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Hashim HT, Al-Obaidi AD, Al-Fatlawi N, Hassan KH, Al-Asadi AK, Al-Rihaymee AMA, Al-Obiade R, Joffrey M, Al-Badri SG, Al-Awad A. Evans syndrome in conjunction with rheumatoid arthritis and SLE: A unique case of autoimmune intersection. Radiol Case Rep 2024; 19:6323-6327. [PMID: 39387031 PMCID: PMC11461976 DOI: 10.1016/j.radcr.2024.09.053] [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: 08/14/2024] [Revised: 09/09/2024] [Accepted: 09/11/2024] [Indexed: 10/12/2024] Open
Abstract
Evans syndrome is a rare autoimmune disorder characterized by autoimmune hemolytic anemia (AIHA) and immune thrombocytopenia (ITP), often linked with systemic lupus erythematosus (SLE). We present a case of a 25-year-old female with a history of rheumatoid arthritis (RA) who presented with new SLE symptoms, including left-sided weakness, pallor, and a photosensitive rash. Laboratory tests confirmed Evans syndrome, and MRI showed a cerebral infarction. Treatment with corticosteroids, hydroxychloroquine, and mycophenolate mofetil led to significant improvement. This case highlights the complexity of managing Evans syndrome in patients with coexisting autoimmune diseases like RA and SLE, emphasizing the need for early and aggressive treatment.
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Affiliation(s)
- Hashim Talib Hashim
- Research Department, University of Warith Al-Anbiyaa, College of Medicine, Karbala, Iraq
| | - Ahmed Dheyaa Al-Obaidi
- Deparment of Internal Medicine, University of Baghdad, College of Medicine, Baghdad, Iraq
| | - Nabeel Al-Fatlawi
- Deparment of Internal Medicine, University of Baghdad, College of Medicine, Baghdad, Iraq
| | | | - Azhar Kareem Al-Asadi
- Deparment of Internal Medicine, University of Baghdad, College of Medicine, Baghdad, Iraq
| | | | - Reem Al-Obiade
- Deparment of Internal Medicine, University of Baghdad, College of Medicine, Baghdad, Iraq
| | - Meelad Joffrey
- BDS, University of Baghdad, College of Dentistry, Baghdad, Iraq
| | - Sajjad Ghanim Al-Badri
- Deparment of Internal Medicine, University of Baghdad, College of Medicine, Baghdad, Iraq
| | - Abdullah Al-Awad
- Deparment of Internal Medicine, University of Baghdad, College of Medicine, Baghdad, Iraq
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Molina YL, Blasco-Santana L, Sanz A, Blázquez Gómez CJ, Zubicaray J, Iriondo J, González de Pablo J, Sevilla J, Sebastián E. Myelofibrosis associated with immune cytopenia in an infant: a diagnostic and therapeutic challenge. Pediatr Hematol Oncol 2024; 41:382-387. [PMID: 38712347 DOI: 10.1080/08880018.2024.2350424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Revised: 04/27/2024] [Accepted: 04/27/2024] [Indexed: 05/08/2024]
Affiliation(s)
- Yessenia L Molina
- Onco-Hematology Department, Hospital Infantil Universitario Niño Jesús, Fundación para la Investigación Biomédica del Hospital Infantil Universitario Niño Jesús, Madrid, Spain
| | - Luis Blasco-Santana
- Pathology Department. Hospital Infantil Universitario Niño Jesús, Madrid, Spain
| | - Alejandro Sanz
- Onco-Hematology Department, Hospital Infantil Universitario Niño Jesús, Fundación para la Investigación Biomédica del Hospital Infantil Universitario Niño Jesús, Madrid, Spain
| | | | - Josune Zubicaray
- Onco-Hematology Department, Hospital Infantil Universitario Niño Jesús, Fundación para la Investigación Biomédica del Hospital Infantil Universitario Niño Jesús, Madrid, Spain
| | - June Iriondo
- Onco-Hematology Department, Hospital Infantil Universitario Niño Jesús, Fundación para la Investigación Biomédica del Hospital Infantil Universitario Niño Jesús, Madrid, Spain
| | - Jesús González de Pablo
- Onco-Hematology Department, Hospital Infantil Universitario Niño Jesús, Fundación para la Investigación Biomédica del Hospital Infantil Universitario Niño Jesús, Madrid, Spain
| | - Julián Sevilla
- Onco-Hematology Department, Hospital Infantil Universitario Niño Jesús, Fundación para la Investigación Biomédica del Hospital Infantil Universitario Niño Jesús, Madrid, Spain
| | - Elena Sebastián
- Onco-Hematology Department, Hospital Infantil Universitario Niño Jesús, Fundación para la Investigación Biomédica del Hospital Infantil Universitario Niño Jesús, Madrid, Spain
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Acar SO, Tahta N, Al IO, Erdem M, Gözmen S, Karapınar TH, Kılınç B, Celkan T, Kirkiz S, Koçak Ü, Ören H, Yıldırım AT, Arslantaş E, Ayhan AC, Oymak Y. Sirolimus is effective and safe in childhood relapsed-refractory autoimmune cytopenias: A multicentre study. Scand J Immunol 2024; 100:e13376. [PMID: 38741164 DOI: 10.1111/sji.13376] [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: 09/18/2023] [Accepted: 03/24/2024] [Indexed: 05/16/2024]
Abstract
Autoimmune cytopenias are a heterogeneous group of disorders characterized by immune-mediated destruction of haematopoietic cell lines. Effective and well-tolerated treatment options for relapsed-refractory immune cytopenias are limited. In this study, the aim was to evaluate the efficacy and safety of sirolimus in this disease group within the paediatric age group. The study enrolled patients in the paediatric age group who used sirolimus with a diagnosis of immune cytopenia between December 2010 and December 2020, followed at six centres in Turkey. Of the 17 patients, five (29.4%) were treated for autoimmune haemolytic anaemia (AIHA), six (35.2%) for immune thrombocytopenic purpura (ITP) and six (35.2%) for Evans syndrome (ES). The mean response time was 2.7 months (range, 0-9 months). Complete response (CR) and partial response (PR) were obtained in 13 of 17 patients (76.4%) and nonresponse (NR) in four patients (23.5%). Among the 13 patients who achieved CR, three of them were NR in the follow-up and two of them had remission with low-dose steroid and sirolimus. Thus, overall response rate (ORR) was achieved in 12 of 17 patients (70.5%). In conclusion, sirolimus may be an effective and safe option in paediatric patients with relapsed-refractory immune cytopenia.
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Affiliation(s)
- Sultan Okur Acar
- Deparment of Hematology and Oncology, University of Health Sciences Dr. Behçet Uz Children's Hospital, Izmir, Turkey
| | - Neryal Tahta
- Deparment of Hematology and Oncology, University of Health Sciences Dr. Behçet Uz Children's Hospital, Izmir, Turkey
| | - Işık Odaman Al
- Deparment of Hematology and Oncology, University of Health Sciences Dr. Behçet Uz Children's Hospital, Izmir, Turkey
| | - Melek Erdem
- Deparment of Hematology and Oncology, University of Health Sciences Dr. Behçet Uz Children's Hospital, Izmir, Turkey
| | - Salih Gözmen
- Deparment of Hematology and Oncology, University of Health Sciences Dr. Behçet Uz Children's Hospital, Izmir, Turkey
| | - Tuba Hilkay Karapınar
- Deparment of Hematology and Oncology, University of Health Sciences Dr. Behçet Uz Children's Hospital, Izmir, Turkey
| | - Burcu Kılınç
- Faculty of Medicine Hospital, Istanbul University Cerrahpaşa, Istanbul, Turkey
| | - Tiraje Celkan
- Faculty of Medicine Hospital, Istanbul University Cerrahpaşa, Istanbul, Turkey
| | - Serap Kirkiz
- Faculty of Medicine Hospital, Ankara Gazi University, Ankara, Turkey
| | - Ülker Koçak
- Faculty of Medicine Hospital, Ankara Gazi University, Ankara, Turkey
| | - Hale Ören
- Faculty of Medicine Hospital, Dokuz Eylül University, Izmir, Turkey
| | | | - Esra Arslantaş
- Başakşehir Çam and Sakura City Hospital, Istanbul, Turkey
| | | | - Yeşim Oymak
- Deparment of Hematology and Oncology, University of Health Sciences Dr. Behçet Uz Children's Hospital, Izmir, Turkey
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Comella M, Palmisani E, Mariani M, Dell’Orso G, Licciardello M, Giarratana MC, Arcuri L, Pestarino S, Grossi A, Lanciotti M, Brucci G, Guardo D, Russo G, Dufour C, Fioredda F, Castagnola E, Miano M. Infection risk in patients with autoimmune cytopenias and immune dysregulation treated with mycophenolate mofetil and sirolimus. Front Immunol 2024; 15:1415389. [PMID: 38873600 PMCID: PMC11169563 DOI: 10.3389/fimmu.2024.1415389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2024] [Accepted: 05/14/2024] [Indexed: 06/15/2024] Open
Abstract
Introduction Autoimmune cytopenias (AICs) are a group of disorders characterized by immune-mediated destruction of blood cells. In children, they are often secondary to immune dysregulation that may require long-lasting immunosuppression. Mycophenolate mofetil and sirolimus represent two well-tolerated options to treat these disorders, often as a steroid-sparing option. However, no data are available on the infection risk for patients undergoing long-lasting treatments. Patients and methods The rate of severe infective events was calculated in episodes per 100 persons/months at risk (p/m/r) documented by the analysis of hospitalization charts between January 2015 and July 2023 of patients treated with mycophenolate mofetil or sirolimus given for isolated AIC or AICs associated with autoimmune lymphoproliferative syndrome (ALPS)/ALPS-like syndromes in two large Italian pediatric hematology units. Results From January 2015 to July 2023, 13 out of 96 patients treated with mycophenolate mofetil or sirolimus developed 16 severe infectious events requiring hospitalization. No patients died. Overall infection rate was 0.24 person/*100 months/risk (95% CI 0.09-0.3). Serious infectious events incidence was higher in patients with ALPS-like compared to others (0.42 versus 0.09; p = 0.006) and lower in patients who underwent mycophenolate treatment alone compared to those who started sirolimus after mycophenolate failure (0.04 versus 0.29, p = 0.03). Considering only patients who started treatment at the beginning of study period, overall cumulative hazard was 18.6% at 60 months (95% CI 3.4-31.4) with higher risk of infectious events after 5 years in ALPS-like patients (26.1%; 95% CI 3.2-43.5) compared to other AICs (4%; 95% CI 0-11.4; p = 0.041). Discussion To the best of our knowledge, this is the first study to describe the infectious risk related to mycophenolate and sirolimus chronic treatment in patients with AICs and immune dysregulation. Our data highlight that infection rate is very low and mainly related to the underlying hematological condition. Conclusions Mycophenolate and sirolimus represent a safe immunosuppressive therapy in AICs and immune dysregulation syndromes.
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Affiliation(s)
- Mattia Comella
- Haematology Unit, Department of Haematology/Oncology, IRCCS Istituto Giannina Gaslini, Genoa, Italy
- Pediatric Hematology and Oncology Unit, Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Elena Palmisani
- Haematology Unit, Department of Haematology/Oncology, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Marcello Mariani
- Infectious Diseases Unit, Department of Pediatrics, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Gianluca Dell’Orso
- Haematology Unit, Department of Haematology/Oncology, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Maria Licciardello
- Pediatric Hematology and Oncology Unit, Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Maria Carla Giarratana
- Haematology Unit, Department of Haematology/Oncology, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Luca Arcuri
- Haematology Unit, Department of Haematology/Oncology, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Sara Pestarino
- Haematology Unit, Department of Haematology/Oncology, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Alice Grossi
- Genetic and Genomic of Rare Disease Unit, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Marina Lanciotti
- Haematology Unit, Department of Haematology/Oncology, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Giorgia Brucci
- Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy
| | - Daniela Guardo
- Haematology Unit, Department of Haematology/Oncology, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Giovanna Russo
- Pediatric Hematology and Oncology Unit, Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Carlo Dufour
- Haematology Unit, Department of Haematology/Oncology, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Francesca Fioredda
- Haematology Unit, Department of Haematology/Oncology, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Elio Castagnola
- Infectious Diseases Unit, Department of Pediatrics, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Maurizio Miano
- Haematology Unit, Department of Haematology/Oncology, IRCCS Istituto Giannina Gaslini, Genoa, Italy
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Berrueco R, González-Forster E, Deya-Martinez A, Solsona M, García-García A, Calzada-Hernández J, Yiyi L, Vlagea A, Ruiz-Llobet A, Alsina L. Mycophenolate mofetil for autoimmune cytopenias in children: high rates of response in inborn errors of immunity. Front Pediatr 2023; 11:1174671. [PMID: 37915985 PMCID: PMC10616248 DOI: 10.3389/fped.2023.1174671] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Accepted: 09/25/2023] [Indexed: 11/03/2023] Open
Abstract
Second-line treatments of autoimmune cytopenias (AC) are not well-defined in children. Mycophenolate mofetil (MMF) is an immunosuppressant agent that has been demonstrated to be safe and effective in this setting. A retrospective observational study was conducted in 18 children with prolonged AC who received MMF, in order to describe clinical and biological markers of response. The overall response rate of MMF at 20-30 mg/kg per day was 73.3%. All patients with Evans syndrome (n = 9) achieved complete response. Among the patients with monolineage AC (n = 9), those with an underlying inborn errors of immunity (IEI), tended to respond better to MMF. No biological markers related to treatment response were found. Rather, lymphocyte subpopulations proved useful for patient selection as a marker suggestive of IEI along with immunoglobulin-level determination.
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Affiliation(s)
- Rubén Berrueco
- Pediatric Hematology Department, Hospital Sant Joan de Déu, Barcelona, Spain
- Institut de Recerca Sant Joan de Déu de Barcelona (IRSJD), Barcelona, Spain
- Instituto Nacional de Investigación Biomédica en Enfermedades Raras (CIBER ER), Instituto de Salud Carlos III, Madrid, Spain
| | - Elisa González-Forster
- Pediatric Hematology Department, Hospital Sant Joan de Déu, Barcelona, Spain
- Institut de Recerca Sant Joan de Déu de Barcelona (IRSJD), Barcelona, Spain
| | - Angela Deya-Martinez
- Institut de Recerca Sant Joan de Déu de Barcelona (IRSJD), Barcelona, Spain
- Clinical Immunology and Primary Immunodeficiencies Unit, Pediatric Allergy and Clinical Immunology Department, Hospital Sant Joan de Déu, Barcelona, Spain
- Clinical Immunology Unit, Hospital Sant Joan de Déu-Hospital Clínic Barcelona, Barcelona, Spain
| | - María Solsona
- Pediatric Hematology Department, Hospital Sant Joan de Déu, Barcelona, Spain
- Institut de Recerca Sant Joan de Déu de Barcelona (IRSJD), Barcelona, Spain
| | - Ana García-García
- Institut de Recerca Sant Joan de Déu de Barcelona (IRSJD), Barcelona, Spain
- Clinical Immunology and Primary Immunodeficiencies Unit, Pediatric Allergy and Clinical Immunology Department, Hospital Sant Joan de Déu, Barcelona, Spain
- Clinical Immunology Unit, Hospital Sant Joan de Déu-Hospital Clínic Barcelona, Barcelona, Spain
| | - Joan Calzada-Hernández
- Pediatric Rheumatology Unit, Hospital Sant Joan de Déu, Universitat de Barcelona, Barcelona, Spain
| | - Luo Yiyi
- Clinical Immunology and Primary Immunodeficiencies Unit, Pediatric Allergy and Clinical Immunology Department, Hospital Sant Joan de Déu, Barcelona, Spain
- Clinical Immunology Unit, Hospital Sant Joan de Déu-Hospital Clínic Barcelona, Barcelona, Spain
| | - Alexandru Vlagea
- Clinical Immunology Unit, Hospital Sant Joan de Déu-Hospital Clínic Barcelona, Barcelona, Spain
- Immunology Department, Centre of Biomedical Diagnosis, Hospital Clínic, Barcelona, Spain
| | - Anna Ruiz-Llobet
- Pediatric Hematology Department, Hospital Sant Joan de Déu, Barcelona, Spain
- Institut de Recerca Sant Joan de Déu de Barcelona (IRSJD), Barcelona, Spain
- Instituto Nacional de Investigación Biomédica en Enfermedades Raras (CIBER ER), Instituto de Salud Carlos III, Madrid, Spain
| | - Laia Alsina
- Institut de Recerca Sant Joan de Déu de Barcelona (IRSJD), Barcelona, Spain
- Clinical Immunology and Primary Immunodeficiencies Unit, Pediatric Allergy and Clinical Immunology Department, Hospital Sant Joan de Déu, Barcelona, Spain
- Clinical Immunology Unit, Hospital Sant Joan de Déu-Hospital Clínic Barcelona, Barcelona, Spain
- Department of Surgery and Surgical Specializations, Facultat de Medicina I Ciències de la Salut, Universitat de Barcelona, Barcelona, Spain
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Guillaume GI, O'Bryhim BE, Saini S, Lueder GT. SUBHYALOID HEMORRHAGE IN EVANS SYNDROME. Retin Cases Brief Rep 2023; 17:359-361. [PMID: 34352833 DOI: 10.1097/icb.0000000000001185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE Evans syndrome is a rare disorder characterized by autoimmune hemolytic anemia and immune thrombocytopenia. We report the first case of ophthalmic involvement in a pediatric patient with Evans syndrome, in which painless vision loss was the presenting symptom. METHOD A 15-year-old girl presented with acute painless loss of vision in her right eye and was found to have bilateral subhyaloid hemorrhages. RESULTS She was treated with intravenous steroids and transitioned to hydroxychloroquine. Her retinal hemorrhages resolved and her vision improved. CONCLUSION Nontraumatic subhyaloid hemorrhage is a rare cause of vision loss in children. Evans syndrome should be considered in the differential diagnosis of such patients when hematologic abnormalities are present.
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Affiliation(s)
- Georges I Guillaume
- Department of Ophthalmology and Visual Sciences, Washington University in St. Louis, St. Louis, Missouri
| | - Bliss E O'Bryhim
- Department of Ophthalmology and Visual Sciences, Washington University in St. Louis, St. Louis, Missouri
| | - Surbhi Saini
- Department of Pediatrics, Division of Pediatric Hematology and Oncology, Washington University School of Medicine and St. Louis Children's Hospital, St. Louis, Missouri; and
| | - Gregg T Lueder
- Department of Ophthalmology and Visual Sciences, Washington University in St. Louis, St. Louis, Missouri
- Departments of Ophthalmology and Pediatrics, Washington University School of Medicine and St. Louis Children's Hospital, St. Louis, Missouri
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Abdel-Salam A, Bassiouni ST, Goher AM, Shafie ES. Autoimmune Hemolytic Anemia in the Pediatric Age Group: The Egyptian Experience. Ann Hematol 2023:10.1007/s00277-023-05230-5. [PMID: 37093240 DOI: 10.1007/s00277-023-05230-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Accepted: 04/11/2023] [Indexed: 04/25/2023]
Abstract
Autoimmune hemolytic anemia (AIHA) is a common disease entity among adults; however, it is rare among the pediatric age group. Evidence is scarce regarding pediatric AIHA in the literature. The objective of this study is to assess the frequency of AIHA and describe the clinical and laboratory characteristics and treatment outcomes of a cohort of children with AIHA in Egypt. A retrospective study was conducted on 50 children with AIHA who were registered and followed up at the New Children's Hospital in Cairo, Egypt, between January 2010 and January 2021. The study group comprised 60% females and 40% males. Their median age was 8.25 years. All patients showed low hemoglobin levels with a mean of 5.40 ± 1.34 g/dl and a median reticulocyte count of 10 (IQR: 8-15). Twelve (24%) patients were diagnosed with Evans syndrome, and a positive Coombs test was detected in 46 patients (92%). The frequency of primary AIHA was 40%, whereas it was 60% for secondary AIHA. The first line of therapy for acute attacks was high-dose IV steroids which responded well in 38 (76%) patients. Secondary AIHA was more common among our children (60%). AIHA is more prevalent in females (60%). The clinical and laboratory characteristics matched previous reports.
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Affiliation(s)
- Amina Abdel-Salam
- Deparment of Pediatrics, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Sherifa Tarek Bassiouni
- Department of Clinical and Chemical Pathology, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Alaa Magdi Goher
- Deparment of Pediatrics, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Eman Shafik Shafie
- Deparment of Pediatrics, Faculty of Medicine, Cairo University, Cairo, Egypt.
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8
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Kim Y, Shim YJ, Kim DH, Ha JS, Jung HR. Autoimmune cytopenia in a Korean pediatric patient with Kabuki syndrome treated with sirolimus. Pediatr Blood Cancer 2023; 70:e30275. [PMID: 36860120 DOI: 10.1002/pbc.30275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Revised: 02/01/2023] [Accepted: 02/03/2023] [Indexed: 03/03/2023]
Affiliation(s)
- Youngeun Kim
- Department of Pediatrics, Keimyung University School of Medicine, Keimyung University Dongsan Hospital, Daegu, South Korea
| | - Ye Jee Shim
- Department of Pediatrics, Keimyung University School of Medicine, Keimyung University Dongsan Hospital, Daegu, South Korea
| | - Do Hoon Kim
- Department of Laboratory Medicine, Keimyung University School of Medicine, Keimyung University Dongsan Hospital, Daegu, South Korea
| | - Jung Sook Ha
- Department of Laboratory Medicine, Keimyung University School of Medicine, Keimyung University Dongsan Hospital, Daegu, South Korea
| | - Hye Ra Jung
- Department of Pathology, Keimyung University School of Medicine, Keimyung University Dongsan Hospital, Daegu, South Korea
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9
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Kumar D, Nguyen TH, Bennett CM, Prince C, Lucas L, Park S, Lawrence T, Chappelle K, Ishaq M, Waller EK, Prahalad S, Briones M, Chandrakasan S. mTOR inhibition attenuates cTfh cell dysregulation and chronic T-cell activation in multilineage immune cytopenias. Blood 2023; 141:238-243. [PMID: 36206504 PMCID: PMC9936300 DOI: 10.1182/blood.2022015966] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 09/14/2022] [Accepted: 09/26/2022] [Indexed: 02/05/2023] Open
Abstract
mTOR inhibitors such as sirolimus are increasingly used in the management of multilineage immune cytopenia (m-IC) in children. Although sirolimus is effective in improving IC, it is unclear how sirolimus affects the broader immune dysregulation associated with m-IC. We profiled T- and B-cell subsets longitudinally and measured cytokines and chemokines before and after sirolimus treatment. Eleven of the 12 patients with m-IC who tolerated sirolimus were followed for a median duration of 17 months. All patients had an improvement in IC, and sirolimus therapy did not result in significant decreases in T-, B- and NK-cell numbers. However, the expansion and activation of circulating T follicular helper and the Th1 bias noted before the initiation of sirolimus were significantly decreased. Features of chronic T-cell activation and exhaustion within effector memory compartments of CD4+ and CD8+ T cells decreased with sirolimus therapy. Corresponding to these changes, plasma levels of CXCL9 and CXCL10 also decreased. Interestingly, no significant improvement in the proportion of class-switched memory B cells or frequencies of CD4+ naive T cells were noted. Longer follow-up and additional studies are needed to validate these findings and evaluate the effect of sirolimus on B-cell maturation.
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Affiliation(s)
- Deepak Kumar
- Aflac Cancer and Blood Disorders Center, Department of Pediatrics, Children’s Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA
| | - Thinh H. Nguyen
- Aflac Cancer and Blood Disorders Center, Department of Pediatrics, Children’s Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA
| | - Carolyn M. Bennett
- Aflac Cancer and Blood Disorders Center, Department of Pediatrics, Children’s Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA
| | - Chengyu Prince
- Aflac Cancer and Blood Disorders Center, Department of Pediatrics, Children’s Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA
| | - Laura Lucas
- Aflac Cancer and Blood Disorders Center, Children’s Healthcare of Atlanta, Atlanta, GA
| | - Sunita Park
- Department of Pathology, Children’s Healthcare of Atlanta, Atlanta, GA
| | - Taylor Lawrence
- Aflac Cancer and Blood Disorders Center, Children’s Healthcare of Atlanta, Atlanta, GA
| | - Karin Chappelle
- Aflac Cancer and Blood Disorders Center, Children’s Healthcare of Atlanta, Atlanta, GA
| | - Mariam Ishaq
- Aflac Cancer and Blood Disorders Center, Children’s Healthcare of Atlanta, Atlanta, GA
| | - Edmund K. Waller
- Department of Hematology and Medical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA
| | - Sampath Prahalad
- Division of Pediatric Rheumatology, Department of Pediatrics, Children’s Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA
| | - Michael Briones
- Aflac Cancer and Blood Disorders Center, Department of Pediatrics, Children’s Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA
| | - Shanmuganathan Chandrakasan
- Aflac Cancer and Blood Disorders Center, Department of Pediatrics, Children’s Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA
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10
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Wang D, Cassady K, Zou Z, Zhang X, Feng Y. Progress on the efficacy and potential mechanisms of rapamycin in the treatment of immune thrombocytopenia. Hematology 2022; 27:1282-1289. [DOI: 10.1080/16078454.2022.2151230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Affiliation(s)
- Dan Wang
- Medical Center of Hematology, The Xinqiao Hospital of Army Medical University, Chongqing, People’s Republic of China
- Department of Hematology, Affiliated Hospital of North Sichuan Medical College, Nanchong, People’s Republic of China
| | | | - Zhongmin Zou
- Department of Chemical Defense Medicine, School of Military Preventive Medicine, Army Medical University, Chongqing, People’s Republic of China
| | - Xi Zhang
- Medical Center of Hematology, The Xinqiao Hospital of Army Medical University, Chongqing, People’s Republic of China
| | - Yimei Feng
- Medical Center of Hematology, The Xinqiao Hospital of Army Medical University, Chongqing, People’s Republic of China
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11
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Achini-Gutzwiller FR, Snowden JA, Corbacioglu S, Greco R. Haematopoietic stem cell transplantation for severe autoimmune diseases in children: A review of current literature, registry activity and future directions on behalf of the autoimmune diseases and paediatric diseases working parties of the European Society for Blood and Marrow Transplantation. Br J Haematol 2022; 198:24-45. [PMID: 37655707 DOI: 10.1111/bjh.18176] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Revised: 03/14/2022] [Accepted: 03/18/2022] [Indexed: 11/27/2022]
Abstract
Although modern clinical management strategies have improved the outcome of paediatric patients with severe autoimmune and inflammatory diseases over recent decades, a proportion will experience ongoing or recurrent/relapsing disease activity despite multiple therapies often leading to irreversible organ damage, and compromised quality of life, growth/development and long-term survival. Autologous and allogeneic haematopoietic stem cell transplantation (HSCT) have been used successfully to induce disease control and often apparent cure of severe treatment-refractory autoimmune diseases (ADs) in children. However, transplant-related outcomes are disease-dependent and long-term outcome data are limited in respect to efficacy and safety. Moreover, balancing risks of HSCT against AD prognosis with continually evolving non-transplant options is challenging. This review appraises published literature on HSCT strategies and outcomes in individual paediatric ADs. We also provide a summary of the European Society for Blood and Marrow Transplantation (EBMT) Registry, where 343 HSCT procedures (176 autologous and 167 allogeneic) have been reported in 326 children (<18 years) for a range of AD indications. HSCT is a promising treatment modality, with potential long-term disease control or cure, but therapy-related morbidity and mortality need to be reduced. Further research is warranted to establish the position of HSCT in paediatric ADs via registries and prospective clinical studies to support evidence-based interspeciality guidelines and recommendations.
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Affiliation(s)
- Federica R Achini-Gutzwiller
- Division of Paediatric Stem Cell Transplantation and Haematology, Children's Research Centre (CRC), University Children's Hospital of Zurich, Zurich, Switzerland
| | - John A Snowden
- Department of Haematology, Sheffield Teaching Hospitals NHS Foundation Trust, Royal Hallamshire Hospital, Sheffield, UK
| | - Selim Corbacioglu
- Department of Paediatric Oncology, Haematology and Stem Cell Transplantation, University Children's Hospital Regensburg, Regensburg, Germany
| | - Raffaella Greco
- Unit of Haematology and Bone Marrow Transplantation, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
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12
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Miano M, Guardo D, Grossi A, Palmisani E, Fioredda F, Terranova P, Cappelli E, Lupia M, Traverso M, Dell'Orso G, Corsolini F, Beccaria A, Lanciotti M, Ceccherini I, Dufour C. Underlying Inborn Errors of Immunity in Patients With Evans Syndrome and Multilineage Cytopenias: A Single-Centre Analysis. Front Immunol 2022; 13:869033. [PMID: 35655776 PMCID: PMC9152001 DOI: 10.3389/fimmu.2022.869033] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Accepted: 04/07/2022] [Indexed: 02/05/2023] Open
Abstract
Background Evans syndrome (ES) is a rare disorder classically defined as the simultaneous or sequential presence of autoimmune haemolytic anaemia and immune thrombocytopenia, but it has also been described as the presence of at least two autoimmune cytopenias. Recent reports have shown that ES is often a manifestation of an underlying inborn error of immunity (IEI) that can benefit from specific treatments. Aims The aim of this study is to investigate the clinical and immunological characteristics and the underlying genetic background of a single-centre cohort of patients with ES. Methods Data were obtained from a retrospective chart review of patients with a diagnosis of ES followed in our centre. Genetic studies were performed with NGS analysis of 315 genes related to both haematological and immunological disorders, in particular IEI. Results Between 1985 and 2020, 40 patients (23 men, 17 women) with a median age at onset of 6 years (range 0-16) were studied. ES was concomitant and sequential in 18 (45%) and 22 (55%) patients, respectively. Nine of the 40 (8%) patients had a positive family history of autoimmunity. Other abnormal immunological features and signs of lymphoproliferation were present in 24/40 (60%) and 27/40 (67%) of cases, respectively. Seventeen out of 40 (42%) children fit the ALPS diagnostic criteria. The remaining 21 (42%) and 2 (5%) were classified as having an ALPS-like and an idiopathic disease, respectively. Eighteen patients (45%) were found to have an underlying genetic defect on genes FAS, CASP10, TNFSF13B, LRBA, CTLA4, STAT3, IKBGK, CARD11, ADA2, and LIG4. No significant differences were noted between patients with or without variant and between subjects with classical ES and the ones with other forms of multilineage cytopenias. Conclusions This study shows that nearly half of patients with ES have a genetic background being in most cases secondary to IEI, and therefore, a molecular evaluation should be offered to all patients.
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Affiliation(s)
- Maurizio Miano
- Hematology Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Daniela Guardo
- Hematology Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Alice Grossi
- Unità Operativa Semplice DIpartimentale (UOSD) Genetics and Genomics of Rare Diseases, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Elena Palmisani
- Hematology Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | | | - Paola Terranova
- Hematology Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Enrico Cappelli
- Hematology Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Michela Lupia
- Hematology Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Monica Traverso
- Pediatric Neurology and Muscular Diseases Unit, IRCCS Istituto Giannina Gaslini, University of Genoa, Genoa, Italy
| | - Gianluca Dell'Orso
- Stem Cell Transplantation Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Fabio Corsolini
- Laboratory of Molecular Genetics and Biobanks, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Andrea Beccaria
- Hematology Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | | | - Isabella Ceccherini
- Unità Operativa Semplice DIpartimentale (UOSD) Genetics and Genomics of Rare Diseases, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Carlo Dufour
- Hematology Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
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13
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Cortesi M, Soresina A, Dotta L, Gorio C, Cattalini M, Lougaris V, Porta F, Badolato R. Pathogenesis of Autoimmune Cytopenias in Inborn Errors of Immunity Revealing Novel Therapeutic Targets. Front Immunol 2022; 13:846660. [PMID: 35464467 PMCID: PMC9019165 DOI: 10.3389/fimmu.2022.846660] [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: 12/31/2021] [Accepted: 03/21/2022] [Indexed: 12/02/2022] Open
Abstract
Autoimmune diseases are usually associated with environmental triggers and genetic predisposition. However, a few number of autoimmune diseases has a monogenic cause, mostly in children. These diseases may be the expression, isolated or associated with other symptoms, of an underlying inborn error of immunity (IEI). Autoimmune cytopenias (AICs), including immune thrombocytopenic purpura (ITP), autoimmune hemolytic anemia (AIHA), autoimmune neutropenia (AN), and Evans’ syndrome (ES) are common presentations of immunological diseases in the pediatric age, with at least 65% of cases of ES genetically determined. Autoimmune cytopenias in IEI have often a more severe, chronic, and relapsing course. Treatment refractoriness also characterizes autoimmune cytopenia with a monogenic cause, such as IEI. The mechanisms underlying autoimmune cytopenias in IEI include cellular or humoral autoimmunity, immune dysregulation in cases of hemophagocytosis or lymphoproliferation with or without splenic sequestration, bone marrow failure, myelodysplasia, or secondary myelosuppression. Genetic characterization of autoimmune cytopenias is of fundamental importance as an early diagnosis improves the outcome and allows the setting up of a targeted therapy, such as CTLA-4 IgG fusion protein (Abatacept), small molecule inhibitors (JAK-inhibitors), or gene therapy. Currently, gene therapy represents one of the most attractive targeted therapeutic approaches to treat selected inborn errors of immunity. Even in the absence of specific targeted therapies, however, whole exome genetic testing (WES) for children with chronic multilineage cytopenias should be considered as an early diagnostic tool for disease diagnosis and genetic counseling.
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Affiliation(s)
- Manuela Cortesi
- Paediatrics Clinic and Institute for Molecular Medicine A. Nocivelli, Department of Clinical and Experimental Sciences, ASST- Spedali Civili of Brescia, University of Brescia, Brescia, Italy
| | - Annarosa Soresina
- Paediatrics Clinic and Institute for Molecular Medicine A. Nocivelli, Department of Clinical and Experimental Sciences, ASST- Spedali Civili of Brescia, University of Brescia, Brescia, Italy
| | - Laura Dotta
- Paediatrics Clinic and Institute for Molecular Medicine A. Nocivelli, Department of Clinical and Experimental Sciences, ASST- Spedali Civili of Brescia, University of Brescia, Brescia, Italy
| | - Chiara Gorio
- Paediatrics Clinic and Institute for Molecular Medicine A. Nocivelli, Department of Clinical and Experimental Sciences, ASST- Spedali Civili of Brescia, University of Brescia, Brescia, Italy
| | - Marco Cattalini
- Paediatrics Clinic and Institute for Molecular Medicine A. Nocivelli, Department of Clinical and Experimental Sciences, ASST- Spedali Civili of Brescia, University of Brescia, Brescia, Italy
| | - Vassilios Lougaris
- Paediatrics Clinic and Institute for Molecular Medicine A. Nocivelli, Department of Clinical and Experimental Sciences, ASST- Spedali Civili of Brescia, University of Brescia, Brescia, Italy
| | - Fulvio Porta
- Paediatrics Clinic and Institute for Molecular Medicine A. Nocivelli, Department of Clinical and Experimental Sciences, ASST- Spedali Civili of Brescia, University of Brescia, Brescia, Italy
| | - Raffaele Badolato
- Paediatrics Clinic and Institute for Molecular Medicine A. Nocivelli, Department of Clinical and Experimental Sciences, ASST- Spedali Civili of Brescia, University of Brescia, Brescia, Italy
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14
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Conti F, Gottardi F, Moratti M, Belotti T, Ferrari S, Selva P, Bassi M, Zama D, Pession A. Refractory immune thrombocytopenia successfully treated with bortezomib in a child with 22q11.2 deletion syndrome, complicated by Evans syndrome and hypogammaglobulinemia. Platelets 2022; 33:801-806. [PMID: 35132908 DOI: 10.1080/09537104.2021.2002835] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Treatment of refractory autoimmune cytopenias (AICs) and Evans syndrome (ES) represent a great challenge in pediatric setting, where an underlying primary immunodeficiency is recurrent. Frequently, second or third line treatments are employed, with an increased risk of toxicity and infections. The advent of novel drugs is the object of research in order to modify the management of these patients.We report a case of successful use of bortezomib in a child with 22q11.2 deletion syndrome and CVID-like phenotype with a multi-refractory severe ES. Last flares were prolonged and dominated by severe and symptomatic ITP, refractory to different courses of high dose steroid and IVIG, mofetil mycophenolate, thrombopoietin receptor agonists, sirolimus, and rituximab. Persistence of AICs in subjects with depletion of CD20 + B-cells and IgG strengthens the hypothesis about the production of autoantibodies by terminally differentiated plasma-cells, not targetable from immunosuppressants and rituximab.In the attempt to enhance plasma-cells inhibition, the child was addressed to bortezomib, with a good response at 6 month follow-up without side effects. Nowadays, the use of bortezomib in ES/AICs is based only on small retrospective studies and case reports. Despite the lack of long term follow-up, our work highlights the potential role of bortezomib in the management of pediatric patients with multi-resistant AICs secondary to immune-system impairment.
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Affiliation(s)
- Francesca Conti
- Pediatric Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | | | - Mattia Moratti
- Specialty School of Paediatrics, University of Bologna, Bologna, Italy
| | - Tamara Belotti
- Pediatric Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Simona Ferrari
- Medical Genetics Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Paola Selva
- Pediatric Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Mirna Bassi
- Laboratory of Immuno-haematology - Laboratorio Unico Metropolitano, Azienda USL, Bologna, Italy
| | - Daniele Zama
- Pediatric Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Andrea Pession
- Pediatric Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
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15
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Blanco BP, Garanito MP. Pediatric Evans Syndrome: A 20-year experience from a tertiary center in Brazil. Hematol Transfus Cell Ther 2022:S2531-1379(22)00032-3. [DOI: 10.1016/j.htct.2022.01.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2021] [Revised: 01/06/2022] [Accepted: 01/28/2022] [Indexed: 10/19/2022] Open
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16
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Kumar D, Prince C, Bennett CM, Briones M, Lucas L, Russell A, Patel K, Chonat S, Graciaa S, Edington H, White MH, Kobrynski L, Abdalgani M, Parikh S, Chandra S, Bleesing J, Marsh R, Park S, Waller EK, Prahalad S, Chandrakasan S. T-follicular helper cell expansion and chronic T-cell activation are characteristic immune anomalies in Evans syndrome. Blood 2022; 139:369-383. [PMID: 34424963 PMCID: PMC8777200 DOI: 10.1182/blood.2021012924] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2021] [Accepted: 08/02/2021] [Indexed: 11/20/2022] Open
Abstract
Pediatric Evans syndrome (pES) is increasingly identified as the presenting manifestation of several inborn errors of immunity. Despite an improved understanding of genetic defects in pES, the underlying immunobiology of pES is poorly defined, and characteristic diagnostic immune parameters are lacking. We describe the immune characteristics of 24 patients with pES and compared them with 22 patients with chronic immune thrombocytopenia (cITP) and 24 healthy controls (HCs). Compared with patients with cITP and HC, patients with pES had increased circulating T-follicular helper cells (cTfh), increased T-cell activation, and decreased naïve CD4+ T cells for age. Despite normal or high immunoglobulin G (IgG) in most pES at presentation, class-switched memory B cells were decreased. Within the cTfh subset, we noted features of postactivation exhaustion with upregulation of several canonical checkpoint inhibitors. T-cell receptor β chain (TCR-β) repertoire analysis of cTfh cells revealed increased oligoclonality in patients with pES compared with HCs. Among patients with pES, those without a known gene defect had a similar characteristic immune abnormality as patients with defined genetic defects. Similarly, patients with pES with normal IgG had similar T-cell abnormalities as patients with low IgG. Because genetic defects have been identified in less than half of patients with pES, our findings of similar immune abnormalities across all patients with pES help establish a common characteristic immunopathology in pES, irrespective of the underlying genetic etiology.
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MESH Headings
- Adolescent
- Adult
- Anemia, Hemolytic, Autoimmune/immunology
- Anemia, Hemolytic, Autoimmune/pathology
- Child
- Child, Preschool
- Female
- Humans
- Infant
- Lymphocyte Activation
- Male
- Purpura, Thrombocytopenic, Idiopathic/immunology
- Purpura, Thrombocytopenic, Idiopathic/pathology
- T-Lymphocytes, Helper-Inducer/immunology
- T-Lymphocytes, Helper-Inducer/pathology
- Thrombocytopenia/immunology
- Thrombocytopenia/pathology
- Young Adult
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Affiliation(s)
- Deepak Kumar
- Aflac Cancer and Blood Disorder Center, Department of Pediatrics, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA
| | - Chengyu Prince
- Aflac Cancer and Blood Disorder Center, Department of Pediatrics, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA
| | - Carolyn M Bennett
- Aflac Cancer and Blood Disorder Center, Department of Pediatrics, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA
| | - Michael Briones
- Aflac Cancer and Blood Disorder Center, Department of Pediatrics, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA
| | - Laura Lucas
- Aflac Cancer and Blood Disorder Center, Children's Healthcare of Atlanta, Atlanta; GA
| | - Athena Russell
- Genetics and Molecular Biology Graduate Program, Laney Graduate School, Emory University, Atlanta, GA
| | - Kiran Patel
- Allergy/Immunology Section, Department of Pediatrics, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA
| | - Satheesh Chonat
- Aflac Cancer and Blood Disorder Center, Department of Pediatrics, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA
| | - Sara Graciaa
- Aflac Cancer and Blood Disorder Center, Children's Healthcare of Atlanta, Atlanta; GA
| | - Holly Edington
- Aflac Cancer and Blood Disorder Center, Department of Pediatrics, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA
| | - Michael H White
- Aflac Cancer and Blood Disorder Center, Department of Pediatrics, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA
| | - Lisa Kobrynski
- Allergy/Immunology Section, Department of Pediatrics, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA
| | | | - Suhag Parikh
- Aflac Cancer and Blood Disorder Center, Department of Pediatrics, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA
| | - Sharat Chandra
- Division of Bone Marrow Transplantation and Immune Deficiency, University of Cincinnati, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Jack Bleesing
- Division of Bone Marrow Transplantation and Immune Deficiency, University of Cincinnati, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Rebecca Marsh
- Division of Bone Marrow Transplantation and Immune Deficiency, University of Cincinnati, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Sunita Park
- Department of Pathology, Children's Healthcare of Atlanta, Atlanta, GA
| | - Edmund K Waller
- Department of Hematology and Medical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA; and
| | - Sampath Prahalad
- Division of Pediatric Rheumatology, Department of Pediatrics, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA
| | - Shanmuganathan Chandrakasan
- Aflac Cancer and Blood Disorder Center, Department of Pediatrics, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA
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17
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ÖZCAN A, CANSEVER M, YILMAZ E, ÜNAL E, KARAKÜKÇÜ M, PATIROĞLU T. The spectrum of underlying diseases in children with autoimmune hemolytic anemia. JOURNAL OF HEALTH SCIENCES AND MEDICINE 2021. [DOI: 10.32322/jhsm.985008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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18
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Gabelli M, Ademokun C, Cooper N, Amrolia PI. Pathogenesis, risk factors and therapeutic options for autoimmune haemolytic anaemia in the post-transplant setting. Br J Haematol 2021; 196:45-62. [PMID: 34195990 DOI: 10.1111/bjh.17648] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 05/26/2021] [Indexed: 11/27/2022]
Abstract
Autoimmune haemolytic anaemia (AIHA) is a rare complication of allogeneic haematopoietic stem cell transplantation (HSCT), observed with an incidence of 1-5%. Paediatric age, diagnosis of non-malignant disease, lympho-depleting agents in the conditioning regimen, use of unrelated donor, graft versus host disease and infections have been associated with a higher risk of AIHA post HSCT. Post-HSCT AIHA is associated with high mortality and morbidity, and it is often very difficult to treat. Steroids and rituximab are used with a response rate around 30-50%. These and other therapeutic strategies are mainly derived from data on primary AIHA, although response rates in post-HSCT AIHA have been generally lower. Here we review the currently available data on risk factors and therapeutic options. There is a need for prospective studies in post-HSCT AIHA to guide clinicians in managing these complex patients.
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Affiliation(s)
- Maria Gabelli
- Department of Bone Marrow Transplantation, Great Ormond Street Hospital, London, UK
| | - Christine Ademokun
- Department of Haematology, Imperial College Healthcare NHS Trust, London, UK
| | - Nichola Cooper
- Department of Immunology and Inflammation, Imperial College, London, UK
| | - Persis I Amrolia
- Department of Bone Marrow Transplantation, Great Ormond Street Hospital, London, UK
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19
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Andres AM, Talayero P, Alcolea Sanchez A, Sanchez Galán A, Serradilla Rodríguez J, Bueno Jimenez A, Gonzalez Sacristan R, Stringa P, Papa Gobbi R, Lasa Lazaro M, Díaz Almirón M, Ramos Boluda E, Lopez Santamaría M, Hernández Oliveros F. Delayed introduction of sirolimus in paediatric intestinal transplant recipients: indications and long-term benefits. Transpl Int 2021; 34:1895-1907. [PMID: 34174115 DOI: 10.1111/tri.13959] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 04/16/2021] [Accepted: 06/16/2021] [Indexed: 12/11/2022]
Abstract
To review our experience using sirolimus in a single centre paediatric intestinal transplantation cohort. Intestinal transplant patients with more than 3 months follow-up were divided into two groups according to their immunosuppression regimen: tacrolimus, (TAC group, n = 45 grafts) or sirolimus (SRL group, n = 38 grafts), which included those partially or completely converted from tacrolimus to sirolimus. The indications to switch were tacrolimus side effects and immunological complications. Survival and complications were retrospectively analysed comparing both groups. SRL was introduced 9 months (0 months-16.9 years) after transplant. The main cause for conversion was worsening renal function (45%), followed by haemolytic anaemia (21%) and graft-versus-host-disease (16%). Both groups showed a similar overall patient/graft survival (P = 0.76/0.08) and occurrence of rejection (24%/17%, P = 0.36). Immunological complications did not recur after conversion. Renal function significantly improved in most SRL patients. After a median follow-up of 65.17 months, 28/46 survivors were on SRL, 26 with monotherapy, with good graft function. Over one-third of our patients eventually required SRL conversion that allowed to improve their kidney function and immunological events, without entailing additional complications or survival impairment. Further trials are warranted to clarify the potential improvement of the standard tacrolimus maintenance by sirolimus conversion or addition.
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Affiliation(s)
- Ane M Andres
- Pediatric Surgery Department, La Paz University Hospital, Madrid, Spain.,Idipaz Institute, La Paz University Hospital, Madrid, Spain.,TransplantChild ERN, La Paz University Hospital, Madrid, Spain
| | - Paloma Talayero
- Immunology Department, 12 de Octubre University Hospital, Madrid, Spain
| | | | | | | | | | | | - Pablo Stringa
- Idipaz Institute, La Paz University Hospital, Madrid, Spain.,Institute for Immunological and Physiopathological Studies (IIFP-CONICET-UNLP), National University of La Plata, La plata, Buenos Aires, Argentina
| | | | - Maria Lasa Lazaro
- Immunology Department, 12 de Octubre University Hospital, Madrid, Spain
| | - Mariana Díaz Almirón
- Biostatistics Department, Idipaz Institute, La Paz University Hospital, Madrid, Spain
| | | | | | - Francisco Hernández Oliveros
- Pediatric Surgery Department, La Paz University Hospital, Madrid, Spain.,Idipaz Institute, La Paz University Hospital, Madrid, Spain.,TransplantChild ERN, La Paz University Hospital, Madrid, Spain
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20
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Grimes AB, Kim TO, Kirk SE, Flanagan J, Lambert MP, Grace RF, Despotovic JM. Refractory autoimmune cytopenias in pediatric Evans syndrome with underlying systemic immune dysregulation. Eur J Haematol 2021; 106:783-787. [PMID: 33570766 DOI: 10.1111/ejh.13600] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 02/10/2021] [Indexed: 01/03/2023]
Abstract
Evans syndrome is a rare but challenging disorder in children; and despite rapidly growing evidence for targetable systemic immune dysregulation driving these "idiopathic" autoimmune cytopenias, precision diagnosis and management remains sub-optimal among these patients. We analyzed retrospective clinical data for 60 pediatric ES patients followed at 3 large tertiary referral centers in the United States over a recent 6-year period and found that definable underlying systemic immune dysregulation was identified in only 42% of these patients throughout the course of clinical care. Median time from ES diagnosis to identification of the underlying systemic immune dysregulation disorder was 1.3 years (<1 month for rheumatologic disease, 2.3 years for CVID, 3.4 years for ALPS, and 7.4 years for monogenic disorders of immune regulation). Notably, a significantly higher percentage of patients in whom a definitive immune dysregulation disorder was ultimately identified required ≥3 cytopenia-directed therapies (92%) and also second- and third-line immunomodulatory agents (84%), vs those in whom no unifying immune dysregulation was diagnosed (65%, and 35%, respectively)-indicating that autoimmune cytopenias as a manifestation of systemic immune dysregulation are more treatment-refractory and severe. These data underline the importance of identifying the underlying systemic immune dysregulation and providing targeted therapy in pediatric ES.
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Affiliation(s)
- Amanda B Grimes
- Section of Hematology/Oncology, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA.,Texas Children's Cancer and Hematology Centers, Houston, TX, USA
| | - Taylor O Kim
- Section of Hematology/Oncology, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA.,Texas Children's Cancer and Hematology Centers, Houston, TX, USA
| | - Susan E Kirk
- Section of Hematology/Oncology, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA.,Texas Children's Cancer and Hematology Centers, Houston, TX, USA
| | - Jonathan Flanagan
- Section of Hematology/Oncology, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA.,Texas Children's Cancer and Hematology Centers, Houston, TX, USA
| | - Michele P Lambert
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.,Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Rachael F Grace
- Harvard Medical School, Boston, MA, USA.,Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, MA, USA
| | - Jenny M Despotovic
- Section of Hematology/Oncology, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA.,Texas Children's Cancer and Hematology Centers, Houston, TX, USA
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21
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Oikonomopoulou C, Paisiou A, Komitopoulou A, Ioannidou ED, Kaisari A, Tzannou I, Mpourazani E, Vessalas G, Peristeri I, Kitra-Roussou V, Goussetis E. Increased incidence of autoimmune cytopenias after allogeneic haematopoietic stem cell transplantation using a matched unrelated donor in children with β-thalassaemia. Br J Haematol 2021; 192:e127-e129. [PMID: 33522599 DOI: 10.1111/bjh.17335] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Affiliation(s)
| | - Anna Paisiou
- Stem Cell Transplant Unit, Aghia Sophia Children's Hospital, Athens, Greece
| | - Anna Komitopoulou
- Stem Cell Transplant Unit, Aghia Sophia Children's Hospital, Athens, Greece
| | | | - Aikaterini Kaisari
- Stem Cell Transplant Unit, Aghia Sophia Children's Hospital, Athens, Greece
| | - Ifigeneia Tzannou
- Stem Cell Transplant Unit, Aghia Sophia Children's Hospital, Athens, Greece
| | - Evdoxia Mpourazani
- Pediatric Intensive Care Unit, Aghia Sophia Children's Hospital, Athens, Greece
| | - George Vessalas
- Stem Cell Transplant Unit, Aghia Sophia Children's Hospital, Athens, Greece
| | - Ioulia Peristeri
- Stem Cell Transplant Unit, Aghia Sophia Children's Hospital, Athens, Greece
| | | | - Evgenios Goussetis
- Stem Cell Transplant Unit, Aghia Sophia Children's Hospital, Athens, Greece
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22
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Pincez T, Fernandes H, Leblanc T, Michel G, Barlogis V, Bertrand Y, Neven B, Chahla WA, Pasquet M, Guitton C, Marie-Cardine A, Pellier I, Armari-Alla C, Benadiba J, Blouin P, Jeziorski E, Millot F, Paillard C, Thomas C, Cheikh N, Bayart S, Fouyssac F, Piguet C, Deparis M, Briandet C, Dore E, Picard C, Rieux-Laucat F, Landman-Parker J, Leverger G, Aladjidi N. Long term follow-up of pediatric-onset Evans syndrome: broad immunopathological manifestations and high treatment burden. Haematologica 2021; 107:457-466. [PMID: 33440924 PMCID: PMC8804581 DOI: 10.3324/haematol.2020.271106] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Indexed: 11/12/2022] Open
Abstract
Pediatric-onset Evans syndrome (pES) is defined by both immune thrombocytopenic purpura (ITP) and autoimmune hemolytic anemia (AIHA) before the age of 18 years. There have been no comprehensive long-term studies of this rare disease, which can be associated to various immunopathological manifestations (IM). We report outcomes of the 151 patients with pES and more than 5 years of follow-up from the nationwide French prospective OBS’CEREVANCE cohort. Median age at final follow-up was 18.5 years (range, 6.8–50.0 years) and the median follow-up period was 11.3 years (range, 5.1–38.0 years). At 10 years, ITP and AIHA were in sustained complete remission in 54.5% and 78.4% of patients, respectively. The frequency and number of clinical and biological IM increased with age: at the age of 20 years, 74% had at least one clinical IM (cIM). A wide range of cIM occurred, mainly lymphoproliferation, dermatological, gastrointestinal/hepatic and pneumological IM. The number of cIM was associated with a subsequent increase in the number of second-line treatments received (other than steroids and immunoglobulins; hazard ratio 1.4, 95% Confidence Interval: 1.15–1.60, P=0.0002, Cox proportional hazards method). Survival at 15 years after diagnosis was 84%. Death occurred at a median age of 18 years (range, 1.7–31.5 years), and the most frequent cause was infection. The number of second-line treatments and severe/recurrent infections were independently associated with mortality. In conclusion, long-term outcomes of pES showed remission of cytopenias but frequent IM linked to high second-line treatment burden. Mortality was associated to drugs and/or underlying immunodeficiencies, and adolescents-young adults are a high-risk subgroup.
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Affiliation(s)
- Thomas Pincez
- Centre de Référence National des Cytopénies Auto-immunes de l'Enfant (CEREVANCE), Bordeaux, France; Division of Pediatric Hematology-Oncology, Charles-Bruneau Cancer Center, Department of Pediatrics, Sainte-Justine University Hospital, Université de Montréal, Montréal, Québec
| | - Helder Fernandes
- Centre de Référence National des Cytopénies Auto-immunes de l'Enfant (CEREVANCE), Bordeaux, France; Pediatric Oncology Hematology Unit, University Hospital, Plurithématique CIC (CICP), Centre d'Investigation Clinique (CIC) 1401, INSERM Bordeaux
| | - Thierry Leblanc
- Pediatric Hematology Unit, Robert Debré University Hospital, AP-HP, Paris
| | - Gérard Michel
- Department of Pediatric Hematology, La Timone Hospital, Marseille University Hospital, Marseille
| | - Vincent Barlogis
- Department of Pediatric Hematology, La Timone Hospital, Marseille University Hospital, Marseille
| | - Yves Bertrand
- Institute of Pediatric Hematology and Oncology, Lyon University Hospital, Lyon
| | - Bénédicte Neven
- Pediatric Immuno-Hematology and Rheumatology Department, Necker-Enfants Malades University Hospital, AP-HP, Paris, France; Laboratory of Immunogenetics of Pediatric Autoimmune Diseases, Paris, France; Imagine Institute, UMR 1163 INSERM and Paris University, Paris
| | - Wadih Abou Chahla
- Department of Pediatric Hematology, Jeanne de Flandre Hospital, Lille University Hospital, Lille
| | - Marlène Pasquet
- Pediatric Oncology Immunology Hematology Unit, Children's University Hospital, Toulouse
| | - Corinne Guitton
- Department of Pediatrics, Bicêtre University Hospital, AP-HP, Le Kremlin-Bicêtre
| | - Aude Marie-Cardine
- Department of Pediatric Hematology and Oncology, Rouen University Hospital, Rouen
| | | | | | - Joy Benadiba
- Department of Hemato-Oncology Pediatric, Nice University Hospital, Nice
| | - Pascale Blouin
- Department of Pediatric Hematology-Oncology, Clocheville Hospital, Tours University Hospital, Tours
| | - Eric Jeziorski
- Pediatric Oncology Hematology Unit, Arnaud de Villeneuve University Hospital, Montpellier
| | - Frédéric Millot
- Department of Pediatric Hematology, Poitiers University Hospital, Poitiers
| | - Catherine Paillard
- Department of Pediatric Hematology and Oncology, Hautepierre University Hospital, Strasbourg
| | - Caroline Thomas
- Pediatric Hematology Unit, Nantes University Hospital, Nantes
| | - Nathalie Cheikh
- Department of Pediatric Hematology-Oncology, Besanc_on University Hospital, Besanc_on
| | - Sophie Bayart
- Pediatric Hematology Unit, Rennes University Hospital, Rennes
| | - Fanny Fouyssac
- Pediatric Hematology Unit, Nancy University Hospital, Nancy
| | - Christophe Piguet
- Pediatric Oncology Hematology Unit, Limoges University Hospital, Limoges
| | - Marianna Deparis
- Pediatric Oncology-Hematology Unit Department, Caen University Hospital, Caen
| | | | - Eric Dore
- Pediatric Unit, Clermont-Ferrand University Hospital, Clermont-Ferrand
| | - Capucine Picard
- Imagine Institute, UMR 1163 INSERM and Paris University, Paris, France; Study Center for Primary Immunodeficiencies, Necker-Enfants Malades University Hospital, AP-HP, Paris
| | - Frédéric Rieux-Laucat
- Laboratory of Immunogenetics of Pediatric Autoimmune Diseases, Paris, France; Imagine Institute, UMR 1163 INSERM and Paris University, Paris
| | - Judith Landman-Parker
- Pediatric Oncology Immunology Hematology Unit, Armand-Trousseau University Hospital, AP-HP, Paris
| | - Guy Leverger
- Pediatric Oncology Immunology Hematology Unit, Armand-Trousseau University Hospital, AP-HP, Paris
| | - Nathalie Aladjidi
- Centre de Référence National des Cytopénies Auto-immunes de l'Enfant (CEREVANCE), Bordeaux, France; Pediatric Oncology Hematology Unit, University Hospital, Plurithématique CIC (CICP), Centre d'Investigation Clinique (CIC) 1401, INSERM Bordeaux.
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Feng Y, Chen X, Cassady K, Zou Z, Yang S, Wang Z, Zhang X. The Role of mTOR Inhibitors in Hematologic Disease: From Bench to Bedside. Front Oncol 2021; 10:611690. [PMID: 33489922 PMCID: PMC7821787 DOI: 10.3389/fonc.2020.611690] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 11/27/2020] [Indexed: 02/05/2023] Open
Abstract
The mTOR pathway plays a central role in many cellular processes, such as cellular growth, protein synthesis, glucose, and lipid metabolism. Aberrant regulation of mTOR is a hallmark of many cancers, including hematological malignancies. mTOR inhibitors, such as Rapamycin and Rapamycin analogs (Rapalogs), have become a promising class of agents to treat malignant blood diseases-either alone or in combination with other treatment regimens. This review highlights experimental evidence underlying the molecular mechanisms of mTOR inhibitors and summarizes their evolving role in the treatment of hematologic disease, including leukemia, lymphoma, myeloma, immune hemocytopenia, and graft-versus-host disease (GVHD). Based on data presented in this review, we believe that mTOR inhibitors are becoming a trusted therapeutic in the clinical hematologist's toolbelt and should be considered more routinely in combination therapy for the management of hematologic disease.
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Affiliation(s)
- Yimei Feng
- Medical Center of Hematology, The Xinqiao Hospital of Third Military Medical University, Chongqing, China
- State Key Laboratory of Trauma, Burns and Combined Injury, Third Military Medical University, Chongqing, China
- Chongqing Sub-center of National Clinical Research Center for Hematologic Disease, Chongqing, China
| | - Xiaoli Chen
- Medical Center of Hematology, The Xinqiao Hospital of Third Military Medical University, Chongqing, China
- State Key Laboratory of Trauma, Burns and Combined Injury, Third Military Medical University, Chongqing, China
- Chongqing Sub-center of National Clinical Research Center for Hematologic Disease, Chongqing, China
| | - Kaniel Cassady
- Irell and Manella Graduate School of Biological Sciences of City of Hope, Duarte, CA, United States
| | - Zhongmin Zou
- Department of Chemical Defense Medicine, School of Military Preventive Medicine, Third Military Medical University, Chongqing, China
| | - Shijie Yang
- Medical Center of Hematology, The Xinqiao Hospital of Third Military Medical University, Chongqing, China
- State Key Laboratory of Trauma, Burns and Combined Injury, Third Military Medical University, Chongqing, China
- Chongqing Sub-center of National Clinical Research Center for Hematologic Disease, Chongqing, China
| | - Zheng Wang
- Medical Center of Hematology, The Xinqiao Hospital of Third Military Medical University, Chongqing, China
- State Key Laboratory of Trauma, Burns and Combined Injury, Third Military Medical University, Chongqing, China
- Chongqing Sub-center of National Clinical Research Center for Hematologic Disease, Chongqing, China
| | - Xi Zhang
- Medical Center of Hematology, The Xinqiao Hospital of Third Military Medical University, Chongqing, China
- State Key Laboratory of Trauma, Burns and Combined Injury, Third Military Medical University, Chongqing, China
- Chongqing Sub-center of National Clinical Research Center for Hematologic Disease, Chongqing, China
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24
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Prakash A, Paul V, Ittoop A. Autoimmune hemolytic anemia in children: Clinical profile and outcomes. JOURNAL OF APPLIED HEMATOLOGY 2021. [DOI: 10.4103/joah.joah_235_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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25
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Du Y, Yang C, Chen M, Ruan J, Huang Y, Chen F, Han B. Tacrolimus is effective in relapsed/refractory autoimmune cytopenias: results of a single-center retrospective study. Hematology 2020; 25:478-483. [PMID: 33297889 DOI: 10.1080/16078454.2020.1852763] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND The standard therapies for autoimmune cytopenias, including idiopathic thrombocytopenia (ITP), autoimmune hemolytic anemia (AIHA) and Evans syndrome (ES), are corticosteroids and intravenous immunoglobulin G. However, the recurrence rate is high. METHOD Data from 80 patients with ITP, AIHA and ES who were refractory to corticosteroids/relapsed and were treated with tacrolimus from January 2018 to January 2019 in Peking Union Medical Colleague Hospital were reviewed retrospectively. RESULTS There were 24 males and 56 females, with a median age of 43 (14-81) years, including 66 with ITP, 11 with AIHA and 3 with ES. The median disease duration before tacrolimus was 16 (2-432) months. The complete response (CR) rates were 30.3%, 63.6% and 0%; the overall response (OR) rates were 63.6%, 72.7% and 66.7% for ITP, AIHA and ES, respectively; and the median time to response was 3 (2-10) months. In a median of 18 (10-24) months of follow-up time, 21.4% of ITP patients relapsed at a median time of 7 months. No relapse was found for patients with AIHA and ES. Side effects occurred in 16.3% of patients, including elevated creatinine (N = 3, 3.8%), gastrointestinal reactions (N = 3, 3.8%), and pulmonary infection (N = 2, 2.5%), and resulted in 3 patients stopping tacrolimus. The OR rate was found to be related with age (P = 0.01) but not with sex (P = 0.62), the duration of disease (P = 0.66), tacrolimus concentration (P = 0.99) or disease type (P = 0.84). CONCLUSION Tacrolimus can achieve a durable response with mild side effects in patients with steroid-refractory/relapsed autoimmune cytopenias. Patients with younger age had a better response.
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Affiliation(s)
- Yali Du
- Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, People's Republic of China
| | - Chen Yang
- Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, People's Republic of China
| | - Miao Chen
- Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, People's Republic of China
| | - Jing Ruan
- Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, People's Republic of China
| | - Yuzhou Huang
- Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, People's Republic of China
| | - Fangfei Chen
- Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, People's Republic of China
| | - Bing Han
- Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, People's Republic of China
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26
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Seidel MG. Treatment of immune-mediated cytopenias in patients with primary immunodeficiencies and immune regulatory disorders (PIRDs). HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2020; 2020:673-679. [PMID: 33275670 PMCID: PMC7727533 DOI: 10.1182/hematology.2020000153] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
Severe immune cytopenias (SICs) are rare acquired conditions characterized by immune-mediated blood cell destruction. They may necessitate emergency medical management and long-term immunosuppressive therapy, strongly compromising the quality of life. The initial diagnostic workup involves excluding malignancies, congenital cytopenias, bone marrow failure syndromes, infections, and rheumatologic diseases such as systemic lupus erythematosus. Causal factors for SIC such as primary immunodeficiencies or immune regulatory disorders, which are referred to as inborn errors of immunity (IEIs), should be diagnosed as early as possible to allow the initiation of a targeted therapy and avoid multiple lines of ineffective treatment. Ideally, this therapy is directed against an overexpressed or overactive gene product or substitutes a defective protein, restoring the impaired pathway; it can also act indirectly, enhancing a countermechanism against the disease-causing defect. Ultimately, the diagnosis of an underling IEI in patients with refractory SIC may lead to evaluation for hematopoietic stem cell transplantation or gene therapy as a definitive treatment. Interdisciplinary care is highly recommended in this complex patient cohort. This case-based educational review supports decision making for patients with immune-mediated cytopenias and suspected inborn errors of immunity.
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Affiliation(s)
- Markus G Seidel
- Research Unit for Pediatric Hematology and Immunology, Division of Pediatric Hemato-Oncology, Department of Pediatrics and Adolescent Medicine, Medical University Graz, Graz, Austria
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27
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Beydoun SB, Persaud Y, Lafferty J, Callaghan MU, Savaşan S. Bortezomib treatment of steroid-refractory Evans syndrome in children. Pediatr Blood Cancer 2020; 67:e28725. [PMID: 32969165 DOI: 10.1002/pbc.28725] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 09/08/2020] [Accepted: 09/09/2020] [Indexed: 12/13/2022]
Abstract
Treatment of refractory Evans syndrome (ES) remains a challenge in hematology practice. Due to rarity of this condition, evidence-based approaches are limited and often treatment choices stem from small case series or anecdotal experiences. There is mounting evidence that some patients have genetic defects that could be targeted with promising preliminary results. Here, we describe three very refractory pediatric ES cases treated on bortezomib without adverse effects. Two of the three patients had dramatic and long-lasting recovery that started following the initial doses of the drug. Clinical trials to assess the role of bortezomib in ES treatment are warranted.
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Affiliation(s)
- Serina B Beydoun
- Division of Hematology/Oncology, Children's Hospital of Michigan
| | - Yogindra Persaud
- Division of Hematology/Oncology, Children's Hospital of Michigan
| | | | - Michael U Callaghan
- Division of Hematology/Oncology, Children's Hospital of Michigan Department of Pediatrics, Barbara Ann Karmanos Cancer Center, Children's Hospital of Michigan, Central Michigan University College of Medicine
| | - Süreyya Savaşan
- Division of Hematology/Oncology, Children's Hospital of Michigan Department of Pediatrics, Barbara Ann Karmanos Cancer Center, Children's Hospital of Michigan, Central Michigan University College of Medicine
- Division of Hematology/Oncology, Pediatric Bone Marrow Transplant Program, Children's Hospital of Michigan Department of Pediatrics, Barbara Ann Karmanos Cancer Center, Children's Hospital of Michigan, Central Michigan University College of Medicine
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28
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A case of Evans syndrome secondary to COVID-19. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2020; 19:85-88. [PMID: 33263526 DOI: 10.2450/2020.0221-20] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 08/31/2020] [Indexed: 11/21/2022]
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29
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Maggiore R, Grossi A, Fioredda F, Palmisani E, Terranova P, Cappelli E, Lanza T, Pierri F, Guardo D, Calvillo M, Micalizzi C, Beccaria A, Coccia MC, Arrigo S, Dufour C, Ceccherini I, Miano M. Unusual Late-onset Enteropathy in a Patient With Lipopolysaccharide-responsive Beige-like Anchor Protein Deficiency. J Pediatr Hematol Oncol 2020; 42:e768-e771. [PMID: 31876783 DOI: 10.1097/mph.0000000000001708] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
In recent years, monogenic causes of immune dysregulation syndromes, with variable phenotypes, have been documented. Mutations in the lipopolysaccharide-responsive beige-like anchor (LRBA) protein are associated with common variable immunodeficiency, autoimmunity, chronic enteropathy, and immune dysregulation disorders. The LRBA protein prevents degradation of cytotoxic T-lymphocyte antigen 4 (CTLA4) protein, thus inhibiting immune responses. Both LRBA and CTLA4 deficiencies usually present with immune dysregulation, mostly characterized by autoimmunity and lymphoproliferation. In this report, we describe a patient with an atypical clinical onset of LRBA deficiency and the patient's response to abatacept, a fusion protein-drug that mimics the action of CTLA4.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | - Serena Arrigo
- Gastroenterology Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
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30
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Thrombotic thrombocytopenic purpura and defective apoptosis due to CASP8/10 mutations: the role of mycophenolate mofetil. Blood Adv 2020; 3:3432-3435. [PMID: 31714957 DOI: 10.1182/bloodadvances.2019000575] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Accepted: 09/17/2019] [Indexed: 01/19/2023] Open
Abstract
Key Points
Immunological dysregulation may underlie unusual autoimmune diseases, which also deserve to be investigated from a genetic point of view.
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31
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Li H, Ji J, Du Y, Huang Y, Gu H, Chen M, Wu R, Han B. Sirolimus is effective for primary relapsed/refractory autoimmune cytopenia: a multicenter study. Exp Hematol 2020; 89:87-95. [PMID: 32771553 DOI: 10.1016/j.exphem.2020.08.001] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 07/31/2020] [Accepted: 08/02/2020] [Indexed: 10/23/2022]
Abstract
Autoimmune cytopenia includes autoimmune hemolytic anemia (AIHA), immune thrombocytopenia (ITP), and Evans syndrome (ES) caused by abnormal activation of autoimmunity and has a considerable refractory/relapse rate. To evaluate the efficacy and toxicity of sirolimus of primary relapsed/refractory autoimmune cytopenia, records of 45 patients with primary relapsed/refractory AIHA, ES, or ITP from October 2016 to January 2019 in two institutions, were collected; there were 3 pediatric patients and 42 adult patients. The median age at diagnosis was 31 (1-84) years. Patients were treated for a median of 14 (6-39) months and followed-up for a median of 18 (10-40) months. Thirty-eight patients responded to sirolimus, with 28 complete responses (CRs) and a median of 2 (2-5) months to response. Five patients had mucositis; the incidences of other adverse events were all less than 5%. Four patients relapsed, making the CR and overall response rate 46.7% and 75.6% at the end of follow-up. There were no differences in patient age, sex, time from diagnosis to sirolimus, serum sirolimus concentration, and disease distribution between CR and non-CR patients, or between responders and nonresponders, though AIHA patients were likely to relapse less and respond better. In conclusion, sirolimus is effective for patients with primary relapsed/refractory autoimmune cytopenia with a low relapse rate and good tolerance.
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Affiliation(s)
- Hongmin Li
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jiang Ji
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yali Du
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yuzhou Huang
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hao Gu
- Hematology-Oncology Center, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Miao Chen
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - RunHui Wu
- Hematology-Oncology Center, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Bing Han
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
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32
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Miano M, Madeo A, Cappelli E, Lanza F, Lanza T, Stroppiano M, Terranova P, Venè R, Bleesing JJH, Di Rocco M. Defective FAS-Mediated Apoptosis and Immune Dysregulation in Gaucher Disease. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 8:3535-3542. [PMID: 32702516 DOI: 10.1016/j.jaip.2020.06.065] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Revised: 06/29/2020] [Accepted: 06/30/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Gaucher disease (GD) is a rare disorder characterized by defective function of β-glucocerebrosidase, which leads to progressive accumulation of its substrate in various organs, particularly the mononuclear phagocyte system. Hepatosplenomegaly and cytopenia represent the disease's most common features, but patients with GD also show hyperinflammation, hypergammaglobulinemia, and immune dysregulation involving B, T, and natural killer cells. As clinical phenotype can be underhand, symptoms can overlap with autoimmune lymphoproliferative syndrome (ALPS) or other ALPS-like disorders. OBJECTIVE To evaluate the ALPS-like immunological pattern and apoptosis function in patients with GD. METHODS We evaluated lymphocyte subsets and immunophenotypic and serological features of ALPS (double-negative T cells [DNTs], B220+DNTs, CD27+, T-reg/HLA-DR ratio, IL-10, IL-18, vitamin B12) in a population of patients with GD. Moreover, we tested FAS/TRAIL-induced apoptosis and CASP8/CASP10/PARP function in patients showing an immune-dysregulation pattern. RESULTS A total of 41 patients (33 treated, 8 treatment-naïve) were studied. Nine (21%) and 7 (17%) of 41 patients had high DNT and B220+DNT counts, respectively. Overall, 10 of 41(24%) patients showed immunological features suggestive of ALPS that were more frequent in treatment-naïve subjects (P = .040 vs P = .031) and in those with early onset of the disease (P = .046 vs P = .011), respectively. FAS-induced apoptosis and caspase activation were further evaluated in these 10 patients and were found to be defective in 7 of them. CONCLUSIONS We show that patients with GD may have ALPS-like features and FAS-mediated apoptosis defects that are more pronounced in treatment-naïve subjects and in patients with early onset of the disease. Therefore, diagnostic workup of patients with an ALPS-like phenotype should include screening for GD.
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Affiliation(s)
- Maurizio Miano
- Hematology Unit, Department of Hematology and Oncology, Istituto di Ricovero e Cura a Carattere Scientifico, Istituto Giannina Gaslini, Genoa, Italy
| | - Annalisa Madeo
- Unit of Rare Diseases, Department of Pediatrics, Istituto di Ricovero e Cura a Carattere Scientifico, Istituto Giannina Gaslini, Genoa, Italy
| | - Enrico Cappelli
- Hematology Unit, Department of Hematology and Oncology, Istituto di Ricovero e Cura a Carattere Scientifico, Istituto Giannina Gaslini, Genoa, Italy
| | - Federica Lanza
- Laboratory of Molecular Genetics and Biobanks, Istituto di Ricovero e Cura a Carattere Scientifico, Istituto Giannina Gaslini, Genoa, Italy
| | - Tiziana Lanza
- Hematology Unit, Department of Hematology and Oncology, Istituto di Ricovero e Cura a Carattere Scientifico, Istituto Giannina Gaslini, Genoa, Italy
| | - Marina Stroppiano
- Laboratory of Molecular Genetics and Biobanks, Istituto di Ricovero e Cura a Carattere Scientifico, Istituto Giannina Gaslini, Genoa, Italy
| | - Paola Terranova
- Hematology Unit, Department of Hematology and Oncology, Istituto di Ricovero e Cura a Carattere Scientifico, Istituto Giannina Gaslini, Genoa, Italy
| | - Roberta Venè
- Molecular Oncology and Angiogenesis Unit, Istituto di Ricovero e Cura a Carattere Scientifico, San Martino-IST, Genoa, Italy
| | - Jack J H Bleesing
- Division of Bone Marrow Transplantation and Immune Deficiencies, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Maja Di Rocco
- Unit of Rare Diseases, Department of Pediatrics, Istituto di Ricovero e Cura a Carattere Scientifico, Istituto Giannina Gaslini, Genoa, Italy.
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33
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Mannering N, Hansen DL, Frederiksen H. Evans syndrome in children below 13 years of age - A nationwide population-based cohort study. PLoS One 2020; 15:e0231284. [PMID: 32271826 PMCID: PMC7145102 DOI: 10.1371/journal.pone.0231284] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Accepted: 03/19/2020] [Indexed: 12/31/2022] Open
Abstract
Evans syndrome is defined by autoimmune haemolytic anaemia and immune thrombocytopenia occurring in the same patient. Although known to be rare the frequency and prognosis of Evans syndrome in children is unknown, and only few registry-based studies are available. The epidemiology and prognosis of Evans syndrome in patients above 13 years of age has recently been investigated. In this age group both incidence and prevalence of Evans syndrome increased during the study period and median survival was just 7.2 years. Using Danish health registries and the same approach, we identified 21 children below 13 years of age with Evans syndrome during 1981–2015. Patients with Evans syndrome were age–and sex matched with children both from the general population, and with patients with either autoimmune haemolytic anaemia or immune thrombocytopenia. The incidence of Evans syndrome ranged between 0.5 and 1.2/1,000,000 person-years. Prevalence was 6.7 and 19.3/1,000,000 in 1990 and 2015 respectively. Hazard ratio for death was 22 fold higher for children with ES compared to matched children from general population, and was also elevated compared to children with autoimmune haemolytic anaemia or immune thrombocytopenia. We conclude that pediatric ES is very rare and associated with elevated mortality. However, despite the nationwide study and a long and complete follow-up, results are imprecise due to the rarity of this disorder.
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Affiliation(s)
- Nikolaj Mannering
- Department of Hematology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- * E-mail:
| | - Dennis Lund Hansen
- Department of Hematology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Henrik Frederiksen
- Department of Hematology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
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Weli M, Ben Hlima A, Belhadj R, Maalej B, Elleuch A, Mekki N, Gargouri L, Kamoun T, Barbouche MR, Mahfoudh A. Diagnosis and management of autoimmune hemolytic anemia in children. Transfus Clin Biol 2020; 27:61-64. [PMID: 32280062 DOI: 10.1016/j.tracli.2020.03.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Accepted: 03/18/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND AND AIM The aim of this study is to evaluate the clinical, biological and hematological profiles of autoimmune hemolytic anemia (AIHA) in children and to specify its etiologies, therapeutic modalities, and treatment responses. METHODS This is a 14-year retrospective study of AIHA cases collected at the department of pediatric emergency and reanimation of Hedi Chaker University Hospital in Sfax. We included patients under 14 years old with clinical and biological features of hemolysis and a positive direct antiglobulin test (DAT). The selected patients' demographic characteristics, physical signs, laboratory findings, and treatment responses were recorded. RESULTS Thirteen cases of AIHA were collected, including 8 girls and 5 boys. The median age at diagnosis was 4 years and 6 months (range: 8 months to 13 years). Consanguinity was reported in 6 cases and 4 patients had a previous infection history. The onset of AIHA was progressive in 9 cases, marked by an anemic syndrome and hemolysis symptoms in 6 and 8 cases, respectively. The clinical triad (pallor, jaundice and splenomegaly) was found in only 4 cases. At the time of diagnosis, the median hemoglobin (Hb) level was 6g/dL (range: 4.2 to 9.2g/dL), anemia was non-regenerative in 2 patients. Thrombocytopenia and neutropenia were noted in 5 and 1 patient, respectively. Peripheral smear examination showed spherocytosis in 2 cases. All the patients had a positive DAT. Of these, 10 were positive with IgG and 3 with both IgG and C3d. AIHA was secondary to other conditions in 9 patients: infection (3 cases), autoimmune disease (4 cases), and immunodeficiency (2 cases). All the patients received first-line corticosteroid therapy but only 8 of them required blood transfusions due to severe anemia. Complete remission was obtained in 7 cases. Corticosteroid resistance and dependence were noted in 1 and 2 cases, respectively. During evolution, additional therapy was indicated in 4 patients and it included cyclosporine A, azathioprine, and mycophenolate mofetil (MMF). After a median follow-up of 4.5 years, the cure rate was 80% and only 1 patient (a boy) died due to his underlying pathology. CONCLUSION Our study highlights the rarity, severity, and heterogeneity of etiological contexts of AIHA in children. The therapeutic difficulties justify specific expertise in pediatric hematology.
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Affiliation(s)
- M Weli
- Department of pediatric emergency and reanimation, Hedi Chaker university hospital of Sfax, Sfax, Tunisia; Faculty of medicine, university of Sfax, Sfax, Tunisia
| | - A Ben Hlima
- Department of pediatric emergency and reanimation, Hedi Chaker university hospital of Sfax, Sfax, Tunisia; Faculty of medicine, university of Sfax, Sfax, Tunisia
| | - R Belhadj
- Department of pediatrics, Hedi Cheker university hospital of Sfax, Sfax, Tunisia; Faculty of medicine, university of Sfax, Sfax, Tunisia.
| | - B Maalej
- Department of pediatric emergency and reanimation, Hedi Chaker university hospital of Sfax, Sfax, Tunisia; Faculty of medicine, university of Sfax, Sfax, Tunisia
| | - A Elleuch
- Department of pediatric emergency and reanimation, Hedi Chaker university hospital of Sfax, Sfax, Tunisia; Faculty of medicine, university of Sfax, Sfax, Tunisia
| | - N Mekki
- Laboratory of transmission, control and immunobiology of infections (LR11IPT02), Tunis, Tunisia
| | - L Gargouri
- Department of pediatric emergency and reanimation, Hedi Chaker university hospital of Sfax, Sfax, Tunisia; Faculty of medicine, university of Sfax, Sfax, Tunisia
| | - T Kamoun
- Department of pediatrics, Hedi Cheker university hospital of Sfax, Sfax, Tunisia; Faculty of medicine, university of Sfax, Sfax, Tunisia
| | - M-R Barbouche
- Laboratory of transmission, control and immunobiology of infections (LR11IPT02), Tunis, Tunisia
| | - A Mahfoudh
- Department of pediatric emergency and reanimation, Hedi Chaker university hospital of Sfax, Sfax, Tunisia; Faculty of medicine, university of Sfax, Sfax, Tunisia
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Successful Treatment of an Adolescent Male With Severe Refractory Evans Syndrome Using Bortezomib-based Therapy. J Pediatr Hematol Oncol 2020; 42:e110-e113. [PMID: 30299351 DOI: 10.1097/mph.0000000000001325] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Evans syndrome is defined by bilineal autoimmune cytopenia, typically coombs positive hemolytic anemia and thrombocytopenia. Corticosteroids are the mainstay of treatment, with rituximab and/or mycophenolate mofetil often used in steroid-refractory cases. However, no treatment methodology has ever evaluated by a randomized clinical trial. We present a 15-year-old boy with Evans syndrome and common variable immunodeficiency who experienced a severe, refractory flare 16 months postsplenectomy. After failing to respond to multiple other agents, he achieved a durable response to a bortezomib-based regimen. Bortezomib may be a reasonable second or third line option, especially before high-morbidity therapies such as splenectomy or stem cell transplantation.
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Miller PDE, Snowden JA, De Latour RP, Iacobelli S, Eikema DJ, Knol C, Marsh JCW, Rice C, Koh M, Fagioli F, Chaganti S, Finke J, Duarte RF, Bader P, Farge D, Passweg JR, Madrigal JA, Dufour C. Autoimmune cytopenias (AIC) following allogeneic haematopoietic stem cell transplant for acquired aplastic anaemia: a joint study of the Autoimmune Diseases and Severe Aplastic Anaemia Working Parties (ADWP/SAAWP) of the European Society for Blood and Marrow Transplantation (EBMT). Bone Marrow Transplant 2020; 55:441-451. [PMID: 31554929 PMCID: PMC6995778 DOI: 10.1038/s41409-019-0680-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2018] [Revised: 07/06/2019] [Accepted: 07/20/2019] [Indexed: 12/03/2022]
Abstract
This retrospective study explored the incidence of autoimmune cytopenia (AIC) in 530 paediatric and adult patients with acquired aplastic anaemia (aAA) who underwent first allogeneic HSCT between 2002 and 2012. AIC was a rare complication with a cumulative incidence of AIC at 1, 3, 5 and 10 years post HSCT of 2.5% (1.2-3.9 95% CI), 4.4% (2.6-6.2 95% CI), 4.6% (2.8-6.5 95% CI) and 5.1% (3.1-7.2 95% CI). Overall survival at 5 years after diagnosis of AIC was 85.9% (71-100 95% CI). Twenty-five patients were diagnosed with AIC at a median of 10.6 (2.6-91.5) months post HSCT. Eight (32%) patients were diagnosed with immune thrombocytopenia (ITP), seven (28%) with autoimmune haemolytic anaemia (AIHA), seven (24%) with Evans syndrome and four (16%) with autoimmune neutropenia (AIN). Treatment strategies were heterogeneous. Complete responses were seen in 12 of 25 patients, with death in three patients. In multivariable Cox analysis of a subgroup of 475 patients, peripheral blood stem cell (PBSC) transplant was associated with higher risk of AIC compared with bone marrow (BM) when conditioning regimens contained fludarabine and/or alemtuzumab (2.81 [1.06-7.49 95% CI]; p = 0.038), or anti-thymocyte globulin (ATG) (2.86 [1.11-7.37 95% CI]; p = 0.029). Myeloablative conditioning was associated with a lower risk of AIC compared with reduced intensity conditioning (RIC) in fludarabine and/or alemtuzumab (0.34 [0.12-0.98 95% CI]; p = 0.046) and ATG containing regimens (0.34 [0.12-0.95 95% CI]; p = 0.04). These findings provide clinically useful information regarding the incidence of a rare and potentially life-threatening complication of allogeneic HSCT for aAA, and further support for BM as the preferred stem cell source for transplant of patients with aAA.
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Affiliation(s)
| | - John A Snowden
- Department of Haematology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | | | - Simona Iacobelli
- Department of Biology, University of Rome Tor Vergata, Rome, Italy
| | | | - Cora Knol
- EBMT Data Office, Leiden, Netherlands
| | - Judith C W Marsh
- Department of Haematological Medicine, Kings College Hospital, London, UK
| | - Carmel Rice
- Department of Haematological Medicine, Kings College Hospital, London, UK
| | - Mickey Koh
- Department of Haematology, St George's Hospital NHS Foundation Trust, London, UK
| | - Franca Fagioli
- Pediatric Onco-Hematology, Stem Cell Transplantation and Cellular Therapy Division, Regina Margherita Children's Hospital, Torino, Italy
| | - Sridhar Chaganti
- Centre for Clinical Haematology, University Hospital Birmingham, Birmingham, UK
| | - Jürgen Finke
- Department of Hematology and Oncology, University Medical Center, Freiburg, Germany
| | - Rafael F Duarte
- Department of Hematology, Hospital Universitario Puerta de Hierro, Madrid, Spain
| | - Peter Bader
- University Children's Hospital Frankfurt, Frankfurt, Germany
| | - Dominique Farge
- Department of Autoimmune Diseases and Vascular Pathology, Hopital Saint-Louis, Paris, France
| | - Jakob R Passweg
- Division of Hematology, University Hospital of Santander, Basel, Switzerland
| | | | - Carlo Dufour
- Hematology Unit, G. Gaslini Children's Hospital, Genova, Italy
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Szanto CL, Langenhorst J, de Koning C, Nierkens S, Bierings M, Huitema AD, Lindemans CA, Boelens JJ. Predictors for Autoimmune Cytopenias after Allogeneic Hematopoietic Cell Transplantation in Children. Biol Blood Marrow Transplant 2020; 26:114-122. [DOI: 10.1016/j.bbmt.2019.07.022] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Revised: 07/05/2019] [Accepted: 07/16/2019] [Indexed: 12/27/2022]
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Diagnosis and treatment of autoimmune hemolytic anemia in adults: Recommendations from the First International Consensus Meeting. Blood Rev 2019; 41:100648. [PMID: 31839434 DOI: 10.1016/j.blre.2019.100648] [Citation(s) in RCA: 249] [Impact Index Per Article: 49.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2019] [Revised: 11/21/2019] [Accepted: 11/25/2019] [Indexed: 12/15/2022]
Abstract
Autoimmune hemolytic anemias (AIHAs) are rare and heterogeneous disorders characterized by the destruction of red blood cells through warm or cold antibodies. There is currently no licensed treatment for AIHA. Due to the paucity of clinical trials, recommendations on diagnosis and therapy have often been based on expert opinions and some national guidelines. Here we report the recommendations of the First International Consensus Group, who met with the aim to review currently available data and to provide standardized diagnostic criteria and therapeutic approaches as well as an overview of novel therapies. Exact diagnostic workup is important because symptoms, course of disease, and therapeutic management relate to the type of antibody involved. Monospecific direct antiglobulin test is considered mandatory in the diagnostic workup, and any causes of secondary AIHA have to be diagnosed. Corticosteroids remain first-line therapy for warm-AIHA, while the addition of rituximab should be considered early in severe cases and if no prompt response to steroids is achieved. Rituximab with or without bendamustine should be used in the first line for patients with cold agglutinin disease requiring therapy. We identified a need to establish an international AIHA network. Future recommendations should be based on prospective clinical trials whenever possible.
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Sulpizio ED, Raghunathan V, Shatzel JJ, Zilberman-Rudenko J, Worrest T, Sheppard BC, DeLoughery TG. Long-term remission rates after splenectomy in adults with Evans syndrome compared to immune thrombocytopenia: A single-center retrospective study. Eur J Haematol 2019; 104:55-58. [PMID: 31594025 DOI: 10.1111/ejh.13336] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Revised: 10/01/2019] [Accepted: 10/04/2019] [Indexed: 12/01/2022]
Abstract
OBJECTIVE Evans syndrome, the combination of immune thrombocytopenia (ITP) and autoimmune hemolytic anemia (AIHA) or autoimmune neutropenia, is associated with a high rate of relapsed/refractory disease. There are limited data on the efficacy of splenectomy for this condition. We reviewed patient outcomes after splenectomy for Evans syndrome compared to ITP at our institution. METHODS We performed a retrospective analysis of patients who underwent splenectomy for autoimmune cytopenias over a 23-year period with the intention of comparing disease relapse rates after splenectomy in patients with Evans syndrome and in those with ITP. RESULTS During the study period, 77 patients underwent splenectomy for ITP and seven underwent splenectomy for Evans syndrome. In the Evans cohort, splenectomy led to an 85.7% initial response rate with a 42.8% rate of relapse within one year and a long-term (one-year) response rate of 42.8%. In the ITP cohort, the initial response rate was 90.9% with a long-term response rate of 70.1%. CONCLUSION Our data suggest that long-term remission rates after splenectomy are lower in adults with Evans syndrome compared to those with ITP, although splenectomy may still be an acceptable treatment for certain patients with Evans syndrome. Our findings underscore the need for further research and development of additional therapeutic strategies for this patient population.
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Affiliation(s)
- Emilio D Sulpizio
- Department of Internal Medicine, Oregon Health and Science University, Portland, Oregon
| | - Vikram Raghunathan
- Division of Hematology and Medical Oncology, Knight Cancer Institute, Oregon Health and Science University, Portland, Oregon
| | - Joseph J Shatzel
- Division of Hematology and Medical Oncology, Knight Cancer Institute, Oregon Health and Science University, Portland, Oregon
| | | | - Tarin Worrest
- Department of Surgery, Oregon Health and Science University, Portland, Oregon
| | - Brett C Sheppard
- Department of Surgery, Oregon Health and Science University, Portland, Oregon
| | - Thomas G DeLoughery
- Division of Hematology and Medical Oncology, Knight Cancer Institute, Oregon Health and Science University, Portland, Oregon
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Cepika AM, Sato Y, Liu JMH, Uyeda MJ, Bacchetta R, Roncarolo MG. Tregopathies: Monogenic diseases resulting in regulatory T-cell deficiency. J Allergy Clin Immunol 2019; 142:1679-1695. [PMID: 30527062 DOI: 10.1016/j.jaci.2018.10.026] [Citation(s) in RCA: 88] [Impact Index Per Article: 17.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Revised: 10/25/2018] [Accepted: 10/25/2018] [Indexed: 12/21/2022]
Abstract
Monogenic diseases of the immune system, also known as inborn errors of immunity, are caused by single-gene mutations resulting in immune deficiency and dysregulation. More than 350 diseases have been described to date, and the number is rapidly expanding, with increasing availability of next-generation sequencing facilitating the diagnosis. The spectrum of immune dysregulation is wide, encompassing deficiencies in humoral, cellular, innate, and adaptive immunity; phagocytosis; and the complement system, which lead to autoinflammation and autoimmunity. Multiorgan autoimmunity is a dominant symptom when genetic mutations lead to defects in molecules essential for the development, survival, and/or function of regulatory T (Treg) cells. Studies of "Tregopathies" are providing critical mechanistic information on Treg cell biology, the role of Treg cell-associated molecules, and regulation of peripheral tolerance in human subjects. The pathogenic immune networks underlying these diseases need to be dissected to apply and develop immunomodulatory treatments and design curative treatments using cell and gene therapy. Here we review the pathogenetic mechanisms, clinical presentation, diagnosis, and current and future treatments of major known Tregopathies caused by mutations in FOXP3, CD25, cytotoxic T lymphocyte-associated antigen 4 (CTLA4), LPS-responsive and beige-like anchor protein (LRBA), and BTB domain and CNC homolog 2 (BACH2) and gain-of-function mutations in signal transducer and activator of transcription 3 (STAT3). We also discuss deficiencies in genes encoding STAT5b and IL-10 or IL-10 receptor as potential Tregopathies.
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Affiliation(s)
- Alma-Martina Cepika
- Department of Pediatrics, Division of Stem Cell Transplantation and Regenerative Medicine, Stanford School of Medicine, Stanford, Calif
| | - Yohei Sato
- Department of Pediatrics, Division of Stem Cell Transplantation and Regenerative Medicine, Stanford School of Medicine, Stanford, Calif
| | - Jeffrey Mao-Hwa Liu
- Department of Pediatrics, Division of Stem Cell Transplantation and Regenerative Medicine, Stanford School of Medicine, Stanford, Calif
| | - Molly Javier Uyeda
- Department of Pediatrics, Division of Stem Cell Transplantation and Regenerative Medicine, Stanford School of Medicine, Stanford, Calif; Stanford Institute for Stem Cell Biology and Regenerative Medicine, Stanford School of Medicine, Stanford, Calif
| | - Rosa Bacchetta
- Department of Pediatrics, Division of Stem Cell Transplantation and Regenerative Medicine, Stanford School of Medicine, Stanford, Calif.
| | - Maria Grazia Roncarolo
- Department of Pediatrics, Division of Stem Cell Transplantation and Regenerative Medicine, Stanford School of Medicine, Stanford, Calif; Stanford Institute for Stem Cell Biology and Regenerative Medicine, Stanford School of Medicine, Stanford, Calif.
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41
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Delmonte OM, Castagnoli R, Calzoni E, Notarangelo LD. Inborn Errors of Immunity With Immune Dysregulation: From Bench to Bedside. Front Pediatr 2019; 7:353. [PMID: 31508401 PMCID: PMC6718615 DOI: 10.3389/fped.2019.00353] [Citation(s) in RCA: 66] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Accepted: 08/08/2019] [Indexed: 12/20/2022] Open
Abstract
Inborn errors of immunity are genetic disorders with broad clinical manifestations, ranging from increased susceptibility to infections to significant immune dysregulation, often leading to multiple autoimmune phenomena, lymphoproliferation, and malignancy. The treatment is challenging as it requires careful balancing of immunosuppression in subjects at increased risk of infections. Recently, the improved ability to define inborn errors of immunity pathophysiology at the molecular level has set the basis for the development of targeted therapeutic interventions. Such a "precision medicine" approach is mainly bases on the use of available small molecules and biologics to target a specific cell function. In this article, we summarize the clinical and laboratory features of various recently described inborn errors of immunity associated with immune dysregulation and hyperinflammation in which mechanism-based therapeutic approaches have been implemented.
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Affiliation(s)
- Ottavia Maria Delmonte
- Laboratory of Clinical Immunology and Microbiology, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, United States
| | - Riccardo Castagnoli
- Laboratory of Clinical Immunology and Microbiology, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, United States
- Foundation IRCCS Policlinico San Matteo, Department of Pediatrics, University of Pavia, Pavia, Italy
| | - Enrica Calzoni
- Laboratory of Clinical Immunology and Microbiology, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, United States
- Department of Molecular and Translational Medicine, A. Nocivelli Institute for Molecular Medicine, University of Brescia, Brescia, Italy
| | - Luigi Daniele Notarangelo
- Laboratory of Clinical Immunology and Microbiology, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, United States
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Miano M, Cappelli E, Pezzulla A, Venè R, Grossi A, Terranova P, Palmisani E, Maggiore R, Guardo D, Lanza T, Calvillo M, Micalizzi C, Pierri F, Vernarecci C, Beccaria A, Corsolini F, Lanciotti M, Russo G, Ceccherini I, Dufour C, Fioredda F. FAS‐mediated apoptosis impairment in patients with ALPS/ALPS‐like phenotype carrying variants on
CASP10
gene. Br J Haematol 2019; 187:502-508. [DOI: 10.1111/bjh.16098] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Accepted: 05/21/2019] [Indexed: 02/05/2023]
Affiliation(s)
- Maurizio Miano
- Haematology Unit IRCCS Istituto Giannina Gaslini GenoaItaly
| | | | - Agnese Pezzulla
- Haematology Unit IRCCS Istituto Giannina Gaslini GenoaItaly
- Pediatric Hematology/Oncology Unit University of Catania CataniaItaly
| | - Roberta Venè
- Molecular Oncology and Angiogenesis Unit IRCCS Ospedale Policlinico San Martino GenoaItaly
| | - Alice Grossi
- Genetic Unit IRCCS Istituto Giannina Gaslini GenoaItaly
| | | | | | | | - Daniela Guardo
- Haematology Unit IRCCS Istituto Giannina Gaslini GenoaItaly
- Haematology Clinic, Department of Internal Medicine (DiMI) University of Genoa, IRCCS AOU S. Martino‐IST GenoaItaly
| | - Tiziana Lanza
- Haematology Unit IRCCS Istituto Giannina Gaslini GenoaItaly
| | | | | | | | | | | | - Fabio Corsolini
- Laboratory of Molecular Genetics and Biobanks IRCCS Istituto Giannina Gaslini Genoa Italy
| | | | - Giovanna Russo
- Pediatric Hematology/Oncology Unit University of Catania CataniaItaly
| | | | - Carlo Dufour
- Haematology Unit IRCCS Istituto Giannina Gaslini GenoaItaly
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Al Hazmi A, Winters ME. Evans Syndrome. Clin Pract Cases Emerg Med 2019; 3:128-131. [PMID: 31061968 PMCID: PMC6497206 DOI: 10.5811/cpcem.2019.1.41028] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2018] [Revised: 12/31/2019] [Accepted: 01/23/2019] [Indexed: 11/16/2022] Open
Abstract
A 22-year-old man presented to the emergency department with facial swelling, rash, and fatigue. He had a past medical history of pericarditis and pericardial effusion. His evaluation showed anemia and thrombocytopenia. He was admitted for intravenous administration of steroids, plasmapheresis, and workup of his anemia and thrombocytopenia. He was ultimately diagnosed with Evans syndrome as a presenting feature of systemic lupus erythematosus. Plasmapheresis was stopped but administration of steroids continued. His blood counts improved, and the facial swelling and rash subsided. Evans syndrome is an immunologic conundrum that requires early recognition and treatment.
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Affiliation(s)
- Ahmed Al Hazmi
- University of Maryland Medical Center, Department of Emergency Medicine, Baltimore, Maryland
| | - Michael E Winters
- University of Maryland School of Medicine, Department of Emergency Medicine, Baltimore, Maryland
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Kim TO, Grimes AB, Kirk S, Arulselvan A, Lambert MP, Grace RF, Despotovic JM. Association of a positive direct antiglobulin test with chronic immune thrombocytopenia and use of second line therapies in children: A multi-institutional review. Am J Hematol 2019; 94:461-466. [PMID: 30663792 DOI: 10.1002/ajh.25409] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Revised: 01/10/2019] [Accepted: 01/16/2019] [Indexed: 01/19/2023]
Abstract
Immune thrombocytopenia (ITP) is the most common autoimmune cytopenia in children. Approximately, 25% of patients develop chronic disease, which may be unpredictable and challenging to treat. It is not currently possible to predict at the time of presentation which patients will have chronic disease or will experience symptoms requiring second-line therapy defined as treatment beyond corticosteroids, intravenous immunoglobulin, or Rh immune globulin. A multi-institutional retrospective review of 311 pediatric patients with ITP was performed with the goal of identifying clinical characteristics associated with disease course. In a cohort of 216 patients tested and for whom disease status was known, a positive direct antiglobulin test (DAT) was associated with chronic ITP vs spontaneous resolution of disease (29.2% vs 8.1%, P < 0.001) as well as the need for treatment with second line agents (38.5% vs 11.4%, P < 0.001) in 241 patients. Controlling for the effect of Evans syndrome, defined as having two immune cytopenias, a positive DAT was independently associated with chronic ITP (OR = 2.7, 95% CI: 1.0-7.2, P = 0.041) and use of second-line agents (OR: 3.6, 95% CI: 1.7-7.7, P = 0.001) by multivariate logistic regression model. These findings demonstrate an association with positive DAT and chronic disease, as well as refractory disease requiring second-line agents.
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Affiliation(s)
- Taylor Olmsted Kim
- Baylor College of Medicine, Department of Pediatrics Division of Hematology/Oncology Houston Texas
- Texas Children's Hematology Centers Houston Texas
| | - Amanda B. Grimes
- Baylor College of Medicine, Department of Pediatrics Division of Hematology/Oncology Houston Texas
- Texas Children's Hematology Centers Houston Texas
| | - Susan Kirk
- Baylor College of Medicine, Department of Pediatrics Division of Hematology/Oncology Houston Texas
- Texas Children's Hematology Centers Houston Texas
| | - Abinaya Arulselvan
- Children's Hospital of Philadelphia, Division of Hematology Philadelphia Pennsylvania
| | - Michele P. Lambert
- Perelman School of Medicine at the University of Pennsylvania, Department of Pediatrics Philadelphia Pennsylvania
- Children's Hospital of Philadelphia, Department of Pediatrics Philadelphia Pennsylvania
| | - Rachael F. Grace
- Harvard Medical School Boston Massachusetts
- Dana Farber Boston Children's Cancer and Blood Disorders Center Boston Massachusetts
| | - Jenny M. Despotovic
- Baylor College of Medicine, Department of Pediatrics Division of Hematology/Oncology Houston Texas
- Texas Children's Hematology Centers Houston Texas
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Neunert CE, Despotovic JM. Autoimmune hemolytic anemia and immune thrombocytopenia following hematopoietic stem cell transplant: A critical review of the literature. Pediatr Blood Cancer 2019; 66:e27569. [PMID: 30537439 DOI: 10.1002/pbc.27569] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Revised: 10/29/2018] [Accepted: 11/02/2018] [Indexed: 01/19/2023]
Abstract
Autoimmune cytopenias (AIC) post-hematopoietic stem cell transplant (HSCT) are rare but exceptionally challenging complication. We conducted a comprehensive literature review and identified a pooled incidence of post-HSCT autoimmune hemolytic anemia and/or immune thrombocytopenia of 2.66% (SE = 0.27) in pediatric patients. Nonmalignant disease, unrelated donor transplant, peripheral or cord blood stem cell source, conditioning regimen without total body irradiation, and presence of chronic graft-versus-host disease were prominent risk factors. Treatment was highly variable, and cytopenias were commonly refractory. AIC represent a significant post-HSCT complication. We report here the incidence, risk factors, and possible biology behind the development of AIC in pediatric post-HSCT patients.
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Affiliation(s)
- C E Neunert
- Department of Pediatrics, Hematology/Oncology/Bone Marrow Transplant, Columbia University School of Medicine, New York, New York
| | - J M Despotovic
- Department of Pediatrics, Hematology/Oncology Section, Baylor College of Medicine, Houston, Texas
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Rivalta B, Zama D, Pancaldi G, Facchini E, Cantarini ME, Miniaci A, Prete A, Pession A. Evans Syndrome in Childhood: Long Term Follow-Up and the Evolution in Primary Immunodeficiency or Rheumatological Disease. Front Pediatr 2019; 7:304. [PMID: 31396497 PMCID: PMC6664023 DOI: 10.3389/fped.2019.00304] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Accepted: 07/08/2019] [Indexed: 12/23/2022] Open
Abstract
Evans syndrome (ES) is a rare but challenging condition, characterized by recurrent and refractory cytopenia episodes. Recent discoveries highlighted that an appropriate diagnostic workup is fundamental to identify an underlying immune dysregulation such as primary immunodeficiencies or a rheumatological disease. We hereby describe clinical features and laboratory results of 12 pediatric patients affected by ES referred to the Pediatric Onco-Hematology Unit of Bologna. Patients experienced a median of four acute episodes of cytopenia with 9 years as median age at the onset of symptoms. In 8/12 (67%) patients an underlying etiology, primary immunodeficiencies, or rheumatological disease was identified. In 4/12 children, other immune manifestations were associated (Thyroiditis, Celiac disease, Psoriasis, Vitiligo, Myositis, Membranoproliferative Glomerulonephritis). ES remained the primary diagnosis in four patients (33%). At a median follow-up time of 4 years, 5/12 (42%) patients revealed a chronic ITP, partially responsive to second line therapy. Immunoglobulin Replacement Therapy (IRT) was effective with a good hematological values control in three patients with a secondary ES (ALPS, CVID, and a patient with Rubinstein Taybi Syndrome and a progressive severe B cell deficiency with hypogammaglobulinemia). Our experience highlights that, in pediatric patients, ES is often only the first manifestation of an immunological or rheumatological disease, especially when cytopenias are persistent or resistant to therapy, with an early-onset or when are associated with lymphadenopathy.
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Affiliation(s)
- Beatrice Rivalta
- Department of Pediatrics, Sant'Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Daniele Zama
- Department of Pediatrics, Sant'Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Giovanni Pancaldi
- Department of Pediatrics, Sant'Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Elena Facchini
- Department of Pediatrics, Sant'Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Maria Elena Cantarini
- Department of Pediatrics, Sant'Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Angela Miniaci
- Department of Pediatrics, Sant'Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Arcangelo Prete
- Department of Pediatrics, Sant'Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Andrea Pession
- Department of Pediatrics, Sant'Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
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Jaime-Pérez JC, Aguilar-Calderón PE, Salazar-Cavazos L, Gómez-Almaguer D. Evans syndrome: clinical perspectives, biological insights and treatment modalities. J Blood Med 2018; 9:171-184. [PMID: 30349415 PMCID: PMC6190623 DOI: 10.2147/jbm.s176144] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Evans syndrome (ES) is a rare and chronic autoimmune disease characterized by autoimmune hemolytic anemia and immune thrombocytopenic purpura with a positive direct anti-human globulin test. It is classified as primary and secondary, with the frequency in patients with autoimmune hemolytic anemia being 37%–73%. It predominates in children, mainly due to primary immunodeficiencies or autoimmune lymphoproliferative syndrome. ES during pregnancy is associated with high fetal morbidity, including severe hemolysis and intracranial bleeding with neurological sequelae and death. The clinical presentation can include fatigue, pallor, jaundice and mucosal bleeding, with remissions and exacerbations during the person’s lifetime, and acute manifestations as catastrophic bleeding and massive hemolysis. Recent molecular theories explaining the physiopathology of ES include deficiencies of CTLA-4, LRBA, TPP2 and a decreased CD4/CD8 ratio. As in other autoimmune cytopenias, there is no established evidence-based treatment and steroids are the first-line therapy, with intravenous immunoglobulin administered as a life-saving resource in cases of severe immune thrombocytopenic purpura manifestations. Second-line treatment for refractory ES includes rituximab, mofetil mycophenolate, cyclosporine, vincristine, azathioprine, sirolimus and thrombopoietin receptor agonists. In cases unresponsive to immunosuppressive agents, hematopoietic stem cell transplantation has been successful, although it is necessary to consider its potential serious adverse effects. In conclusion, ES is a disease with a heterogeneous course that remains challenging to patients and physicians, with prospective clinical trials needed to explore potential targeted therapy to achieve an improved long-term response or even a cure.
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Affiliation(s)
- José Carlos Jaime-Pérez
- Department of Hematology, Internal Medicine Division, Dr José E González University Hospital, School of Medicine of the Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, México,
| | - Patrizia Elva Aguilar-Calderón
- Department of Hematology, Internal Medicine Division, Dr José E González University Hospital, School of Medicine of the Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, México,
| | - Lorena Salazar-Cavazos
- Department of Hematology, Internal Medicine Division, Dr José E González University Hospital, School of Medicine of the Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, México,
| | - David Gómez-Almaguer
- Department of Hematology, Internal Medicine Division, Dr José E González University Hospital, School of Medicine of the Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, México,
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Rotz SJ, Ware RE, Kumar A. Diagnosis and management of chronic and refractory immune cytopenias in children, adolescents, and young adults. Pediatr Blood Cancer 2018; 65:e27260. [PMID: 29856527 DOI: 10.1002/pbc.27260] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2017] [Revised: 04/26/2018] [Accepted: 05/06/2018] [Indexed: 12/13/2022]
Abstract
Children, adolescents, and young adults with chronic refractory autoimmune cytopenias represent a rare but challenging group of patients, who are managed frequently by pediatric hematologists. Novel diagnostic tests and genomic discoveries are refining historical diagnoses of Evans syndrome and common variable immunodeficiency, while also elucidating the cellular and molecular basis for these disorders. Genetic characterization of chronic and refractory autoimmune cytopenias has led to targeted therapies with improved clinical outcomes and fewer off-target toxicities. In this review, we focus on the appropriate diagnostic workup, expanded genetic testing, and novel treatment opportunities that are available for these challenging patients.
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Affiliation(s)
- Seth J Rotz
- Department of Pediatric Hematology, Oncology, and Blood and Marrow Transplantation, Cleveland Clinic Children's Hospital, Cleveland, Ohio
| | - Russell E Ware
- Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
- Division of Hematology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Ashish Kumar
- Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
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Second-line therapy in paediatric warm autoimmune haemolytic anaemia. Guidelines from the Associazione Italiana Onco-Ematologia Pediatrica (AIEOP). BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2018; 16:352-357. [PMID: 29757134 DOI: 10.2450/2018.0024-18] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Accepted: 03/27/2018] [Indexed: 02/08/2023]
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50
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Kruizinga MD, van Tol MJ, Bekker V, Netelenbos T, Smiers FJ, Bresters D, Jansen-Hoogendijk AM, van Ostaijen-ten Dam MM, Kollen WJ, Zwaginga JJ, Lankester AC, Bredius RG. Risk Factors, Treatment, and Immune Dysregulation in Autoimmune Cytopenia after Allogeneic Hematopoietic Stem Cell Transplantation in Pediatric Patients. Biol Blood Marrow Transplant 2018; 24:772-778. [DOI: 10.1016/j.bbmt.2017.12.782] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2017] [Accepted: 12/09/2017] [Indexed: 10/18/2022]
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