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Oh SB, Shin HJ. Neutropenia following intravenous immunoglobulin therapy in adult patients with immune thrombocytopenic purpura: A single center experience and literature review. Medicine (Baltimore) 2020; 99:e18624. [PMID: 31895820 PMCID: PMC6946410 DOI: 10.1097/md.0000000000018624] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
The purpose of this study was to evaluate neutropenia following intravenous immunoglobulin (IVIG) therapy in adults with immune thrombocytopenic purpura (ITP).Our analysis included 88 patients with ITP, who received IVIG from January 2006 to March 2016, at Pusan National University Hospital in Korea. Their white blood cell (WBC) count and absolute neutrophil count (ANC) before and after IVIG treatment were analyzed.Of 88 patients, 24 patients (27.3%) were male, and 64 patients (72.7%) were female. Neutropenia developed in 8 patients (18.7%) after IVIG treatment. In patients with a decrease in WBC count and ANC compared to baseline, median WBC count decreased from 6280/μL to 4530/μL after IVIG therapy, and median ANC decreased from 3840/μL to 2840/μL after IVIG therapy. The neutropenia induced by IVIG had resolved spontaneously after several days, and the mean recovery time was 8.72 days after the completion of the IVIG treatment. During the neutropenic episodes, only one patient developed neutropenic fever, which subsided soon without any treatment.The results of this study suggest that IVIG may cause neutropenia commonly in adults with ITP, and it seems to be transient and self-limited. This study is meaningful as the first report that not only pediatric ITP patients may develop neutropenia post IVIG administration, but also adult patients suffering ITP.
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Affiliation(s)
- Sang-Bo Oh
- Division of Hematology-Oncology, Department of Internal Medicine, School of Medicine, Medical Research Institute, Pusan National University Yangsan Hospital, Yangsan
| | - Ho-Jin Shin
- Division of Hematology-Oncology, Department of Internal Medicine, School of Medicine, Medical Research Institute, Pusan National University Hospital, Busan, Republic of Korea
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Ghorbani M, Fekrvand S, Shahkarami S, Yazdani R, Sohani M, Shaghaghi M, Hassanpour G, Mohammadi J, Negahdari B, Abolhassani H, Aghamohammadi A. The evaluation of neutropenia in common variable immune deficiency patients. Expert Rev Clin Immunol 2019; 15:1225-1233. [PMID: 31592698 DOI: 10.1080/1744666x.2020.1677154] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Objectives: Common variable immunodeficiency is a primary immunodeficiency disease characterized by hypogammaglobulinemia and heterogeneous clinical features. Neutropenia is a rare complication among CVID patients leading to a higher rate of infections and morbidity. Multiple factors (e.g. autoimmunity, infections, drugs and etc.) are found to underlie this complication.Methods: In the present study, demographic, clinical and laboratory data were compared between two groups of CVID patients with and without neutropenia.Results: Frequency of neutropenia was 8.1%. Infectious complications were the most prevalent clinical manifestations regardless of presence of neutropenia. However, candida infection and septicemia were significantly higher in neutropenic patients (p = 0.001 and p = 0.01, respectively). The most prominent clinical phenotypes of CVID patients with neutropenia were polyclonal lymphocytic infiltration and autoimmunity, both being considerably higher compared to the non-neutropenic group (p = 0.04 and p = 0.009, respectively). The mortality rate in neutropenic patients was higher than in patients without neutropenia (61.1 vs. 25.2%, p = 0.004).Conclusion: Although neutropenia is a rare complication among CVID patients, it is associated with frequent and severe clinical complications, including autoimmunity and lymphoproliferative conditions. Also, its accompaniment with higher mortality frequency in CVID patients indicates a need for more precise attention and consideration regarding specific treatment in neutropenic patients.
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Affiliation(s)
- Mohammad Ghorbani
- Research Center for Immunodeficiencies, Pediatrics Center of Excellence, Children's Medical Center, Tehran University of Medical Science, Tehran, Iran
| | - Saba Fekrvand
- Research Center for Immunodeficiencies, Pediatrics Center of Excellence, Children's Medical Center, Tehran University of Medical Science, Tehran, Iran
| | - Sepideh Shahkarami
- Research Center for Immunodeficiencies, Pediatrics Center of Excellence, Children's Medical Center, Tehran University of Medical Science, Tehran, Iran.,Medical Genetics Network (MeGeNe), Universal Scientific Education and Research Network (USERN), Tehran, Iran
| | - Reza Yazdani
- Research Center for Immunodeficiencies, Pediatrics Center of Excellence, Children's Medical Center, Tehran University of Medical Science, Tehran, Iran
| | - Mahsa Sohani
- Research Center for Immunodeficiencies, Pediatrics Center of Excellence, Children's Medical Center, Tehran University of Medical Science, Tehran, Iran
| | - Mohammadreza Shaghaghi
- Research Center for Immunodeficiencies, Pediatrics Center of Excellence, Children's Medical Center, Tehran University of Medical Science, Tehran, Iran.,Network of Immunology in Infections, Malignancy and Autoimmunity (NIIMA), Universal Scientific Education and Research Network (USERN), Tehran, Iran
| | - Gholamreza Hassanpour
- Center for Research of Endemic Parasites of Iran, Tehran University of Medical Sciences, Tehran, Iran
| | - Javad Mohammadi
- Department of Life Science, Faculty of New Science and Technology, University of Tehran, Tehran, Iran
| | - Babak Negahdari
- School of Advanced Technologies in Medicine, Department of Medical Biotechnology, Tehran University of Medical Sciences, Tehran, Iran
| | - Hassan Abolhassani
- Research Center for Immunodeficiencies, Pediatrics Center of Excellence, Children's Medical Center, Tehran University of Medical Science, Tehran, Iran.,Division of Clinical Immunology, Department of Laboratory Medicine, Karolinska Institute at Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - Asghar Aghamohammadi
- Research Center for Immunodeficiencies, Pediatrics Center of Excellence, Children's Medical Center, Tehran University of Medical Science, Tehran, Iran
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Cicha A, Fischer MB, Wesinger A, Haas S, Bauer WM, Wolf HM, Sauerwein KMT, Reininger B, Petzelbauer P, Pehamberger H, Handisurya A. Effect of intravenous immunoglobulin administration on erythrocyte and leucocyte parameters. J Eur Acad Dermatol Venereol 2017; 32:1004-1010. [PMID: 29114967 DOI: 10.1111/jdv.14671] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Accepted: 10/20/2017] [Indexed: 12/22/2022]
Abstract
BACKGROUND Intravenous immunoglobulins (IVIG) are an attractive therapeutic tool for therapy of toxic epidermal necrolysis and severe forms of certain autoimmune diseases, including dermatomyositis, autoimmune blistering diseases, systemic vasculitis and lupus erythematodes. OBJECTIVES Prompted by a case of IVIG-associated haemolytic anaemia, the effects of IVIG administrations on haematological parameters in patients with dermatological conditions were investigated. METHODS Erythrocyte and leucocyte parameters were retrospectively analysed in 16 patients who had received IVIG at doses from 1 to 3 g/kg bodyweight (n = 35 cycles). The influence of IVIG on leucocyte survival was determined in vitro. RESULTS Decreased absolute erythrocyte numbers, haemoglobin and haematocrit levels and a case of haemolytic anaemia were linked to transfusion of high-, but not low-dose IVIG. In contrast, leucopenia post-IVIG occurred in the vast majority of the recipients, unrelated to the administered IVIG amounts. In vitro investigations revealed a dose-dependent impairment of cell survival by IVIG in the neutrophil and monocyte, but not in the lymphocyte subpopulations. In several IVIG preparations, substantial amounts of blood group anti-A/anti-B antibodies were detected which could have accounted for the observed changes in the haematological parameters in our study cohort. CONCLUSIONS IVIG products should be administered strictly according to indications. Commercially available IVIG products can contain blood group-specific antibodies that may induce haemolysis in some recipients. Monitoring of blood counts during applied IVIG therapy, especially when high doses are administered, is recommended.
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Affiliation(s)
- A Cicha
- Department of Dermatology, Medical University of Vienna, Vienna, Austria
| | - M B Fischer
- Department of Health Science and Biomedicine, Danube University Krems, Krems an der Donau, Austria.,Department of Transfusion Medicine, Medical University of Vienna, Vienna, Austria
| | - A Wesinger
- Department of Dermatology, Medical University of Vienna, Vienna, Austria
| | - S Haas
- Department of Dermatology, Medical University of Vienna, Vienna, Austria
| | - W M Bauer
- Department of Dermatology, Medical University of Vienna, Vienna, Austria
| | - H M Wolf
- Immunology Outpatient Clinic, Vienna, Austria.,Medical School, Sigmund Freud University Vienna, Vienna, Austria
| | | | - B Reininger
- Department of Dermatology, Medical University of Vienna, Vienna, Austria
| | - P Petzelbauer
- Department of Dermatology, Medical University of Vienna, Vienna, Austria
| | - H Pehamberger
- Department of Dermatology, Medical University of Vienna, Vienna, Austria
| | - A Handisurya
- Department of Dermatology, Medical University of Vienna, Vienna, Austria
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Neutropenia in Patients with Common Variable Immunodeficiency: a Rare Event Associated with Severe Outcome. J Clin Immunol 2017; 37:715-726. [PMID: 28842786 DOI: 10.1007/s10875-017-0434-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2017] [Accepted: 08/15/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Common variable immunodeficiency (CVID) is characterized by infections and hypogammaglobulinemia. Neutropenia is rare during CVID. METHODS The French DEFI study enrolled patients with primary hypogammaglobulinemia. Patients with CVID and neutropenia were retrospectively analyzed. RESULTS Among 473 patients with CVID, 16 patients displayed neutropenia (lowest count [0-1400]*106/L). Sex ratio (M/F) was 10/6. Five patients died during the follow-up (11 years) with an increased percentage of deaths compared to the whole DEFI group (31.3 vs 3.4%, P < 0.05). Neutropenia was diagnosed for 10 patients before 22 years old. The most frequent symptoms, except infections, were autoimmune cytopenia, i.e., thrombopenia or anemia (11/16). Ten patients were affected with lymphoproliferative diseases. Two patients were in the infection only group and the others belonged to one or several other CVID groups. The median level of IgG was 2.6 g/L [0.35-4.4]. Most patients presented increased numbers of CD21low CD38low B cell, as already described in CVID autoimmune cytopenia group. Neutropenia was considered autoimmune in 11 cases. NGS for 52 genes of interest was performed on 8 patients. No deleterious mutations were found in LRBA, CTLA4, and PIK3. More than one potentially damaging variant in other genes associated with CVID were present in most patients arguing for a multigene process. CONCLUSION Neutropenia is generally associated with another cytopenia and presumably of autoimmune origin during CVID. In the DEFI study, neutropenia is coupled with more severe clinical outcomes. It appears as an "alarm bell" considering patients' presentation and the high rate of deaths. Whole exome sequencing diagnosis should improve management.
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A Multicentre Study on the Efficacy, Safety and Pharmacokinetics of IqYmune®, a Highly Purified 10% Liquid Intravenous Immunoglobulin, in Patients with Primary Immune Deficiency. J Clin Immunol 2017; 37:539-547. [PMID: 28711959 PMCID: PMC5554475 DOI: 10.1007/s10875-017-0416-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2016] [Accepted: 06/22/2017] [Indexed: 01/05/2023]
Abstract
This multicentre, open-label, prospective, single-arm study was designed to evaluate the efficacy, pharmacokinetics, and safety of IqYmune®, a highly purified 10% polyvalent immunoglobulin preparation for intravenous administration in patients with primary immunodeficiency. IqYmune® was administered to 62 patients (aged 2–61 years) with X-linked agammaglobulinemia or common variable immune deficiency at a dose from 0.22 to 0.97 g/kg every 3 to 4 weeks for 12 months with an infusion rate up to 8 mL/kg/h. A pharmacokinetic study was performed at steady state between the 8th and the 9th infusion. A single case of serious bacterial infection was observed, leading to an annualized rate of serious bacterial infections/patient (primary endpoint) of 0.017 (98% CI: 0.000, 0.115). Overall, 228 infections were reported, most frequently bronchitis, chronic sinusitis, nasopharyngitis and upper respiratory tract infection. The mean annualized rate of infections was 3.79/patient. A lower risk of infections was associated with an IgG trough level > 8 g/L (p = 0.01). The mean annualized durations of absence from work or school and of hospitalization due to infections were 1.01 and 0.89 days/patient, respectively. The mean serum IgG trough level before the 6th infusion was 7.73 g/L after a mean dose of IqYmune® of 0.57 g/kg. The pharmacokinetic profile of IqYmune® was consistent with that of other intravenous immunoglobulins. Overall, 15.5% of infusions were associated with an adverse event occurring within 72 h post infusion. Headache was the most common adverse event. In conclusion, IqYmune® was shown to be effective and well tolerated in patients with primary immunodeficiency.
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Prise en charge des événements indésirables chez les patients sous traitement par immunoglobulines : recommandations pour la pratique clinique. Rev Med Interne 2017; 38:312-319. [DOI: 10.1016/j.revmed.2016.10.390] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Revised: 09/25/2016] [Accepted: 10/20/2016] [Indexed: 12/29/2022]
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Totzeck A, Stettner M, Hagenacker T. Early platelet and leukocyte decline in patients with neuroinflammatory disorders after intravenous immunoglobulins. Eur J Neurol 2017; 24:638-644. [PMID: 28224702 DOI: 10.1111/ene.13264] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Accepted: 01/11/2017] [Indexed: 12/25/2022]
Abstract
BACKGROUND AND PURPOSE Intravenous immunoglobulins (IVIGs) are a common therapy in patients with neuroinflammatory disorders, especially chronic inflammatory demyelinating polyradiculoneuropathy or Guillain-Barré syndrome. Hematological toxicities upon IVIG infusion are a known side effect and still an important subject of investigation. METHODS Laboratory results and data for clinical efficacy and tolerability of 62 patients with neuroinflammatory disorders treated with IVIG (0.4 g/kg bodyweight per day over 5 days) at the Department of Neurology, University of Duisburg-Essen, Germany, were retrospectively analyzed. Blood samples were taken before and 1 day after IVIG administration. RESULTS In pre-treated and first-time treated patients, there was a significant decrease in white blood cell count (WBC) (8.10 ± 2.85/nl to 5.61 ± 2.50/nl, P < 0.001, n = 57) and platelets (255 ± 72/nl to 215 ± 66/nl, P < 0.001, n = 57). Mild hemolysis of red blood cells was found in patients who received IVIG for the first time (red blood cell count 4.61 ± 0.67/pl to 4.28 ± 0.52/pl, hemoglobin 13.7 ± 1.7 g/l to 13.0 ± 1.7 g/l, P < 0.001, n = 40). Hemolysis was associated with less tolerability of IVIG treatment and clinical efficacy was accompanied with a higher decline of WBC (not significant). CONCLUSIONS Next to mild hemolysis, a significant decrease in WBC and platelets can be detected early after high dose IVIGs in patients with neuroinflammatory disorders. Changes in blood counts may be possible markers for clinical efficacy and tolerability. Patients with low blood counts in advance should be particularly closely monitored whilst on IVIG treatment.
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Affiliation(s)
- A Totzeck
- Department of Neurology, University Hospital Essen, Essen, Germany
| | - M Stettner
- Department of Neurology, University Hospital Essen, Essen, Germany
| | - T Hagenacker
- Department of Neurology, University Hospital Essen, Essen, Germany
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Defective functions of polymorphonuclear neutrophils in patients with common variable immunodeficiency. Immunol Res 2014; 60:69-76. [DOI: 10.1007/s12026-014-8555-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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Baxley A, Akhtari M. Hematologic toxicities associated with intravenous immunoglobulin therapy. Int Immunopharmacol 2011; 11:1663-7. [DOI: 10.1016/j.intimp.2011.07.024] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2011] [Revised: 07/26/2011] [Accepted: 07/27/2011] [Indexed: 11/27/2022]
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Abstract
IMPORTANCE OF THE FIELD Intravenous immunoglobulin (IVIg) is a biologic pharmaceutical that is widely used to treat immunodeficiency conditions and a variety of autoimmune conditions. It is under-recognized that IVIg can be associated with severe complications including death. AREAS COVERED IN THIS REVIEW This review will address common mild side effects and extensively discuss the uncommon but serious complications of IVIg. Mild constitutional reactions include headache, fever and rash and severe complications include anaphylaxis, acute renal failure, stroke and myocardial infarction. IVIg has been used to treat autoimmune illnesses for ~30 years and the literature since then is reviewed with special attention to reports in the last 10 years that detail the serious adverse events. WHAT THE READER WILL GAIN The reader will understand that mild side effects are common and that these can be ameliorated with pre-treatment medications. They will also become familiar with the risk factors for serious complications so that careful patient and IVIg product selection will result in fewer poor outcomes. TAKE HOME MESSAGE IVIg is quite safe across age groups although serious adverse reactions occur particularly in elderly individuals with multiple cardiovascular risk factors and those with preexisting renal failure.
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Affiliation(s)
- James B Caress
- Department of Neurology, Wake Forest University School of Medicine, Medical Center Boulevard, Winston-Salem, NC 27157, USA.
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