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Chiu CY, John TM, Matsuo T, Wurster S, Hicklen RS, Khattak RR, Ariza-Heredia EJ, Bose P, Kontoyiannis DP. Disseminated Histoplasmosis in a Patient with Myelofibrosis on Ruxolitinib: A Case Report and Review of the Literature on Ruxolitinib-Associated Invasive Fungal Infections. J Fungi (Basel) 2024; 10:264. [PMID: 38667935 PMCID: PMC11051496 DOI: 10.3390/jof10040264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2024] [Revised: 03/24/2024] [Accepted: 03/29/2024] [Indexed: 04/28/2024] Open
Abstract
Ruxolitinib, a selective inhibitor of Janus kinases, is a standard treatment for intermediate/high-risk myelofibrosis (MF) but is associated with a predisposition to opportunistic infections, especially herpes zoster. However, the incidence and characteristics of invasive fungal infections (IFIs) in these patients remain uncertain. In this report, we present the case of a 59-year-old woman with MF who developed disseminated histoplasmosis after seven months of ruxolitinib use. The patient clinically improved after ten weeks of combined amphotericin B and azole therapy, and ruxolitinib was discontinued. Later, the patient received fedratinib, a relatively JAK2-selective inhibitor, without relapse of histoplasmosis. We also reviewed the literature on published cases of proven IFIs in patients with MF who received ruxolitinib. Including ours, we identified 28 such cases, most commonly due to Cryptococcus species (46%). IFIs were most commonly disseminated (39%), followed by localized lung (21%) infections. Although uncommon, a high index of suspicion for opportunistic IFIs is needed in patients receiving JAK inhibitors. Furthermore, the paucity of data regarding the optimal management of IFIs in patients treated with JAK inhibitors underscore the need for well-designed studies to evaluate the epidemiology, pathobiology, early diagnosis, and multimodal therapy of IFIs in patients with hematological malignancies receiving targeted therapies.
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Affiliation(s)
- Chia-Yu Chiu
- Department of Infectious Diseases, Infection Control, and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (C.-Y.C.); (T.M.J.); (T.M.); (S.W.); (R.R.K.); (E.J.A.-H.)
| | - Teny M. John
- Department of Infectious Diseases, Infection Control, and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (C.-Y.C.); (T.M.J.); (T.M.); (S.W.); (R.R.K.); (E.J.A.-H.)
| | - Takahiro Matsuo
- Department of Infectious Diseases, Infection Control, and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (C.-Y.C.); (T.M.J.); (T.M.); (S.W.); (R.R.K.); (E.J.A.-H.)
| | - Sebastian Wurster
- Department of Infectious Diseases, Infection Control, and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (C.-Y.C.); (T.M.J.); (T.M.); (S.W.); (R.R.K.); (E.J.A.-H.)
| | - Rachel S. Hicklen
- Research Medical Library, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA;
| | - Raihaan Riaz Khattak
- Department of Infectious Diseases, Infection Control, and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (C.-Y.C.); (T.M.J.); (T.M.); (S.W.); (R.R.K.); (E.J.A.-H.)
| | - Ella J. Ariza-Heredia
- Department of Infectious Diseases, Infection Control, and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (C.-Y.C.); (T.M.J.); (T.M.); (S.W.); (R.R.K.); (E.J.A.-H.)
| | - Prithviraj Bose
- Department of Leukemia, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA;
| | - Dimitrios P. Kontoyiannis
- Department of Infectious Diseases, Infection Control, and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (C.-Y.C.); (T.M.J.); (T.M.); (S.W.); (R.R.K.); (E.J.A.-H.)
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Early Use of Low-Dose Ruxolitinib: A Promising Strategy for the Treatment of Acute and Chronic GVHD. Pharmaceuticals (Basel) 2022; 15:ph15030374. [PMID: 35337171 PMCID: PMC8955311 DOI: 10.3390/ph15030374] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 03/09/2022] [Accepted: 03/17/2022] [Indexed: 02/07/2023] Open
Abstract
Janus kinases (JAK) are a family of tyrosine kinases (JAK1, JAK2, JAK3, and TYK2) that transduce cytokine-mediated signals through the JAK–STAT metabolic pathway. These kinases act by regulating the transcription of specific genes capable of inducing biological responses in several immune cell subsets. Inhibition of Janus kinases interferes with the JAK–STAT signaling pathway. Besides being used in the treatment of cancer and inflammatory diseases, in recent years, they have also been used to treat inflammatory conditions, such as graft-versus-host disease (GVHD) and cytokine release syndrome as complications of allogeneic hematopoietic stem cell transplantation and cell therapy. Recently, the FDA approved the use of ruxolitinib, a JAK1/2 inhibitor, in the treatment of acute steroid-refractory GVHD (SR-aGVHD), highlighting the role of JAK inhibition in this immune deregulation. Ruxolitinib was initially used to treat myelofibrosis and true polycythemia in a high-dose treatment and caused hematological toxicity. Since a lower dosage often could not be effective, the use of ruxolitinib was suspended. Subsequently, ruxolitinib was evaluated in adult patients with SR-aGVHD and was found to achieve a rapid and effective response. In addition, its early low-dose use in pediatric patients affected by GVHD has proved effective, safe, and reasonably preventive. The review aims to describe the potential properties of ruxolitinib to identify new therapeutic strategies.
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Zimran E, Keyzner A, Iancu-Rubin C, Hoffman R, Kremyanskaya M. Novel treatments to tackle myelofibrosis. Expert Rev Hematol 2018; 11:889-902. [PMID: 30324817 DOI: 10.1080/17474086.2018.1536538] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Despite the dramatic progress made in the treatment of patients with myelofibrosis since the introduction of the JAK1/2 inhibitor ruxolitinib, a therapeutic option that can modify the natural history of the disease and prevent evolution to blast-phase is still lacking. Recent investigational treatments including immunomodulatory drugs and histone deacetylase inhibitors benefit some patients but these effects have proven modest at best. Several novel agents do show promising activity in preclinical studies and early-phase clinical trials. We will illustrate a snapshot view of where the management of myelofibrosis is evolving, in an era of personalized medicine and advanced molecular diagnostics. Areas covered: A literature search using MEDLINE and recent meeting abstracts was performed using the keywords below. It focused on therapies in active phases of development based on their scientific and preclinical rationale with the intent to highlight agents that have novel biological effects. Expert commentary: The most mature advances in treatment of myelofibrosis are the development of second-generation JAK1/2 inhibitors and improvements in expanding access to donors for transplantation. In addition, there are efforts to identify drugs that target pathways other than JAK/STAT signaling that might improve the survival of myelofibrosis patients, and limit the need for stem-cell transplantation.
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Affiliation(s)
- Eran Zimran
- a Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai , Myeloproliferative Neoplasms Research Program , New York , NY , USA
| | - Alla Keyzner
- a Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai , Myeloproliferative Neoplasms Research Program , New York , NY , USA
| | - Camelia Iancu-Rubin
- a Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai , Myeloproliferative Neoplasms Research Program , New York , NY , USA
| | - Ronald Hoffman
- a Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai , Myeloproliferative Neoplasms Research Program , New York , NY , USA
| | - Marina Kremyanskaya
- a Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai , Myeloproliferative Neoplasms Research Program , New York , NY , USA
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