Conversion from tacrolimus/mycophenolic acid to tacrolimus/leflunomide to treat cutaneous warts in a series of four pediatric renal allograft recipients

Efficacy and safety of local candida immunotherapy in recalcitrant warts in pediatric kidney transplantation: A case report

BACKGROUND

Warts are common in recipients of kidney transplantation (KT). Resistant warts which are not amenable to conventional therapies may lead to significant morbidity. Limited data exists on safety and efficacy of local immunotherapy among immunocompromised KT recipients.

CASE SUMMARY

We report a seven-year-old child who presented with recalcitrant plantar periungual warts in the early KT period. Immunosuppression consisted of tacrolimus, mycophenolate and steroid. Due to failure of conventional anti-wart therapies, he was treated with two sessions of intralesional (IL) candida immunotherapy along with liquid nitrogen cryotherapy leading to complete resolution of the warts. Interestingly, de novo BK viremia was seen about three weeks following the last candida immunotherapy. This required reduction of immunosuppression and other anti-BK viral therapies. Allograft function remained stable but there were donor specific antibodies detected. There also was elevated level of plasma donor derived cell-free DNA. A pneumocystis jirovecii pneumonia occurred ten months following completion of immunotherapy that was successfully treated with trimethoprim-sulfamethoxazole. During this ten-month follow-up period, there have been no recurrence of warts, and transplant kidney function has remained stable.

CONCLUSION

Stimulation of cell-mediated immunity against the human papilloma virus induced by the IL candida immunotherapy is thought to be a cause for wart resolution. With this therapy, whether it is necessary to augment the immunosuppression to prevent rejection is unclear as that may come with a risk of infectious complications. Larger, prospective studies in pediatric KT recipients are needed to explore these important issues.

Leflunomide: Traditional immunosuppressant with concurrent antiviral effects

Leflunomide is a classic disease-modifying anti-rheumatic drug that is widely used to treat autoimmune diseases. Studies also show its antiviral effects in in vitro and/or in vivo experiments. Considering glucocorticoids, immunosuppressants and newly emerged antibodies commonly used in autoimmune diseases and autoinflammatory disorders bring risk of infection such as viral infection, leflunomide with combination of anti-viral and immunosuppressive features to maintain the balance between infection and anti-inflammation are attractive. Here we summarize the actions and mechanisms of leflunomide in immunoregulatory and antiviral effects.

Oral disease-modifying antirheumatic drugs and immunosuppressants with antiviral potential, including SARS-CoV-2 infection: a review

There have been several episodes of viral infection evolving into epidemics in recent decades, and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the latest example. Its high infectivity and moderate mortality have resulted in an urgent need to find an effective treatment modality. Although the category of immunosuppressive drugs usually poses a risk of infection due to interference of the immune system, some of them have been found to exert antiviral properties and are already used in daily practice. Recently, hydroxychloroquine and baricitinib have been proposed as potential drugs for SARS-CoV-2. In fact, there are other immunosuppressants known with antiviral activities, including cyclosporine A, hydroxyurea, minocycline, mycophenolic acid, mycophenolate mofetil, leflunomide, tofacitinib, and thalidomide. The inherent antiviral activity could be a treatment choice for patients with coexisting rheumatological disorders and infections. Clinical evidence, their possible mode of actions and spectrum of antiviral activities are included in this review article.

LAY SUMMARY

Immunosuppressants often raise the concern of infection risks, especially for patients with underlying immune disorders. However, some disease-modifying antirheumatic drugs (DMARDs) with inherent antiviral activity would be a reasonable choice in the situation of concomitant viral infections and flare up of autoimmune diseases. This review covers DMARDs of treatment potential for SARS-CoV-2 in part I, and antiviral mechanisms plus trial evidence for viruses other than SARS-CoV-2 in part II.

The immunology of COVID-19: is immune modulation an option for treatment?

In December, 2019, an outbreak of COVID-19 emerged in Wuhan, China and quickly spread globally. As of May 7, 2020, there were 3 672 238 confirmed infections and 254 045 deaths attributed to COVID-19. Evidence has shown that there are asymptomatic carriers of COVID-19 who can transmit the disease to others. The virus incubation time shows a wide range (0-24 days) and the virus displays a high infectivity. It is therefore urgent to develop an effective therapy to treat patients with COVID-19 and to control the spread of the causative agent, severe respiratory syndrome coronavirus 2. Repurposing of approved drugs is widely adopted to fight newly emerged diseases such as COVID-19, as these drugs have known pharmacokinetic and safety profiles. As pathological examination has confirmed the involvement of immune hyperactivation and acute respiratory distress syndrome in fatal cases of COVID-19, several disease-modifying anti-rheumatic drugs (DMARDS), such as hydroxychloroquine and tocilizumab, have been proposed as potential therapies for the treatment of COVID-19. In this Review, we discuss the immunological aspects of COVID-19 and the potential implication of DMARDs in treating this disease.

A Case Report of the Resolution of Multiple Recalcitrant Verrucae in a Renal Transplant Recipient After a Mycophenolate Mofetil Dose Reduction

Renal transplant recipients are at an increased risk of developing verrucae due to chronic immunosuppression, and certain therapies may confer a greater risk. Herein, we describe a 51-year-old woman with a 10-year-old unrelated kidney transplant who developed numerous therapy-resistant verrucae while on mycophenolate mofetil and tacrolimus maintenance immunosuppression. Over several years of immunosuppressant therapy, she declined the approach of reducing her mycophenolate mofetil dose to potentially improve her verrucae. Unfortunately, she later developed graft rejection requiring reversion to peritoneal dialysis. Within months of reducing her mycophenolate mofetil dose (her tacrolimus dose remained unchanged), she experienced dramatic resolution of many of her verrucae. In the current case, the observed clinical improvement may have resulted from either the total reduction of immunosuppression or the specific reduction of mycophenolate mofetil. Consequently, mycophenolate mofetil may contribute to the refractory nature of verrucae within renal transplant recipients, and further research should determine the relationship between verrucae development and both specific immunosuppressant therapies and the degree of immunosuppression.