1
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Liston K, Prior AR, McHugh J, Enright H, Desmond R. Hepatitis B screening in hematology patients receiving intravenous immunoglobulin. Transfusion 2024. [PMID: 38982983 DOI: 10.1111/trf.17938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Revised: 06/17/2024] [Accepted: 06/17/2024] [Indexed: 07/11/2024]
Abstract
BACKGROUND Transient positivity for hepatitis B core antibody (Anti-HBc) following intravenous immunoglobulin (IVIG) and subcutaneous immunoglobulin exposure is a well-described phenomenon. The aim of this study was to retrospectively review Hepatitis B viral screening practices in IVIG recipients in a hematology specific cohort at a single center. METHODS Electronic databases were analyzed to identify all hematology patients who received IVIG from September 2022 to March 2022 at a single Irish center (n = 43). The proportion of patients that had a baseline anti-HBc tested prior to IVIG receipt was assessed as well as the proportion of patients that developed a transiently positive anti-HBc following IVIG exposure. Data were also collected relating to signal cut-off ratios in patients with detectable anti-HBc post-IVIG. RESULTS 58.1% of patients had at least one serological hepatitis B viral test sent prior to IVIG exposure. Anti-HBc was the least common serological investigation performed prior to IVIG exposure (21% of recipients). A positive or equivocal "low level antibody" was identified in 15% of recipients and this was proven to be transient in all cases. CONCLUSION The minority of hematology patients had a baseline anti-HBc assessed prior to IVIG exposure. All patients in this study had the potential to require further immunosuppressive therapies, which could be limited by a misleading anti-HBc result. We therefore advocate for baseline anti-HBc testing to be performed prior to IVIG exposure in hematology patients and for cautious interpretation of anti-HBc results taking into account signal cut-off ratios post-IVIG exposure.
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Affiliation(s)
- K Liston
- Department of Haematology, Tallaght University Hospital, Dublin, Ireland
| | - A R Prior
- Department of Microbiology, Tallaght University Hospital, Dublin, Ireland
| | - J McHugh
- Department of Haematology, Tallaght University Hospital, Dublin, Ireland
| | - H Enright
- Department of Haematology, Tallaght University Hospital, Dublin, Ireland
| | - R Desmond
- Department of Haematology, Tallaght University Hospital, Dublin, Ireland
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2
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Lindahl H, Norlin AC, Bergman P. Product Choice Affects Risk of False-Positive Hepatitis B Virus Serology During Immunoglobulin Replacement Therapy. Open Forum Infect Dis 2023; 10:ofad551. [PMID: 38023555 PMCID: PMC10644822 DOI: 10.1093/ofid/ofad551] [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: 08/14/2023] [Accepted: 10/27/2023] [Indexed: 12/01/2023] Open
Abstract
Hepatitis B virus (HBV) core antigen antibodies passively transferred from immunoglobulin products used for replacement or immunomodulation may lead to unnecessary antiviral treatment for patients who are also starting immunosuppressive treatment. We have systematically assessed the contents of 93 commercial immunoglobulin batches and show that there are consistent product-specific differences in the levels of HBV core antigen antibodies and that choice of immunoglobulin product may have an impact on false-positivity rates.
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Affiliation(s)
- Hannes Lindahl
- Department of Clinical Immunology and Transfusion Medicine, Karolinska University Hospital, Stockholm, Sweden
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Anna-Carin Norlin
- Department of Clinical Immunology and Transfusion Medicine, Karolinska University Hospital, Stockholm, Sweden
- Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Peter Bergman
- Department of Clinical Immunology and Transfusion Medicine, Karolinska University Hospital, Stockholm, Sweden
- Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden
- Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden
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3
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Yasuda N, Nishikawa M, Shimosaka H, Ono Y, Yatomi Y. Effect of administration of immunoglobulin preparations on the results of tests for autoantibodies. Mod Rheumatol 2021; 32:946-952. [PMID: 34918126 DOI: 10.1093/mr/roab085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 09/06/2021] [Accepted: 09/27/2021] [Indexed: 11/14/2022]
Abstract
OBJECTIVES We encountered the case in whom the results of autoantibodies tests became transiently positive after high-dose immunoglobulin therapy and investigated the effect of administration of these preparations on autoantibodies tests in subjects with autoimmune diseases who had received high-dose immunoglobulin therapy. METHODS We measured the autoantibodies in residual serum samples after routine clinical testing from eight subjects with autoimmune diseases who had received high-dose immunoglobulin therapy. We also measured the autoantibodies in available immunoglobulin preparations. RESULTS Tests for autoantibodies conducted before and after immunoglobulin therapy revealed a positive conversion of the results for anti-Sjogren's syndrome antigen A (SS-A) antibody, anti-glutamic acid decarboxylase (GAD) antibody, anti-thyroglobulin (Tg) antibody, and anti-thyroid peroxidase (TPO) antibody. In five cases in which changes in the antibody titres of anti-SS-A antibody after the high-dose immunoglobulin administration, it was found that the titres decreased by about 50% from 10 to 20 days after and the test result became negative 25- 30 days later. CONCLUSIONS In patients receiving high-dose immunoglobulin therapy, there appears to be a high likelihood of positive conversion of tests for anti-SS-A antibody, GAD antibody, Tg antibody, and TPO antibody after the treatment, so that cautious interpretation of the results is of importance.
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Affiliation(s)
- Naomi Yasuda
- Department of Clinical Laboratory, University of Tokyo Hospital, Tokyo, Japan
| | - Masako Nishikawa
- Department of Clinical Laboratory, University of Tokyo Hospital, Tokyo, Japan
| | - Hironori Shimosaka
- Department of Clinical Laboratory, University of Tokyo Hospital, Tokyo, Japan
| | - Yoshikazu Ono
- Department of Clinical Laboratory, University of Tokyo Hospital, Tokyo, Japan
| | - Yutaka Yatomi
- Department of Clinical Laboratory, University of Tokyo Hospital, Tokyo, Japan.,Department of Clinical Laboratory Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
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4
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Detection of Antibodies Against Human Leukocyte Antigen Class II in the Sera of Patients Receiving Intravenous Immunoglobulin. Transplant Direct 2021; 7:e697. [PMID: 34036167 PMCID: PMC8133174 DOI: 10.1097/txd.0000000000001146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Accepted: 02/11/2021] [Indexed: 11/25/2022] Open
Abstract
Supplemental Digital Content is available in the text. IVIG is occasionally used for preventing and treating severe infections of patients who are to undergo transplantation. Administration of IVIG, which includes high-titer antibodies (Abs) against HLA class I and II, might have a substantial influence on the HLA Ab test results of these patients. However, this issue has remained unreported.
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5
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Suresh J, Kyle BD. Clinical false positives resulting from recent intravenous immunoglobulin therapy: case report. BMC Infect Dis 2021; 21:288. [PMID: 33743628 PMCID: PMC7981890 DOI: 10.1186/s12879-021-05986-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Accepted: 03/15/2021] [Indexed: 05/31/2023] Open
Abstract
Background Many clinicians are aware that certain therapies administered to their patients can have downstream consequences in the form of clinical laboratory test interferences. This is particularly true of laboratory tests that depend on, or directly involve the use of, antibody-based methodology. Intravenously-administered immunoglobulin therapy is one such treatment that can in theory directly impact the results of particular tests in the area of viral serology. This study can help serve as a reference for clinicians researching the impact of intravenously-administered immunoglobulin therapy in the context of positive results that do not reflect the clinical background of the patient. Case presentation We describe a case whereby an intravenously-administered immunoglobulin therapy led to a series of clinical false positives in viral serology, inconsistent with the known patient history as well as recent laboratory results. The patient presented to hospital with petechiae-type bleeding rashes and was investigated for thrombocytopenia after initial blood investigations indicated very low platelets. Subsequent testing of the potential causes for low-platelet involved several viral serology investigations, including hepatitis, cytomegalovirus and human immunodeficiency virus. Initial testing indicated patient exhibited negative status for all viral antibodies and antigens (except immunity for hepatitis B surface antigen antibody). As part of the thrombocytopenia treatment, intravenously-administered immunoglobulin therapy was administered, and subsequent viral serology was ordered. These investigations indicated a positive status for several hepatitis antibodies as well as cytomegalovirus. Conclusions This case study illustrates the potential for improper diagnosis of previous or ongoing infection status in patients administered IVIg therapy. Caution should be exercised particularly when interpreting results involving cytomegalovirus and hepatitis.
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Affiliation(s)
- Janarthanee Suresh
- Department of Pathology and Laboratory Medicine, College of Medicine, University of Saskatchewan, Saskatoon, S7N 0W8, Canada
| | - Barry D Kyle
- Department of Pathology and Laboratory Medicine, College of Medicine, University of Saskatchewan, Saskatoon, S7N 0W8, Canada.
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6
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Pavlakou P, Papasotiriou M, Ntrinias T, Kourakli A, Bratsiakou A, Goumenos DS, Papachristou E. Case Report: Kidney Transplantation in a Patient With Acquired Agammaglobulinemia and SLE. Issues and Challenges. Front Med (Lausanne) 2021; 8:665475. [PMID: 33777986 PMCID: PMC7994764 DOI: 10.3389/fmed.2021.665475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 02/22/2021] [Indexed: 11/13/2022] Open
Abstract
Lupus nephritis in the context of Systemic Lupus Erythematosus (SLE) is characterized by an unpredicted course with remissions and flare-ups. Among others, it remains a significant cause of end-stage kidney disease (ESKD) in relatively young patients. Therapeutic regimens with newer immunosuppressive agents have been introduced in order to control SLE clinical manifestations more efficiently and limit organ damage induced by immune complex formation and sustained inflammation. Treatment is usually long-term, and the cumulative impact of immunosuppression is expressed through the increased frequency of infections and neoplasms. However, if the observed immunity dysregulation is secondary and pharmaceutically induced or there is a pre-existing, primary immunodeficiency that shares common pathogenetic pathways with SLE's autoimmunity is not always clear. Herein, we present the case of a 39-year-old woman, that reached ESKD due to lupus nephritis. After an upper respiratory cytomegalovirus (CMV) infection and concomitant CMV reactivations the investigation revealed significant immunodeficiency. Not long after the initiation of intravenous immunoglobulin (IVIG) administration, patient received a cadaveric kidney transplant. IVIG was continued along with standard immunosuppression so that both recurrent infections and allograft rejection are avoided. Patient is closely monitored, and her post-transplant course is remarkably satisfying so far. ESKD patients with immunodeficiency syndromes should not be excluded by definition from kidney transplantation.
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Affiliation(s)
- Paraskevi Pavlakou
- Department of Nephrology and Renal Transplantation, University Hospital of Patras, Achaia, Greece
| | - Marios Papasotiriou
- Department of Nephrology and Renal Transplantation, University Hospital of Patras, Achaia, Greece
| | - Theodoros Ntrinias
- Department of Nephrology and Renal Transplantation, University Hospital of Patras, Achaia, Greece
| | - Alexandra Kourakli
- Hematology Division, Department of Internal Medicine, University Hospital of Patras, Achaia, Greece
| | - Adamantia Bratsiakou
- Department of Nephrology and Renal Transplantation, University Hospital of Patras, Achaia, Greece
| | - Dimitrios S Goumenos
- Department of Nephrology and Renal Transplantation, University Hospital of Patras, Achaia, Greece
| | - Evangelos Papachristou
- Department of Nephrology and Renal Transplantation, University Hospital of Patras, Achaia, Greece
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Dysart C, Rozenberg-Ben-Dror K, Sales M. Assessing Hepatitis B Reactivation Risk With Rituximab and Recent Intravenous Immunoglobulin Therapy. Open Forum Infect Dis 2020; 7:ofaa080. [PMID: 32211447 DOI: 10.1093/ofid/ofaa080] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Accepted: 02/27/2020] [Indexed: 12/20/2022] Open
Abstract
Hepatitis B reactivation (HBR) is a complication of immunosuppression associated with significant morbidity and mortality. To further complicate interpretation of hepatitis B serologies, false positivity can occur in patients with recent intravenous immunoglobulin exposure. This scenario is not well recognized and may lead to inappropriate prescribing of HBR prophylaxis.
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Affiliation(s)
- Claire Dysart
- Department of Veterans Affairs, Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, Wisconsin, USA
| | | | - Mariscelle Sales
- Department of Veterans Affairs Pharmacy Benefits Management Services and Center for Medication Safety (VA MedSAFE), Hines, Illinois, USA
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8
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Pharmacists' Role in Managing Patients with Chronic Lymphocytic Leukemia. PHARMACY 2020; 8:pharmacy8020052. [PMID: 32230834 PMCID: PMC7355755 DOI: 10.3390/pharmacy8020052] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Revised: 03/23/2020] [Accepted: 03/24/2020] [Indexed: 02/08/2023] Open
Abstract
Chronic lymphocytic leukemia (CLL) is a hematologic malignancy that has seen significant advances in care over the last 5 years with the approval of oral agents such as ibrutinib and venetoclax for the treatment of this disease. As such, there has been a substantial shift away from the traditional chemotherapy infusions which have allowed patients greater autonomy with oral cancer therapies. This paradigm shift poses new challenges for the medical team, including drug-drug interactions, adherence counseling, and financial toxicity. Pharmacists are uniquely trained and equipped to help to manage the changing landscape of CLL care. From identifying common medications which may impair ibrutinib clearance to ensuring patients are on the appropriate anti-infective prophylaxis while receiving obinutuzumab, pharmacists can play a vital role in ensuring the highest quality of patient care. Furthermore, additional credentialing of clinical pharmacists in select states allows for independent visits with the pharmacists, allowing for greater involvement, particularly for initiation of venetoclax and management of ibrutinib-induced toxicities. Pharmacists are essential to both expanding and enhancing the care of patients with CLL and should be leveraged to improve patient outcomes whenever possible.
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9
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Grüter T, Ott A, Meyer W, Jarius S, Kinner M, Motte J, Pitarokoili K, Gold R, Komorowski L, Ayzenberg I. Effects of IVIg treatment on autoantibody testing in neurological patients: marked reduction in sensitivity but reliable specificity. J Neurol 2019; 267:715-720. [PMID: 31728710 DOI: 10.1007/s00415-019-09614-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Revised: 10/10/2019] [Accepted: 10/26/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND Therapy of autoimmune diseases of the central and peripheral nervous system with intravenous IgG immunoglobulin (IVIg) is well established. Since IVIg is produced from pooled human plasma, autoantibodies can be found in IVIg products and, accordingly, in patient sera after transfusion. The de novo evidence or disappearance of anti-neural autoantibodies after IVIg treatment has so far not been systematically examined. METHODS We screened 50 neurological patients before and after IVIg treatment for classical onconeural and the most common neurological surface autoantibodies as well as for ganglioside autoantibodies and 23 different antinuclear autoantibodies using immunoblot or cell-based indirect immunofluorescence assays. Furthermore, we screened 31 neurological patients with previously known seropositivity for disappearance of the corresponding antibody after treatment. RESULTS After IVIg treatment, 90% of all sera were de novo positive for antinuclear antibodies, especially for Ro-52. In contrast, 94% of all sera did not show any de novo-positive anti-neural antibodies. In the remaining three cases, titers were very low. Importantly, 12.9% of all tested sera of patients with known antibody positivity turned false negative after IVIg treatment and titers were falsely low in 37% of the remaining sera. CONCLUSIONS Here, we present for the first time results of a broad screening for clinically relevant autoantibodies before and after IVIg treatment in neurological patients. We identified a high specificity but reduced sensitivity for anti-neural antibody testing after IVIg transfusion. In contrast, antinuclear antibody testing is not reliable after IVIg treatment. These results are of high practical importance for diagnostic of neuroimmunological diseases.
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Affiliation(s)
- Thomas Grüter
- Department of Neurology, St. Josef Hospital, Ruhr-University Bochum, Gudrunstr. 56, 44791, Bochum, Germany
| | - Anthonina Ott
- Institute for Experimental Immunology, Lübeck, Germany
| | | | - Sven Jarius
- Molecular Neuroimmunology Group, Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany
| | - Markus Kinner
- Department of Neurology, St. Josef Hospital, Ruhr-University Bochum, Gudrunstr. 56, 44791, Bochum, Germany
| | - Jeremias Motte
- Department of Neurology, St. Josef Hospital, Ruhr-University Bochum, Gudrunstr. 56, 44791, Bochum, Germany
| | - Kalliopi Pitarokoili
- Department of Neurology, St. Josef Hospital, Ruhr-University Bochum, Gudrunstr. 56, 44791, Bochum, Germany
| | - Ralf Gold
- Department of Neurology, St. Josef Hospital, Ruhr-University Bochum, Gudrunstr. 56, 44791, Bochum, Germany
| | | | - Ilya Ayzenberg
- Department of Neurology, St. Josef Hospital, Ruhr-University Bochum, Gudrunstr. 56, 44791, Bochum, Germany.
- Department of Neurology, I.M. Sechenov First Moscow State Medical University, Moscow, Russia.
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10
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King C, Sutton-Fitzpatrick U, Houlihan J. Transient derangements in Hepatitis B serology in patients post-intravenous immunoglobulin therapy-a case-based review. Ir J Med Sci 2019; 189:617-620. [PMID: 31643027 DOI: 10.1007/s11845-019-02115-3] [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] [Received: 02/24/2019] [Accepted: 09/25/2019] [Indexed: 11/24/2022]
Abstract
Intravenous immunoglobulin (IVIg) is a commonly utilized therapy in multiple medical subspecialities, indicated for the management of various primary and secondary immunodeficiency states and autoimmune and inflammatory conditions. A lack of awareness exists among clinicians regarding the serological downstream effects of its use. An observed phenomenon post-IVIg is the passive transfer of antibodies from the product which can lead to transiently positive hepatitis B serology in recipients. When confounding viral serology is encountered, there is a risk to patients of treatment delays and mismanagement. Three patients encountered in the hematology department of a tertiary referral hospital developed spurious hepatitis B serology after administration of IVIg, whose cases are briefly outlined here. These cases highlight the need for routine pre-treatment viral screening and emphasize the importance of clinicians recognizing such potentially confounding results. This is of particular relevance to the sizeable subset of hematology patients who are planned for future immunomodulatory treatment (such as rituximab), where previous hepatitis B infection can often be a barrier to timely treatment.
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11
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[MOG encephalomyelitis: international recommendations on diagnosis and antibody testing]. DER NERVENARZT 2019; 89:1388-1399. [PMID: 30264269 DOI: 10.1007/s00115-018-0607-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Over the past few years, new-generation cell-based assays have demonstrated a robust association of autoantibodies to full-length human myelin oligodendrocyte glycoprotein (MOG-IgG) with (mostly recurrent) optic neuritis, myelitis and brainstem encephalitis, as well as with acute disseminated encephalomyelitis (ADEM)-like presentations. Most experts now consider MOG-IgG-associated encephalomyelitis (MOG-EM) a disease entity in its own right, immunopathogenetically distinct from both classic multiple sclerosis (MS) and aquaporin-4 (AQP4)-IgG-positive neuromyelitis optica spectrum disorders (NMOSD). Owing to a substantial overlap in clinicoradiological presentation, MOG-EM was often unwittingly misdiagnosed as MS in the past. Accordingly, increasing numbers of patients with suspected or established MS are currently being tested for MOG-IgG. However, screening of large unselected cohorts for rare biomarkers can significantly reduce the positive predictive value of a test. To lessen the hazard of overdiagnosing MOG-EM, which may lead to inappropriate treatment, more selective criteria for MOG-IgG testing are urgently needed. In this paper, we propose indications for MOG-IgG testing based on expert consensus. In addition, we give a list of conditions atypical for MOG-EM ("red flags") that should prompt physicians to challenge a positive MOG-IgG test result. Finally, we provide recommendations regarding assay methodology, specimen sampling and data interpretation, and propose for the first time diagnostic criteria for MOG-EM.
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12
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den Hoed-Krijnen AWJ, Smak Gregoor PJH. False-positive hepatitis B test results after intravenous immunoglobulin therapy. Clin Kidney J 2019; 12:463. [PMID: 31198550 PMCID: PMC6544086 DOI: 10.1093/ckj/sfz035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Indexed: 12/03/2022] Open
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13
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Passive transfer of anti-HBc after intravenous immunoglobulin administration in patients with cancer: a retrospective chart review. LANCET HAEMATOLOGY 2018; 5:e474-e478. [PMID: 30290904 DOI: 10.1016/s2352-3026(18)30152-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Revised: 08/24/2018] [Accepted: 08/27/2018] [Indexed: 12/14/2022]
Abstract
BACKGROUND Patients previously infected with hepatitis B virus (HBV; indicated by positivity for anti-HBc) can experience HBV reactivation during cancer chemotherapy. Intravenous immunoglobulin infusion, which is frequently used in supportive care, might facilitate passive transfer of anti-HBc. We aimed to estimate the probability of passive transfer of anti-HBc after intravenous immunoglobulin infusion in patients with cancer. METHODS We reviewed institutional databases to identify adult patients who received outpatient chemotherapy between Jan 1, 2004, and Dec 31, 2011, at the University of Texas MD Anderson Cancer Center, Houston, TX, USA. Eligible patients had received intravenous immunoglobulin therapy, had tested negative for both anti-HBc and HBsAg before infusion, and had been tested for anti-HBc after infusion. The primary endpoint was the proportion of patients who became positive for anti-HBc after intravenous immunoglobulin infusion. FINDINGS 950 of 18 874 patients who underwent chemotherapy within the study time frame received intravenous immunoglobulin, of whom 870 had been tested for anti-HBc before infusion. 199 patients who were negative for anti-HBc before receiving intravenous immunoglobulin were retested after infusion, of whom 29 (15% [95% CI 10-20]) became positive for anti-HBc. The probability of anti-HBc conversion at 1 week after intravenous immunoglobulin infusion was 34% (95% CI 22-48) and at 12 weeks was 4% (2-7). INTERPRETATION Conversion of patients from anti-HBc negativity to anti-HBc positivity was common after intravenous immunoglobulin administration. However, the probability of a positive test decreased with time since infusion. Positive anti-HBc tests done shortly after intravenous immunoglobulin infusion should be interpreted with caution because they might indicate passive transfer instead of true infection. FUNDING None.
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14
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Prokopchuk-Gauk O, Khan AS, Misskey S, Lyon ME, Lyon AW. Transient hepatitis B immunity passively acquired from transfusion of packed red blood cells. Transfus Med 2018; 28:462-464. [PMID: 30311289 DOI: 10.1111/tme.12560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2018] [Revised: 08/10/2018] [Accepted: 09/12/2018] [Indexed: 11/28/2022]
Affiliation(s)
- O Prokopchuk-Gauk
- Department of Pathology and Laboratory Medicine, Saskatchewan Health Authority, College of Medicine, University of Saskatchewan, Saskatoon, Canada
| | - A S Khan
- Department of Pathology and Laboratory Medicine, Saskatchewan Health Authority, College of Medicine, University of Saskatchewan, Saskatoon, Canada
| | - S Misskey
- Department of Pathology and Laboratory Medicine, Saskatchewan Health Authority, College of Medicine, University of Saskatchewan, Saskatoon, Canada
| | - M E Lyon
- Department of Pathology and Laboratory Medicine, Saskatchewan Health Authority, College of Medicine, University of Saskatchewan, Saskatoon, Canada
| | - A W Lyon
- Department of Pathology and Laboratory Medicine, Saskatchewan Health Authority, College of Medicine, University of Saskatchewan, Saskatoon, Canada
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15
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Kiely P, Hoad VC, Wood EM. False positive viral marker results in blood donors and their unintended consequences. Vox Sang 2018; 113:530-539. [PMID: 29974475 DOI: 10.1111/vox.12675] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Revised: 05/29/2018] [Accepted: 06/06/2018] [Indexed: 12/15/2022]
Abstract
False positive (FP) viral marker results in blood donors continue to pose many challenges. Informing donors of FP results and subsequent deferral can result in stress and anxiety for donors and additional complexity and workload for blood services. Donor management strategies need to balance the requirement to minimise donor anxiety and inconvenience while maintaining sufficiency of supply. Decisions about how and when to inform donors of FP results and determine deferral periods can be difficult as FP results, while often transitory, can take up to several years to resolve. Additional complexities include the interpretation of indeterminate serological confirmatory testing without detectable viral RNA or non-discriminated NAT results with concomitant anti-HBc reactivity - both may be due to FP results, but the former may also represent past infection and the later may represent occult hepatitis B infection. In this review we discuss strategies to minimise indeterminate serological confirmatory results, possible donor deferral policies and the impact on donors when notified of FP results. We also provide some new data from Australia that address the challenge of interpreting non-discriminated NAT results with concomitant anti-HBc reactivity. Ultimately, the challenge is for each blood service to develop appropriate strategies for donor management, taking into account local information and requirements.
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Affiliation(s)
- Philip Kiely
- Australian Red Cross Blood Service, Melbourne, Victoria, Australia
- Transfusion Research Unit, Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Veronica C Hoad
- Australian Red Cross Blood Service, Perth, Western Australia, Australia
| | - Erica M Wood
- Transfusion Research Unit, Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
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16
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Jarius S, Paul F, Aktas O, Asgari N, Dale RC, de Seze J, Franciotta D, Fujihara K, Jacob A, Kim HJ, Kleiter I, Kümpfel T, Levy M, Palace J, Ruprecht K, Saiz A, Trebst C, Weinshenker BG, Wildemann B. MOG encephalomyelitis: international recommendations on diagnosis and antibody testing. J Neuroinflammation 2018; 15:134. [PMID: 29724224 PMCID: PMC5932838 DOI: 10.1186/s12974-018-1144-2] [Citation(s) in RCA: 500] [Impact Index Per Article: 83.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Accepted: 04/02/2018] [Indexed: 02/11/2023] Open
Abstract
Over the past few years, new-generation cell-based assays have demonstrated a robust association of autoantibodies to full-length human myelin oligodendrocyte glycoprotein (MOG-IgG) with (mostly recurrent) optic neuritis, myelitis and brainstem encephalitis, as well as with acute disseminated encephalomyelitis (ADEM)-like presentations. Most experts now consider MOG-IgG-associated encephalomyelitis (MOG-EM) a disease entity in its own right, immunopathogenetically distinct from both classic multiple sclerosis (MS) and aquaporin-4 (AQP4)-IgG-positive neuromyelitis optica spectrum disorders (NMOSD). Owing to a substantial overlap in clinicoradiological presentation, MOG-EM was often unwittingly misdiagnosed as MS in the past. Accordingly, increasing numbers of patients with suspected or established MS are currently being tested for MOG-IgG. However, screening of large unselected cohorts for rare biomarkers can significantly reduce the positive predictive value of a test. To lessen the hazard of overdiagnosing MOG-EM, which may lead to inappropriate treatment, more selective criteria for MOG-IgG testing are urgently needed. In this paper, we propose indications for MOG-IgG testing based on expert consensus. In addition, we give a list of conditions atypical for MOG-EM ("red flags") that should prompt physicians to challenge a positive MOG-IgG test result. Finally, we provide recommendations regarding assay methodology, specimen sampling and data interpretation.
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Affiliation(s)
- S Jarius
- Molecular Neuroimmunology Group, Department of Neurology, University Hospital Heidelberg, Im Neuenheimer Feld 350, 69120, Heidelberg, Germany.
| | - F Paul
- Department of Neurology and Clinical and Experimental Multiple Sclerosis Research Center, Charité - Universitätsmedizin Berlin, Berlin, Germany.,NeuroCure Clinical Research Center and Clinical and Experimental Multiple Sclerosis Research Center, Berlin, Germany
| | - O Aktas
- Department of Neurology, University of Düsseldorf, Düsseldorf, Germany
| | - N Asgari
- Department of Neurology, University of Southern Denmark, Odense, Denmark
| | - R C Dale
- Children's Hospital at Westmead, University of Sydney, Sydney, Australia
| | - J de Seze
- Department of Neurology, Hôpital de Hautepierre, Strasbourg Cedex, France
| | - D Franciotta
- IRCCS, National Neurological Institute C. Mondino, Pavia, Italy
| | - K Fujihara
- Department of Multiple Sclerosis Therapeutics, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - A Jacob
- The Walton Centre, Walton Centre NHS Foundation Trust, Liverpool, UK
| | - H J Kim
- Department of Neurology, Research Institute and Hospital of National Cancer Center, Goyang, South Korea
| | - I Kleiter
- Department of Neurology, Ruhr University Bochum, Bochum, Germany
| | - T Kümpfel
- Institute of Clinical Neuroimmunology, Ludwig Maximilian University, Munich, Germany
| | - M Levy
- Department of Neurology, Johns Hopkins Hospital, Cleveland, USA
| | - J Palace
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, Oxford, UK
| | - K Ruprecht
- Department of Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - A Saiz
- Service of Neurology, Hospital Clinic, and Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Universitat de Barcelona, Barcelona, Spain
| | - C Trebst
- Department of Neurology, Hannover Medical School, Hanover, Germany
| | | | - B Wildemann
- Molecular Neuroimmunology Group, Department of Neurology, University Hospital Heidelberg, Im Neuenheimer Feld 350, 69120, Heidelberg, Germany.
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17
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Nicolini LA, Zappulo E, Viscoli C, Mikulska M. Management of chronic viral hepatitis in the hematological patient. Expert Rev Anti Infect Ther 2018; 16:227-241. [PMID: 29415584 DOI: 10.1080/14787210.2018.1438264] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Infection with HBV and HCV represents a growing challenge in the management of patients with hematological malignancies. Recently, hepatitis E (HEV) was recognized as an endemic infection in developed countries and as an emerging health problem in immunocompromised patients. Areas covered: We reviewed the current knowledge on the impact of chronic viral hepatitis in the hematological setting. Epidemiological features, screening strategies and indications for treatment and monitoring have been explored and commented. Expert commentary: Knowing patient's complete HBV serostatus is mandatory in order to choose between treatment, prophylaxis or a pre-emptive approach. Recent guidelines favor treatment with high barrier molecules in all patients with chronic HBV infection and long lasting prophylaxis with those with inactive or resolved one. With regard to HCV, the new direct-acting antiviral agents have been safely administered in the hematological setting. Their use as first-line single treatment in indolent lymphomas, and combined with chemotherapy in aggressive ones, should be considered. Due to the existing risk of chronic HEV infection in the immunocompromised, screening with serum HEV-RNA should be performed in case of signs and symptoms indicative of hepatitis. In the event of HEV infection, reduction of immunosuppression and, if not feasible or unsuccessful, ribavirin treatment should be prescribed.
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Affiliation(s)
- Laura Ambra Nicolini
- a Infectious Diseases Unit, Department of Health Science (DISSAL), Ospedale Policlinico San Martino, IRCCS per l'Oncologia , University of Genoa , Genoa , Italy
| | - Emanuela Zappulo
- a Infectious Diseases Unit, Department of Health Science (DISSAL), Ospedale Policlinico San Martino, IRCCS per l'Oncologia , University of Genoa , Genoa , Italy.,b Division of Infectious Diseases, Department of Clinical Medicine and Surgery , University of Naples Federico II , Naples , Italy
| | - Claudio Viscoli
- a Infectious Diseases Unit, Department of Health Science (DISSAL), Ospedale Policlinico San Martino, IRCCS per l'Oncologia , University of Genoa , Genoa , Italy
| | - Malgorzata Mikulska
- a Infectious Diseases Unit, Department of Health Science (DISSAL), Ospedale Policlinico San Martino, IRCCS per l'Oncologia , University of Genoa , Genoa , Italy
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18
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Hoffmann JHO, Enk AH. High-dose intravenous immunoglobulins for the treatment of dermatological autoimmune diseases. J Dtsch Dermatol Ges 2017; 15:1211-1226. [PMID: 29228499 DOI: 10.1111/ddg.13389] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Accepted: 10/23/2017] [Indexed: 12/27/2022]
Abstract
Based on their immunomodulatory properties, high-dose intravenous immunoglobulins (IVIGs) are successfully used in the treatment of various dermatological autoimmune diseases, in particular pemphigus vulgaris and dermatomyositis. In autoimmune bullous diseases, IVIGs can be used in an adjuvant setting (second- or third-line therapy) once combined immunosuppressive regimens have failed. In dermatomyositis, IVIGs may already be employed as an adjuvant second-line therapy after failure of corticosteroid monotherapy. In scleromyxedema, IVIGs may be considered as first-line treatment, given the lack of effective and safe alternatives. Other potential indications for IVIGs may include severe recalcitrant cases of systemic vasculitis and systemic lupus erythematosus. Toxic epidermal necrolysis may be an indication for high-dose IVIGs if administered early. Common, readily manageable side effects include nausea, headache, fatigue, and febrile infusion reactions. Severe adverse events such as thromboembolic events, anaphylaxis, and acute renal failure are very uncommon. The risk of viral transmission is very low. Potential mechanisms of action include upregulation of inhibitory Fc receptors, reduction of the half-life of endogenous immunoglobulins due to displacement from protective receptor sites, neutralization of autoantibodies by anti-idiotypic antibodies, as well as inhibition of complement activation.
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Affiliation(s)
| | - Alexander H Enk
- Department of Dermatology, University of Heidelberg, Heidelberg, Germany
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19
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Hoffmann JH, Enk AH. Hochdosierte intravenöse Immunglobuline bei dermatologischen Autoimmunerkrankungen. J Dtsch Dermatol Ges 2017. [DOI: 10.1111/ddg.13389_g] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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20
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Wang Q, Klenerman P, Semmo N. Significance of anti-HBc alone serological status in clinical practice. Lancet Gastroenterol Hepatol 2017; 2:123-134. [DOI: 10.1016/s2468-1253(16)30076-0] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Revised: 07/26/2016] [Accepted: 07/29/2016] [Indexed: 02/07/2023]
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21
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Dalia S, Suleiman Y, Croy DW, Sokol L. Association of Lymphomagenesis and the Reactivation of Hepatitis B Virus in Non-Hodgkin Lymphoma. Cancer Control 2016; 22:360-5. [PMID: 26351893 DOI: 10.1177/107327481502200315] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Hepatitis B virus (HBV) has been associated with the development of non-Hodgkin lymphoma (NHL) and can be reactivated in patients being treated for NHL. METHODS Articles published between 2000 and 2015 that discussed an association between NHL and HBV, mechanisms of HBV induction of NHL, and HBV reactivation in patients with NHL were reviewed and the results compiled to help health care professionals better understand the risk of developing NHL in HBV-seropositive individuals, describe potential etiologies by which HBV infection may lead to lymphomagenesis, and highlight the recent medical literature with respect to the reactivation of HBV in the setting of NHL. RESULTS An association exists between HBV infection and NHL development. Immunosuppression due to HBV, chronic viral stimulation, and dysregulation of the immune system are possible ways in which lymphoma can develop in patients with HBV infection. All patients being treated with anti-CD20 antibodies or those from or living in HBV-endemic regions should be tested for hepatitis B surface antigen, core antibody, and surface antibody prior to initiating therapy. HBV DNA polymerase chain reaction (PCR) may also be useful in certain cases. Among HBV-seropositive patients or those with detectable HBV DNA, prophylaxis with an antiviral agent should be initiated for 1 year after NHL therapy. HBV DNA PCR monitoring should be undertaken each month during the course of treatment and every 3 months after treatment for a 1-year duration. CONCLUSIONS Health care professionals should become more comfortable treating these high-risk patients with NHL as they become more informed about potential lymphomagenesis and the reactivation of HBV.
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Affiliation(s)
- Samir Dalia
- Mercy Clinic Oncology and Hematology, Joplin, MO 64804, USA.
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22
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Interprétation des tests sérologiques : ne pas oublier le transfert passif des immunoglobulines ! Presse Med 2016; 45:676-81. [DOI: 10.1016/j.lpm.2016.03.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2015] [Revised: 02/15/2016] [Accepted: 03/03/2016] [Indexed: 11/16/2022] Open
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23
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Thibault V, Pinte L, Vergez J, Leger JM, Liou A. Too Often Forgotten: Passive Transfer of Antibodies. Clin Infect Dis 2016; 63:709-10. [PMID: 27208043 DOI: 10.1093/cid/ciw337] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2016] [Accepted: 05/08/2016] [Indexed: 11/14/2022] Open
Affiliation(s)
| | - Laëtitia Pinte
- Department of Virology, CERVI Hôpitaux Universitaires La Pitié Salpêtrière
| | - Julie Vergez
- Department of Virology, CERVI Hôpitaux Universitaires La Pitié Salpêtrière
| | - Jean-Marc Leger
- Centre de Référence Maladies Neuromusculaires Bâtiment Babinski
| | - Amélie Liou
- Department of Pharmacy, Hôpitaux Universitaires La Pitié Salpêtrière - Charles Foix, AP-HP, Paris, France
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24
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Ramsay I, Gorton RL, Patel M, Workman S, Symes A, Haque T, Irish D, Seneviratne SL, Burns SO, Wey E, Lowe DM. Transmission of Hepatitis B Core Antibody and Galactomannan Enzyme Immunoassay Positivity via Immunoglobulin Products: A Comprehensive Analysis. Clin Infect Dis 2016; 63:57-63. [PMID: 27076567 DOI: 10.1093/cid/ciw222] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2015] [Accepted: 04/03/2016] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Therapeutic immunoglobulins are used as replacement or immunomodulatory therapy, but can transmit clinically important molecules. We investigated hepatitis B virus (HBV) antibodies and galactomannan enzyme immunoassay (GM-EIA) positivity. Detection of HBV core antibody may prompt antiviral prophylaxis when commencing therapy such as rituximab; a positive GM-EIA result prompts investigation or treatment for invasive fungal disease. METHODS We performed a cross-sectional analysis of HBV serology in 80 patients established (>6 months) on immunoglobulin therapy; prospective analysis of HBV serology in 16 patients commencing intravenous immunoglobulin (IVIG); and pre- and post-infusion analysis of GM-EIA in 37 patients receiving IVIG. RESULTS Pre-IVIG, 9 of 80 patients tested positive for HBV surface antibody and 1 of 80 tested equivocal for HBV core antibody. On IVIG, 79 of 79 tested positive for surface antibody, 37 of 80 tested positive for core antibody, and 10 of 80 tested equivocal for core antibody. There were significant differences by product, but among patients receiving products that appear to transmit core antibody, negative results correlated with lower surface antibody titers and longer time since infusion, suggesting a simple concentration effect. There was a progressive increase with each infusion in the percentage of patients testing positive for HBV core antibody among patients newly commencing IVIG. Some patients "seroreverted" to negative during therapy. Certain IVIG products tested positive for GM-EIA and there were rises in index values in corresponding patient samples from pre- to post-infusion. Overall, 5 of 37 patient samples pre-infusion and 15 of 37 samples post-infusion tested positive for GM-EIA. CONCLUSIONS HBV antibodies and GM-EIA positivity are common in patients receiving IVIG and confound diagnostic results.
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Affiliation(s)
- Isobel Ramsay
- Department of Virology, Royal Free London National Health Service (NHS) Foundation Trust.,Department of Microbiology, Addenbrooke's Hospital NHS Foundation Trust, Cambridge
| | | | - Mauli Patel
- Department of Virology, Health Services Laboratory, Royal Free Hospital
| | - Sarita Workman
- Department of Clinical Immunology, Royal Free London NHS Foundation Trust
| | - Andrew Symes
- Department of Clinical Immunology, Royal Free London NHS Foundation Trust
| | - Tanzina Haque
- Department of Virology, Royal Free London National Health Service (NHS) Foundation Trust
| | - Dianne Irish
- Department of Virology, Royal Free London National Health Service (NHS) Foundation Trust
| | - Suranjith L Seneviratne
- Department of Clinical Immunology, Royal Free London NHS Foundation Trust.,Institute of Immunity and Transplantation, University College London, Royal Free Campus
| | - Siobhan O Burns
- Department of Clinical Immunology, Royal Free London NHS Foundation Trust.,Institute of Immunity and Transplantation, University College London, Royal Free Campus
| | - Emmanuel Wey
- Department of Microbiology, Royal Free London NHS Foundation Trust, United Kingdom
| | - David M Lowe
- Department of Clinical Immunology, Royal Free London NHS Foundation Trust.,Institute of Immunity and Transplantation, University College London, Royal Free Campus
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25
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Bright PD, Smith L, Usher J, Donati M, Johnston SL, Gompels MM, Unsworth DJ. False interpretation of diagnostic serology tests for patients treated with pooled human immunoglobulin G infusions: a trap for the unwary. Clin Med (Lond) 2015; 15:125-9. [PMID: 25824062 PMCID: PMC4953729 DOI: 10.7861/clinmedicine.15-2-125] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Therapeutic immunoglobulin G (IgG) products are produced from numerous plasma donations, and are infused in many medical conditions. The serological testing of patients who have received IgG infusions may well produce falsely positive and misleading results from this infused IgG, rather than endogenously produced IgG. We present two example cases of clinical situations where this could cause concern. We tested multiple IgG products with a range of serological tests performed in infective or autoimmune conditions, including hepatitis B, syphilis, human immunodeficiency virus, human T-lymphotropic virus, anti-neutrophil cytoplasmic antibody (ANCA), anti-nuclear antibody (ANA), anti-cardiolipin antibodies and anti-double stranded DNA (dsDNA) antibody. We found positivity within these products for hepatitis B surface and core antibody, syphilis, ANCA, ANA, anti-cardiolipin IgG and dsDNA antibody, which may result from specific or non-specific reactivity. The serological testing of patients who have received IgG treatment detects the administered IgG in addition to IgG produced by the patient.
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Affiliation(s)
- Philip D Bright
- Department of Immunology, Southmead Hospital, North Bristol NHS Trust, Bristol, UK;
| | - Lisa Smith
- Department of Immunology, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | - Jane Usher
- Bristol Public Health Laboratory, Bristol, UK
| | | | - Sarah L Johnston
- Department of Immunology, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | - Mark M Gompels
- Department of Immunology, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | - D Joe Unsworth
- Department of Immunology, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
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26
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Kister I, Kuesters G, Chamot E, Omari M, Dontas K, Yarussi M, Subramanyam M, Herbert J. IV immunoglobulin confounds JC virus antibody serostatus determination. NEUROLOGY-NEUROIMMUNOLOGY & NEUROINFLAMMATION 2014; 1:e29. [PMID: 25340081 PMCID: PMC4204227 DOI: 10.1212/nxi.0000000000000029] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/30/2014] [Accepted: 08/13/2014] [Indexed: 11/28/2022]
Abstract
Objective: To determine the impact of therapeutic infusion of IV immunoglobulin (IVIg) on John Cunningham virus antibody (JCV Ab) serostatus and level in serum. Methods: We carried out a retrospective analysis of serum levels of JCV Ab among STRATIFY-2 trial enrollees from 2 multiple sclerosis centers who were exposed to IVIg during the trial. For the subset of eligible patients, we estimated mean linear trends while on IVIg and after stopping IVIg with a linear mixed-effects model. Results: The JCV Ab seropositivity rate in the group of patients that was recently exposed to IVIg was 100%, which is significantly higher than in the IVIg-naive population (58%, p < 0.001). The seropositivity rate in the patient group with remote IVIg exposure was similar to that in the IVIg-naive population (67%, p = 0.68, Fisher exact test). The slope of the linear trend line after stopping IVIg decreased significantly by −0.310 units per 100 days (95% confidence interval, −0.611 to −0.008; p = 0.04). Conclusions: Recent IVIg exposure is invariably associated with JCV Ab seropositivity. After stopping IVIg, JCV Ab levels tend to decrease with time, and seroreversion to innately Ab-negative status can occur.
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Affiliation(s)
- Ilya Kister
- NYU Multiple Sclerosis Care Center (I.K., M.O., J.H.), Department of Neurology, NYU School of Medicine, New York, NY; Barnabas Multiple Sclerosis Care Center (I.K., M.Y., J.H.), Department of Medicine, Barnabas Medical Center, Livingston, NJ; Biogen Idec (G.K., M.S.), Cambridge, MA; Department of Epidemiology (E.C.), University of Alabama at Birmingham School of Public Health, Birmingham, AL; and Specialized Clinical Services (K.D.), Park Ridge, NJ
| | - Geoffrey Kuesters
- NYU Multiple Sclerosis Care Center (I.K., M.O., J.H.), Department of Neurology, NYU School of Medicine, New York, NY; Barnabas Multiple Sclerosis Care Center (I.K., M.Y., J.H.), Department of Medicine, Barnabas Medical Center, Livingston, NJ; Biogen Idec (G.K., M.S.), Cambridge, MA; Department of Epidemiology (E.C.), University of Alabama at Birmingham School of Public Health, Birmingham, AL; and Specialized Clinical Services (K.D.), Park Ridge, NJ
| | - Eric Chamot
- NYU Multiple Sclerosis Care Center (I.K., M.O., J.H.), Department of Neurology, NYU School of Medicine, New York, NY; Barnabas Multiple Sclerosis Care Center (I.K., M.Y., J.H.), Department of Medicine, Barnabas Medical Center, Livingston, NJ; Biogen Idec (G.K., M.S.), Cambridge, MA; Department of Epidemiology (E.C.), University of Alabama at Birmingham School of Public Health, Birmingham, AL; and Specialized Clinical Services (K.D.), Park Ridge, NJ
| | - Mirza Omari
- NYU Multiple Sclerosis Care Center (I.K., M.O., J.H.), Department of Neurology, NYU School of Medicine, New York, NY; Barnabas Multiple Sclerosis Care Center (I.K., M.Y., J.H.), Department of Medicine, Barnabas Medical Center, Livingston, NJ; Biogen Idec (G.K., M.S.), Cambridge, MA; Department of Epidemiology (E.C.), University of Alabama at Birmingham School of Public Health, Birmingham, AL; and Specialized Clinical Services (K.D.), Park Ridge, NJ
| | - Kim Dontas
- NYU Multiple Sclerosis Care Center (I.K., M.O., J.H.), Department of Neurology, NYU School of Medicine, New York, NY; Barnabas Multiple Sclerosis Care Center (I.K., M.Y., J.H.), Department of Medicine, Barnabas Medical Center, Livingston, NJ; Biogen Idec (G.K., M.S.), Cambridge, MA; Department of Epidemiology (E.C.), University of Alabama at Birmingham School of Public Health, Birmingham, AL; and Specialized Clinical Services (K.D.), Park Ridge, NJ
| | - Mary Yarussi
- NYU Multiple Sclerosis Care Center (I.K., M.O., J.H.), Department of Neurology, NYU School of Medicine, New York, NY; Barnabas Multiple Sclerosis Care Center (I.K., M.Y., J.H.), Department of Medicine, Barnabas Medical Center, Livingston, NJ; Biogen Idec (G.K., M.S.), Cambridge, MA; Department of Epidemiology (E.C.), University of Alabama at Birmingham School of Public Health, Birmingham, AL; and Specialized Clinical Services (K.D.), Park Ridge, NJ
| | - Meena Subramanyam
- NYU Multiple Sclerosis Care Center (I.K., M.O., J.H.), Department of Neurology, NYU School of Medicine, New York, NY; Barnabas Multiple Sclerosis Care Center (I.K., M.Y., J.H.), Department of Medicine, Barnabas Medical Center, Livingston, NJ; Biogen Idec (G.K., M.S.), Cambridge, MA; Department of Epidemiology (E.C.), University of Alabama at Birmingham School of Public Health, Birmingham, AL; and Specialized Clinical Services (K.D.), Park Ridge, NJ
| | - Joseph Herbert
- NYU Multiple Sclerosis Care Center (I.K., M.O., J.H.), Department of Neurology, NYU School of Medicine, New York, NY; Barnabas Multiple Sclerosis Care Center (I.K., M.Y., J.H.), Department of Medicine, Barnabas Medical Center, Livingston, NJ; Biogen Idec (G.K., M.S.), Cambridge, MA; Department of Epidemiology (E.C.), University of Alabama at Birmingham School of Public Health, Birmingham, AL; and Specialized Clinical Services (K.D.), Park Ridge, NJ
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27
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Parker S, Gil E, Hewitt P, Ward K, Reyal Y, Wilson S, Manson J. Case report: passive transfer of hepatitis B antibodies from intravenous immunoglobulin. BMC Infect Dis 2014; 14:99. [PMID: 24559411 PMCID: PMC3937526 DOI: 10.1186/1471-2334-14-99] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2013] [Accepted: 02/17/2014] [Indexed: 04/13/2024] Open
Abstract
Background Prior to initiating immunosuppressive therapy in the treatment of autoimmune inflammatory conditions, it is a requirement to screen for certain viral serology, including hepatitis B (HBV). A positive result may indicate the need for antiviral therapy, or contraindicate immunosuppression all together. An accurate interpretation of serological markers is therefore imperative in order to treat patients appropriately. We present a case of passive anti-HBV antibody transfer following intravenous immunoglobulin (IVIg) infusion, in which misinterpretation of serology results almost led to inappropriate treatment with antiviral therapy and the withholding of immunosuppressive agents. This phenomenon has been previously reported, but awareness remains limited. Case presentation A 50 year old Caucasian gentleman with a history of allogeneic haematopoietic stem cell transplant for transformed follicular lymphoma was admitted to hospital with recurrent respiratory tract infections. Investigation found him to be hypogammaglobulinaemic, and he was thus given 1 g/kg of intravenous immunoglobulin. The patient also disclosed a 3-week history of painful, swollen joints, leading to a diagnosis of seronegative inflammatory polyarthritis. Prior to initiating long term immunosuppression, viral screening found hepatitis B serology suggestive of past infection, with positive results for both anti-HBc and anti-HBs antibody, but negative HBV DNA. In response, prednisolone was weaned and the local hepatology team recommended commencement of lamivudine. Having been unable to identify a source of infection, the case was reported to the local blood centre, who tested a remaining vial from the same batch of IVIg and found it to be anti-HBc and anti-HBs positive. Fortunately the blood products were identified and tested prior to the patient initiating HBV treatment, and the effect of a delay in starting disease-modifying therapy was inconsequential in light of an excellent response to first-line therapies. Conclusion Misinterpretation of serology results following IVIg infusion may lead to significant patient harm, including unnecessary antiviral administration, the withholding of treatments, and psychosocial damage. This is especially pertinent at a time when we have an ever increasing number of patients being treated with IVIg for a wide array of immune-mediated disease. Passive antibody transfer should be considered wherever unexpected serological changes are identified.
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28
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Gessoni G, Beggio S, Barin P, Favarato M, Galli C, Valverde S, Nata MB, Salvadego MM, Marchiori G. Significance of anti-HBc only in blood donors: a serological and virological study after hepatitis B vaccination. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2014; 12 Suppl 1:s63-8. [PMID: 23522882 PMCID: PMC3934214 DOI: 10.2450/2013.0227-12] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 10/10/2012] [Accepted: 12/04/2012] [Indexed: 02/06/2023]
Abstract
BACKGROUND Blood donors positive only for anti-HBc may have a resolved hepatitis B virus (HBV) infection, low grade chronic infection or infection with variant strains of HBV. We aimed to assess the significance of this serological pattern after hepatitis B vaccination in such cases. MATERIALS AND METHODS Twenty-four anti-HBc only blood donors were vaccinated with the Engerix HBV vaccine and a serological and virological evaluation was performed before HBV vaccination and 7-10 days after each dose. Subjects were classified as non-responders if their anti-HBs levels stayed below 10 IU/L after full vaccination, while the response was considered secondary (anamnestic) if anti-HBs levels rose over 10 IU/L after the first vaccine dose, and primary if anti-HBs levels rose over 10 IU/L only after the second or third vaccine dose. RESULTS Of the 21 fully evaluable donors, six had no response, eight showed a primary response and seven had an anamnestic response. One non-responder had transient positivity for HBV-DNA at low levels (12 IU/mL) with persistent negativity for HBsAg. DISCUSSION Anti-HBc-only positive blood donors are a heterogeneous population including HBV naïve subjects with a likely false-positive anti-HBc reactivity, subjects with a resolved HBV infection, and subjects with persistent low-level HBV replication. The analysis of the anti-HBs response after a dose of HBV vaccine may help to distinguish among the different causes of the isolated anti-HBc positivity, thereby enabling proper counselling and potential readmission to blood donation.
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Affiliation(s)
- Gianluca Gessoni
- Department of Clinical Pathology, Chioggia, Italy
- Department of Transfusion Medicine, Venice Area, Italy
| | | | - Paolo Barin
- Department of Transfusion Medicine, Venice Area, Italy
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29
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Ilboudo CM, Guest EM, Ferguson AM, Garg U, Jackson MA. Misleading hepatitis B testing in the setting of intravenous immunoglobulin. F1000Res 2013; 2:249. [PMID: 25075281 PMCID: PMC4103488 DOI: 10.12688/f1000research.2-249.v1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/06/2013] [Indexed: 11/24/2022] Open
Abstract
Intravenous immunoglobulin (IVIG) is commonly used for a wide range of diagnoses, by multiple pediatric subspecialists. We report two cases of hepatitis B screening results post IVIG infusion, where positive anti-Hepatitis B core antigen serology tests indicated possible occult hepatitis infection, leading to a delay in care. However, serial antibody testing showed results consistent with the passive transfer of antibodies.
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Affiliation(s)
- Christelle M Ilboudo
- Children's Mercy Hospitals and Clinics, Division of Infectious Diseases and University of Missouri-Kansas City School of Medicine, Kansas City, MO, 64108, USA
| | - Erin M Guest
- Children's Mercy Hospitals and Clinics, Department of Pediatrics, Division of Hematology Oncology and University of Missouri-Kansas City School of Medicine, Kansas City, MO, 64108, USA
| | - Angela M Ferguson
- Children's Mercy Hospital and Clinics, Department of Pathology and Laboratory Medicine, Division of Laboratory Medicine and University of Missouri-Kansas City School of Medicine, Kansas City, MO, 64108, USA
| | - Uttam Garg
- Children's Mercy Hospital and Clinics, Department of Pathology and Laboratory Medicine, Division of Laboratory Medicine and University of Missouri-Kansas City School of Medicine, Kansas City, MO, 64108, USA
| | - Mary Anne Jackson
- Children's Mercy Hospitals and Clinics, Division of Infectious Diseases and University of Missouri-Kansas City School of Medicine, Kansas City, MO, 64108, USA
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30
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Idilman R, Arat M. Evaluation and management of hepatitis B virus infection in hematopoietic stem cell transplantation: before and after transplantation. Expert Rev Anti Infect Ther 2013; 9:641-52. [PMID: 21819330 DOI: 10.1586/eri.11.79] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
HBV infection remains a major global health problem and continues to be a common cause of liver-related morbidity and mortality in both immunocompetent and immunosuppressed individuals. Reactivation of HBV is a serious complication of chemotherapy/immunosuppressive therapy in patients with HBV infection. In this article, we aim to describe the diagnosis, prevention and management of HBV infection in allogeneic hematopoietic stem cell transplant candidates, from the pre- to post-transplant period. The data currently available suggest that all individuals with hemato-/onco-logical malignancies who undergo chemotherapy/immunosuppressive therapy should be screened for hepatotropic viruses such as HBV and HCV. HBV surface antigen-positive individuals who receive chemotherapy/immunosuppressive therapy are at considerable risk of HBV reactivation. Antiviral prophylaxis prevents HBV reactivation, decreases reactivation-related morbidity and mortality, and prevents interruptions in chemotherapy/immunosuppressive therapy in such individuals. The optimal duration of antiviral prophylaxis remains to be elucidated. The vaccination of HBV-naive recipients and their donors against HBV infection prior to transplantation plays an important role in preventing acquired HBV infection. The presence of hepatitis B surface antigen positivity is not an absolute contraindication for allogeneic hematopoietic stem cell transplantation.
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Affiliation(s)
- Ramazan Idilman
- Ankara University Faculty of Medicine, Department of Gastroenterology, Ibn-i Sina Hospital, Sihhiye, Ankara 06100, Turkey.
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Hwang JP, Vierling JM, Zelenetz AD, Lackey SC, Loomba R. Hepatitis B virus management to prevent reactivation after chemotherapy: a review. Support Care Cancer 2012; 20:2999-3008. [PMID: 22933131 PMCID: PMC3469760 DOI: 10.1007/s00520-012-1576-7] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2012] [Accepted: 08/13/2012] [Indexed: 12/11/2022]
Abstract
PURPOSE Reactivation of hepatitis B virus (HBV) infection after chemotherapy can lead to liver failure and death. Conflicting recommendations regarding HBV screening in cancer patients awaiting chemotherapy mean that some patients at risk for HBV reactivation are not being identified and treated with prophylactic antiviral therapy. METHODS We performed a narrative review of the existing evidence regarding screening for and management of HBV infection among patients with cancer using Ovid Medline, PubMed, and the Cochrane Library. RESULTS Our review showed inconsistencies in the definition and management strategies for HBV reactivation. The timeframe of reactivation is variable, and its molecular mechanisms are not clear. There are five effective antiviral agents that can be used as prophylaxis to prevent reactivation of HBV infection in cancer patients; however, the optimal drug and duration of therapy are unknown. Reactivation is more commonly reported in patients with hematologic malignancies receiving rituximab treatment, but reactivation can occur after other chemotherapies and in patients with solid tumors. Screening with all three screening tests-HBsAg, anti-HBc, and anti-HBs-allows the most thorough interpretation of a patient's serologic profile and assessment of reactivation risk; however, decision-making and cost-effectiveness studies are needed to determine optimal screening strategies. CONCLUSIONS Prevention of reactivation of HBV infection depends on identification of patients at risk and initiation of antiviral prophylaxis, but data to guide screening and treatment strategies are lacking. Additional research is necessary to accurately define and predict reactivation, identify best antiviral treatment strategies, and identify cost-effective HBV screening strategies.
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Affiliation(s)
- Jessica P Hwang
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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Glasser L, Cyrus S, Machan JT, Mapother J. Human T-lymphotropic virus laboratory testing of maternal blood at time of cord blood donations and clinical implications. Transfusion 2012; 53:1302-8. [PMID: 22998131 DOI: 10.1111/j.1537-2995.2012.03901.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND In the United States, blood products are tested for infectious diseases including human T-lymphotropic virus (HTLV)-I/II. Positive results of maternal blood samples at the time of cord blood (CB) donation must be reported to mother and physician. Tests for HTLV have a high false-positive rate. This is problematic because there is no prenatal testing of the mother. STUDY DESIGN AND METHODS This study involves 119,769 maternal blood samples at time of CB donation and evaluates positive results for HTLV in screening tests, supplemental immunoassays, and nucleic acid tests (NATs). Infectious disease markers (IDMs) and maternal health histories of HTLV-positive and -negative mothers were compared. RESULTS Of 119,769 mothers donating CB, 545 tested positive with the screening test, 33 were positive with the supplemental tests, and two were positive with NAT. When indeterminate results were excluded from the supplemental test only six were positive. Eight of 34 mothers with positive or indeterminate supplemental test results had received intravenous immunoglobulin. There were no significant differences between HTLV-positive and -negative mothers with regard to the incidence of other IDMs. CONCLUSIONS Testing maternal blood for HTLV is problematic for CB banks, obstetricians, and mothers because of the high false-positive rate. CB banks need rapid turnaround time and supplemental testing. If results on the latter are positive the obstetrician should be notified, educated, do follow-up testing, and counseling. Indeterminate results on supplemental tests are most likely false positives. We recommend that mothers with positive or indeterminate supplemental test results have follow-up NAT.
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Bélanger SS, Fish D, Kim J, Cohen S. False-positive human T-lymphotropic virus serology after intravenous immunoglobulin transfusion. CMAJ 2012; 184:1709-12. [PMID: 22927508 DOI: 10.1503/cmaj.120019] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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Hunter M, Kiernan M, Post J. Human T-lymphotropic virus seroconversion associated with pooled human intravenous immunoglobulin therapy. Intern Med J 2012; 42:729-30. [DOI: 10.1111/j.1445-5994.2012.02803.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Benton E, Iqbal K, Wade P, Wong T, Aarons E, Groves R. False-positive hepatitis B serology following IVIG therapy: forgotten but not gone!! J Am Acad Dermatol 2012; 66:e123-4. [PMID: 22342023 DOI: 10.1016/j.jaad.2011.03.032] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2011] [Revised: 03/24/2011] [Accepted: 03/27/2011] [Indexed: 11/17/2022]
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A pilot randomized trial of adjuvant rituximab or placebo for nonsplenectomized patients with immune thrombocytopenia. Blood 2012; 119:1356-62. [DOI: 10.1182/blood-2011-08-374777] [Citation(s) in RCA: 87] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
Abstract
The benefit of adding rituximab to standard treatment in nonsplenectomized patients with primary immune thrombocytopenia (ITP) is uncertain. We performed a pilot randomized trial to determine the feasibility of recruitment, protocol adherence, and blinding of a larger trial of rituximab versus placebo; and to evaluate the potential efficacy of adjuvant rituximab in ITP. Nonsplenectomized adults with newly diagnosed or relapsed ITP who were receiving standard ITP therapy for a platelet count below 30 × 109/L were randomly allocated to receive 4 weekly infusions of 375 mg/m2 rituximab or saline placebo. Sixty patients were recruited over 46 months, which was slower than anticipated. Protocol adherence and follow-up targets were achieved, and blinding was successful for research staff but not for patients. After 6 months, there was no difference between rituximab and placebo groups for the composite outcome of any platelet count below 50 × 109/L, significant bleeding or rescue treatment once standard treatment was stopped (21/32 [65.6%] vs 21/26 [80.8%]; relative risk = 0.81, 95% confidence intervals, 0.59%-1.11%). Timely accrual poses a challenge to the conduct of a large randomized trial of rituximab for presplenectomy ITP. No difference in the frequency of the composite outcome was observed in this pilot trial (registered at www.clinicaltrials.gov NCT00372892).
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