for Medical Mycology, University of Exeter, United Kingdom
- Department of Paediatric Infectious Diseases, Great Ormond Street Hospital for Children, London, United Kingdom
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