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Spałek MM, Bowszyc-Dmochowska M, Dmochowski M. Intravenous Immunoglobulin for Autoimmune Bullous Diseases: A Case Series from a Central European Referral Center. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1265. [PMID: 37512078 PMCID: PMC10385677 DOI: 10.3390/medicina59071265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Revised: 06/13/2023] [Accepted: 07/05/2023] [Indexed: 07/30/2023]
Abstract
Background and Objectives: Autoimmune bullous diseases (AIBDs) may be treated with intravenous immunoglobulin (IVIG) infusions. This study aimed to evaluate the benefits and safety profiles of high-dose IVIG therapy in AIBD patients, as determined by clinical remission, the glucocorticosteroid-sparing effect, and adverse events at 12 months follow-up in a Central European university dermatology department setting. Materials and Methods: Our case series included 10 patients: five patients with pemphigus vulgaris, one with pemphigus herpetiformis, one with pemphigus foliaceus, one with bullous pemphigoid, two with epidermolysis bullosa acquisita. They underwent 4-12 monthly cycles of IVIG therapy at a dose of 2 g/kg per cycle. Results: The prednisone dosage reduction after 2, 6, and 12 months following the final IVIG course was 65.45%, 70.91%, and 76.37%, respectively. During the 12-month observation period, disease relapse was observed in 20% of patients, while others achieved complete or partial remission without or with minimal therapy. Side effects were seen in 80% of patients; they were transient and did not necessitate discontinuation of IVIG. Conclusions: IVIG demonstrates effectiveness as a treatment with a favorable safety profile. Nevertheless, its high cost remains a significant drawback, particularly in low-income countries. IVIG should be considered, especially in patients opposed to standard therapies or with contraindications to their use.
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Affiliation(s)
- Maciej Marek Spałek
- Autoimmune Blistering Dermatoses Section, Department of Dermatology, Poznan University of Medical Sciences, 60-355 Poznan, Poland
| | - Monika Bowszyc-Dmochowska
- Cutaneous Histopathology and Immunopathology Section, Department of Dermatology, Poznan University of Medical Sciences, 60-355 Poznan, Poland
| | - Marian Dmochowski
- Autoimmune Blistering Dermatoses Section, Department of Dermatology, Poznan University of Medical Sciences, 60-355 Poznan, Poland
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2
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Hudemann C, Hoffmann J, Schmidt E, Hertl M, Eming R. T Regulatory Cell-Associated Tolerance Induction by High-Dose Immunoglobulins in an HLA-Transgenic Mouse Model of Pemphigus. Cells 2023; 12:cells12091340. [PMID: 37174740 PMCID: PMC10177252 DOI: 10.3390/cells12091340] [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: 04/06/2023] [Revised: 05/04/2023] [Accepted: 05/05/2023] [Indexed: 05/15/2023] Open
Abstract
Pemphigus vulgaris (PV) is a potentially lethal autoimmune bullous skin disorder caused by IgG autoantibodies against desmoglein 3 (Dsg3) and Dsg1. During the last three decades, high-dose intravenous immunoglobulins (IVIgs) have been applied as an effective and relatively safe treatment regime in severe, therapy-refractory PV. This prompted us to study T- and B- cell polarization by IVIg in a human-Dsg3-dependent mouse model for PV. Using humanized mice transgenic for HLA-DRB1*04:02, which is a highly prevalent haplotype in PV, we employed IVIg in two different experimental approaches: in prevention and quasi-therapeutic settings. Our data show that intraperitoneally applied IVIg was systemically distributed for up to 42 days or longer. IVIg-treated Dsg3-immunized mice exhibited, in contrast to Dsg3-immunized mice without IVIg, significantly less Dsg3-specific IgG, and showed induction of T regulatory cells in lymphatic tissue. Ex vivo splenocyte analysis upon Dsg3-specific stimulation revealed an initial, temporarily reduced antigen-induced cell proliferation, as well as IFN-γ secretion that became less apparent over the course of time. Marginal-zone B cells were initially reduced in the preventive approach but re-expanded over time. In contrast, in the quasi-therapeutic approach, a robust down-regulation in both spleen and lymph nodes was observed. We found a significant down-regulation of the immature transitional 1 (T1) B cells in IVIg-treated mice in the quasi-therapeutic approach, while T2 and T3, representing a healthy stage of B-cell development, appeared to be up-regulated by IVIg. In summary, in two experimental settings employing an active PV mouse model, we demonstrate distinct alterations of T- and B-cell populations upon IVIg treatment, compatible with a tolerance-associated polarization in lymphatic tissue. Our data suggest that the clinical efficacy of IVIg is at least modulated by distinct alterations of T- and B-cell populations compatible with a tolerance-associated polarization in lymphatic tissue.
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Affiliation(s)
- Christoph Hudemann
- Department of Dermatology and Allergology, Philipps-University Marburg, 35037 Marburg, Germany
| | - Jochen Hoffmann
- Department of Dermatology, University of Heidelberg, 69117 Heidelberg, Germany
| | - Enno Schmidt
- Department of Dermatology, University of Lübeck, 23562 Lübeck, Germany
- Lübeck Institute of Experimental Dermatology (LIED), University of Lübeck, 23562 Lübeck, Germany
| | - Michael Hertl
- Department of Dermatology and Allergology, Philipps-University Marburg, 35037 Marburg, Germany
| | - Rüdiger Eming
- Department of Dermatology and Allergology, Philipps-University Marburg, 35037 Marburg, Germany
- Department of Dermatology, Venerology and Allergology, German Armed Forces Central Hospital Koblenz, 56072 Koblenz, Germany
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3
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Alnoukari M, De La Garza OG, Al Gburi K, Patel N, Lopez H, Shamim M, Kwang H. IVIG for refractory dysphagia in Antisynthetase syndrome: A truth hard to swallow. Clin Case Rep 2022; 10:e6569. [DOI: 10.1002/ccr3.6569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 09/27/2022] [Accepted: 10/17/2022] [Indexed: 11/14/2022] Open
Affiliation(s)
- Mais Alnoukari
- University of Texas Rio Grande Health Sciences Department and Valley Baptist Medical Center Harlingen Texas USA
| | - Oziel Garza De La Garza
- University of Texas Rio Grande Health Sciences Department and Valley Baptist Medical Center Harlingen Texas USA
| | - Karrar Al Gburi
- University of Texas Rio Grande Health Sciences Department and Valley Baptist Medical Center Harlingen Texas USA
| | - Niral Patel
- University of Texas Rio Grande Health Sciences Department and Valley Baptist Medical Center Harlingen Texas USA
| | - Henderson Lopez
- University of Texas Rio Grande Health Sciences Department and Valley Baptist Medical Center Harlingen Texas USA
| | - Muhammad Shamim
- University of Texas Rio Grande Health Sciences Department and Valley Baptist Medical Center Harlingen Texas USA
| | - Henry Kwang
- University of Texas Rio Grande Health Sciences Department and Valley Baptist Medical Center Harlingen Texas USA
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Ciolfi C, Sernicola A, Alaibac M. Role of Rituximab in the Treatment of Pemphigus Vulgaris: Patient Selection and Acceptability. Patient Prefer Adherence 2022; 16:3035-3043. [PMID: 36387051 PMCID: PMC9651071 DOI: 10.2147/ppa.s350756] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Accepted: 10/29/2022] [Indexed: 11/09/2022] Open
Abstract
Anti-CD20 monoclonal antibody rituximab is an approved adjuvant treatment, in combination with oral corticosteroids, for patients with pemphigus vulgaris, a severe and potentially life-threatening autoimmune blistering skin disorder. Updated approaches to the management of pemphigus vulgaris support rituximab as a first-line adjuvant treatment to induce remission early in the course of disease; however, its feasibility in the clinical setting is often reduced by a series of limitations, including high cost of this biological drug, physician and patient concern for the risk of adverse reactions, and uncertainty regarding the optimum dosing and schedule of administration. The standard approved rituximab dosages, which are derived from lymphoma protocols, have been recognized to exceed the effective dose required for inducing B cell depletion, since the B cell burden in pemphigus vulgaris is much lower than in lymphoproliferative disorders. To overcome these limitations, recent research has investigated alternative regimens of rituximab, using lower doses of the drug. Moreover, differences in patient and disease characteristics that are highlighted in the literature strongly suggest that therapy should be tailored individually on a case-by-case basis: personalized treatment schedules may be necessary to optimize response to treatment and tolerability in different subjects, with the possibility of repeated infusions for severe forms and in case of relapse. Finally, low-dose regimens of rituximab were suggested to be favorable during the COVID-19 pandemic by providing a lesser degree of immune cell depletion while retaining a sufficient response. In conclusion, the current literature suggests that lower-dose regimens of rituximab are not only tolerable and cost-effective but may also be associated with a positive response in pemphigus vulgaris, comparable to that achieved with higher doses especially in early disease. Further evidence from rigorous clinical trials will be required to optimize lower-dose regimens of RTX and establish their position within the treatment scenario of pemphigus vulgaris.
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Affiliation(s)
- Christian Ciolfi
- Dermatology Unit, Department of Medicine (DIMED), University of Padua, Padua, Italy
| | - Alvise Sernicola
- Dermatology Unit, Department of Medicine (DIMED), University of Padua, Padua, Italy
- Correspondence: Alvise Sernicola, Dermatology Unit, Department of Medicine (DIMED), University of Padua, Via Vincenzo Gallucci, 4, Padua, 35121, Italy, Tel/Fax +39 049 821 2924, Email
| | - Mauro Alaibac
- Dermatology Unit, Department of Medicine (DIMED), University of Padua, Padua, Italy
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Brand A, De Angelis V, Vuk T, Garraud O, Lozano M, Politis D. Review of indications for immunoglobulin (IG) use: Narrowing the gap between supply and demand. Transfus Clin Biol 2021; 28:96-122. [DOI: 10.1016/j.tracli.2020.12.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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6
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Magdaleno-Tapial J, Valenzuela-Oñate C, Martínez-Doménech Á, García-Legaz-Martínez M, Tamarit-García JJ, Zaragoza-Ninet V, Alegre-de Miquel V, Pérez-Ferriols A. Improvement of plaquelike cutaneous mucinosis after intravenous immunoglobulins treatment. JAAD Case Rep 2020; 6:710-712. [PMID: 32715057 PMCID: PMC7369530 DOI: 10.1016/j.jdcr.2020.06.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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7
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Liu K, Tomlinson G, Reed AM, Huber AM, Saarela O, Bout-Tabaku SM, Curran M, Dvergsten JA, Eberhard BA, Jung LK, Kim S, Ringold S, Rouster-Steven KA, Tesher M, Wahezi DM, Feldman BM. Pilot Study of the Juvenile Dermatomyositis Consensus Treatment Plans: A CARRA Registry Study. J Rheumatol 2020; 48:114-122. [PMID: 32238513 DOI: 10.3899/jrheum.190494] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/10/2020] [Indexed: 01/26/2023]
Abstract
OBJECTIVES To determine the feasibility of comparing the Childhood Arthritis and Rheumatology ResearchAlliance (CARRA) consensus treatment plans (CTP) in treating moderate new-onset juvenile dermatomyositis (JDM) using the CARRA registry, and to establish appropriate analytic methods to control for confounding by indication and missing data. METHODS A pilot cohort of 39 patients with JDM from the CARRA registry was studied. Patients were assigned by the treating physician, considering patient/family preferences, to 1 of 3 CTP: methotrexate (MTX) and prednisone (MP); intravenous (IV) methylprednisolone, MTX, and prednisone (MMP); or IV methylprednisolone, MTX, prednisone, and IV immunoglobulin (MMPI). The primary outcome was the proportion of patients achieving moderate improvement at 6 months under each CTP. Statistical methods including multiple imputation and inverse probability of treatment weighting were used to handle missing data and confounding by indication. RESULTS Patients received MP (n = 13), MMP (n = 18) and MMPI (n = 8). Patients in all CTP had significant improvement in disease activity. Of the 36 patients who remained in our pilot study at 6 months, 16 (44%) of them successfully achieved moderate improvement at 6 months (6/13, 46% for MP; 7/15, 47% for MMP; 3/8, 38% for MMPI). After correcting for confounding, there were no statistically significant pairwise differences between the CTP (P = 0.328-0.88). CONCLUSION We gained valuable experience and insight from our pilot study that can be used to guide the design and analysis of comparative effectiveness studies using the CARRA registry CTP approach. Our analytical methods can be adopted for future comparative effectiveness studies and applied to other rare disease observational studies.
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Affiliation(s)
- Kuan Liu
- K. Liu, MMath, B.M. Feldman, MD, MSc, FRCPC, The Hospital for Sick Children, Toronto, and Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - George Tomlinson
- G. Tomlinson, PhD, Department of Medicine, University Health Network, Toronto, Ontario, Canada.,G. Tomlinson, PhD, Department of Medicine, University Health Network, Toronto, Ontario, Canada
| | - Ann M Reed
- A.M. Reed, MD, Department of Pediatrics, Duke University Medical Center, Durham, North Carolina, USA
| | - Adam M Huber
- A.M. Huber, MD, MSc, IWK Health Centre, Halifax, Nova Scotia, Canada
| | - Olli Saarela
- O. Saarela, PhD, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Sharon M Bout-Tabaku
- S.M. Bout-Tabaku, MD, MSCE, Department of Pediatric Medicine, Sidra Medicine, Doha, Weill Cornell Medicine - Qatar, Doha, Qatar
| | - Megan Curran
- M.L. Curran, MD, Department of Pediatrics, University of Colorado, Denver, Colorado, USA
| | - Jeffrey A Dvergsten
- J.A. Dvergsten, MD, Department of Pediatrics, Duke University Medical Center, Durham, and Department of Pediatrics, Duke Children's Hospital, Durham, North Carolina, USA
| | - Barbara A Eberhard
- B.A. Eberhard, MBBS, MS, Division of Pediatric Rheumatology, Steven and Alexandra Cohen Children's Medical Center of New York, Lake Success, New York, and Department of Pediatrics, Hofstra Northwell School of Medicine, Hempstead, New York, USA
| | - Lawrence K Jung
- L.K. Jung, MD, Division of Rheumatology, Children's National Health System, Washington, D.C., USA
| | - Susan Kim
- S. Kim, MD, MMSc, Department of Pediatrics, University of California San Francisco, San Francisco, California, USA
| | - Sarah Ringold
- S. Ringold, MD, Seattle Children's Hospital and Research Institute, Seattle, Washington, USA
| | - Kelly A Rouster-Steven
- K.A. Rouster-Steven, MD, Department of Pediatrics, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Melissa Tesher
- M. Tesher, MD, Comer Children's Hospital, University of Chicago Medical Center, Chicago, Illinois, USA
| | - Dawn M Wahezi
- D.M. Wahezi, MD, Msc, Division of Pediatric Rheumatology, the Children's Hospital at Montefiore, Bronx, New York, USA
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8
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Ozden MG, Ozdemir H, Şenturk N. Intravenous immunoglobulin in resistant livedoid vasculopathy: Analysis of a case series. Dermatol Ther 2020; 33:e13229. [DOI: 10.1111/dth.13229] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Revised: 01/06/2020] [Accepted: 01/15/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Muge G. Ozden
- Department of Dermatology Ondokuz Mayıs University Medical Faculty Samsun Turkey
| | - Hilal Ozdemir
- Department of Dermatology Ondokuz Mayıs University Medical Faculty Samsun Turkey
| | - Nilgun Şenturk
- Department of Dermatology Ondokuz Mayıs University Medical Faculty Samsun Turkey
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9
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Gaitanis G, Bassukas ID. Combination therapy for toxic epidermal necrolysis: It is time for anti-TNFa biologics comparison. Burns 2020; 46:244-245. [DOI: 10.1016/j.burns.2019.10.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Accepted: 10/04/2019] [Indexed: 10/25/2022]
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10
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Hoffmann JHO, Enk AH. High-Dose Intravenous Immunoglobulin in Skin Autoimmune Disease. Front Immunol 2019; 10:1090. [PMID: 31244821 PMCID: PMC6579842 DOI: 10.3389/fimmu.2019.01090] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Accepted: 04/29/2019] [Indexed: 11/26/2022] Open
Abstract
The immunomodulatory potential and low incidence of severe side effects of high-dose intravenous immunoglobulin (IVIg) treatment led to its successful application in a variety of dermatological autoimmune diseases over the last two decades. IVIg is usually administered at a dose of 2 g per kg body weight distributed over 2–5 days every 4 weeks. They are most commonly used as a second- or third-line treatment in dermatological autoimmune disease (pemphigus vulgaris, pemphigus foliaceus, bullous pemphigoid, mucous membrane pemphigoid, epidermolysis bullosa acquisita, dermatomyositis, systemic vasculitis, and systemic lupus erythematosus). However, first-line treatment may be warranted in special circumstances like concomitant malignancy, a foudroyant clinical course, and contraindications against alternative treatments. Furthermore, IVIg can be considered first line in scleromyxedema. Production of IVIg for medical use is strictly regulated to ensure a low risk of pathogen transmission and comparable quality of individual batches. More common side effects include nausea, headache, fatigue, and febrile infusion reactions. Serious side effects are rare and include thrombosis and embolism, pulmonary edema, renal failure, aseptic meningitis, and severe anaphylactic reactions. Regarding the mechanism of action, one can discriminate between functions of the Fcγ region and the F(ab)2 region and their effects on a cellular level. These functions are not mutually exclusive, and more than one pathway may contribute to the beneficial effects. Here, we present a historical background, details on manufacturing, hypotheses on the mechanisms of action, information on the clinical application in the abovementioned conditions, and a brief outlook on future directions of IVIg treatment in dermatology.
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Affiliation(s)
| | - Alexander H Enk
- Department of Dermatology, University of Heidelberg, Heidelberg, Germany
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11
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Emre S. Intravenous immunoglobulin treatment: Where do dermatologists stand? Dermatol Ther 2019; 32:e12854. [PMID: 30756448 DOI: 10.1111/dth.12854] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2018] [Revised: 01/08/2019] [Accepted: 02/10/2019] [Indexed: 11/29/2022]
Abstract
Intravenous immunoglobulins (IVIG) are therapeutic products, comprising polyclonal IgGs, which are obtained from human plasma pool of healthy blood donors. Despite the lack of Food and Drug Administration (FDA) approval, the experience of using IVIG in various dermatological diseases increases day by day and exciting results are reported. However, experience with the use of IVIG in dermatological indications are mostly case reports whereas randomized, controlled, double-blind, multicentric studies have not been performed. Dermatological diseases treated with IVIG are autoimmune bullous skin diseases, Stevens-Johnson syndrome and toxic epidermal necrolysis, connective tissue diseases, pyoderma gangrenosum, severe atopic dermatitis, chronic urticaria, Kawasaki disease, pretibial myxoedema, scleredema, and graft-versus-host disease.
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Affiliation(s)
- Selma Emre
- Department of Dermatology, Yildirim Beyazit University, Medical School, Ankara, Turkey
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12
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Zhang AJ, Nygaard RM, Endorf FW, Hylwa SA. Stevens‐Johnson syndrome and toxic epidermal necrolysis: retrospective review of 10‐year experience. Int J Dermatol 2019; 58:1069-1077. [DOI: 10.1111/ijd.14409] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Revised: 11/25/2018] [Accepted: 01/29/2019] [Indexed: 12/13/2022]
Affiliation(s)
- Amy J. Zhang
- University of Minnesota Medical School Minneapolis MN USA
| | - Rachel M. Nygaard
- Department of Surgery Hennepin County Medical Center Minneapolis MN USA
| | | | - Sara A. Hylwa
- Department of Dermatology University of Minnesota Minneapolis MN USA
- Department of Dermatology Hennepin County Medical Center Minneapolis MN USA
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13
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Meyer A, Scirè CA, Talarico R, Alexander T, Amoura Z, Avcin T, Barsotti S, Beretta L, Blagojevic J, Burmester G, Cavazzana I, Cherrin P, Damian L, Doria A, Fonseca JE, Furini F, Galetti I, Houssiau F, Krieg T, Larosa M, Launay D, Campanilho-Marques R, Martin T, Matucci-Cerinic M, Moinzadeh P, Montecucco C, Moraes-Fontes MF, Mouthon L, Neri R, Paolino S, Piette Y, Rednic S, Tamirou F, Tincani A, Toplak N, Bombardieri S, Hachulla E, Mueller-Ladner U, Schneider M, Smith V, Vieira A, Cutolo M, Mosca M, Cavagna L. Idiopathic inflammatory myopathies: state of the art on clinical practice guidelines [corrected]. RMD Open 2019; 4:e000784. [PMID: 30886730 PMCID: PMC6397434 DOI: 10.1136/rmdopen-2018-000784] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2018] [Revised: 01/07/2019] [Accepted: 01/08/2019] [Indexed: 12/16/2022] Open
Abstract
Idiopathic inflammatory myopathies (IIMs) encompass a heterogeneous group of rare autoimmune diseases characterised by muscle weakness and inflammation, but in antisynthetase syndrome arthritis and interstitial lung disease are more frequent and often inaugurate the disease. Clinical practice guidelines (CPGs) have been proposed for IIMs, but they are sparse and heterogeneous. This work aimed at identifying: i) current available CPGs for IIMs, ii) patients ' and clinicians' unmet needs not covered by CPGs. It has been performed in the framework of the European Reference Network on rare and complex connective tissue and musculoskeletal diseases (ReCONNET), a network of centre of expertise and patients funded by the European Union's Health Programme. Fourteen original CPGs were identified, notably recommending that: i) extra-muscular involvements should be assessed; ii) corticosteroids and methotrexate or azathioprine are first-line therapies of IIMs. ii) IVIG is a treatment of resistant-DM that may be also used in other resistant-IIMs; iii) physical therapy and sun protection (in DM patients) are part of the treatment; v) tumour screening for patients with DM include imaging of chest, abdomen, pelvis and breast (in woman) along with colonoscopy (in patients over 50 years); vi) disease activity and damages should be monitor using standardised and validated tools. Yet, only half of these CPGs were evidence-based. Crucial unmet needs were identified both by patients and clinicians. In particular, there was a lack of large multidisciplinary working group and of patients ' preferences. The following fields were not or inappropriately targeted: diagnosis; management of extra-muscular involvements other than skin; co-morbidities and severe manifestations.
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Affiliation(s)
- Alain Meyer
- Centre National de Référence des Maladies Systémiques et Auto-immunes Rares Grand-Est Sud-Ouest (RESO), Service de humatologie, Service de physiologie, Unité d’explorations fonctionnelles musculaires, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
- EA3072, Fédération de Médecine Translationelle, Université de Strasbourg, Strasbourg, France
| | - Carlo Alberto Scirè
- Section of Rheumatology, Department of Medical Sciences, University of Ferrara, Ferrara, Italy
| | | | - Tobias Alexander
- Department of Rheumatology and Clinical Immunology, Charité University Hospital Berlin, Berlin, Germany
| | - Zahir Amoura
- Department of Internal Medicine, Hospital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Tadej Avcin
- Department of Allergology, Rheumatology and Clinical Immunology, University Children's Hospital, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Simone Barsotti
- Rheumatology Unit, University of Pisa, Pisa, Italy
- Department of Medical Biotechnology, University of Siena, Siena, Italy
| | - Lorenzo Beretta
- Referral Center for Systemic Autoimmue Diseases, Referral Center for Systemic Autoimmue DiseasesFondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico di Milano, Milan, Italy
| | - Jelena Blagojevic
- Department of Clinical and Experimental Medicine, Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, University of Florence, AOUC, Florence, Italy
| | - Gerd Burmester
- Department of Rheumatology and Clinical Immunology, Charité University Hospital Berlin, Berlin, Germany
| | - Ilaria Cavazzana
- Rheumatology and Clinical Immunology Unit, Civil Hospital, Brescia, Italy
| | - Patrick Cherrin
- Department of Internal Medicine, Hospital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Laura Damian
- Department of Rheumatology, Emergency County Teaching Hospital, Cluj-Napoca, Romania
| | - Andrea Doria
- Rheumatology Unit, Department of Medicine, AO Padova and University of Padua, Padua, Italy
| | - João Eurico Fonseca
- Rheumatology Department, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, Lisbon Academic Medical Centre, Lisbon, Portugal
| | - Federica Furini
- Section of Rheumatology, Department of Medical Sciences, Sant’Anna University Hospital, Ferrara, Italy
| | - Ilaria Galetti
- FESCA, Federation of European Scleroderma Associations, Milan, Italy
| | - Frederic Houssiau
- Department of Rheumatology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Louvain-la-Neuve, Belgium
| | - Thomas Krieg
- Department of Dermatology, Universitätsklinikum Köln, Cologne, Germany
| | - Maddalena Larosa
- Rheumatology Unit, Department of Medicine, AO Padova and University of Padua, Padua, Italy
| | - David Launay
- Département de Médecine Interne et Immunologie Clinique, Centre de Référence des Maladies Systémiques et Auto-Immunes Rares du Nord-Ouest (CERAINO), Université de Lille, CHU Lille, LIRIC, INSERM, Lille, France
| | - Raquel Campanilho-Marques
- Rheumatology Department, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, Lisbon Academic Medical Centre, Lisbon, Portugal
| | - Thierry Martin
- Departement of Internal Medicine, Centre National de Référence des Maladies Systémiques et Auto-immunes Rares Grand-Est Sud-Ouest (RESO), Hôpitaux Universitaires de Strasbourg, France, Strasbourg, France
| | - Marco Matucci-Cerinic
- Department of Clinical and Experimental Medicine, Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, University of Florence, AOUC, Florence, Italy
| | - Pia Moinzadeh
- Department of Dermatology, Universitätsklinikum Köln, Cologne, Germany
| | | | - Maria Francisca Moraes-Fontes
- Unidade de Doenças Auto-imunes/Medicina 7.2, Hospital de Curry Cabral, Centro Hospitalar de Lisboa Central, Lisbon, Portugal
| | - Luc Mouthon
- Service de Médecine Interne, Centre de Référence Maladies systémiques Autoimmunes Rares d’Ile de France, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Cochin, Université Paris Descartes, Paris, France
| | | | - Sabrina Paolino
- Research Laboratory and Academic Division of Clinical Rheumatology, Department of Internal Medicine, IRCCS Polyclinic Hospital San Martino, University of Genoa, Genoa, Italy
| | - Yves Piette
- Department of Rheumatology, Department of Internal Medicine, Ghent University Hospital, Ghent University, Ghent, Belgium
| | - Simona Rednic
- Department of Rheumatology, Emergency County Teaching Hospital, Cluj-Napoca, Romania
| | - Farah Tamirou
- Department of Rheumatology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Louvain-la-Neuve, Belgium
| | - Angela Tincani
- Rheumatology and Clinical Immunology Unit, Civil Hospital, Brescia, Italy
| | - Natasa Toplak
- Department of Allergology, Rheumatology and Clinical Immunology, University Children's Hospital, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | | | - Eric Hachulla
- Département de Médecine Interne et Immunologie Clinique, Centre de Référence des Maladies Systémiques et Auto-Immunes Rares du Nord-Ouest (CERAINO), Université de Lille, CHU Lille, LIRIC, INSERM, Lille, France
| | - Ulf Mueller-Ladner
- Department of Rheumatology and Clinical Immunology, Kerckhoff Klinik, Justus-Liebig University of Giessen, Bad Nauheim, Germany
| | - Matthias Schneider
- Department of Rheumatology, Universitätsklinikum Düsseldorf, Düsseldorf, Germany
| | - Vanessa Smith
- Department of Rheumatology, Department of Internal Medicine, Ghent University Hospital, Ghent University, Ghent, Belgium
| | - Ana Vieira
- Liga Portuguesa Contra as Doenças Reumáticas, Núcleo Síndrome de Sjögren, Lisbon, Portugal
| | - Maurizio Cutolo
- Research Laboratory and Academic Division of Clinical Rheumatology, Department of Internal Medicine, IRCCS Polyclinic Hospital San Martino, University of Genoa, Genoa, Italy
| | - Marta Mosca
- Rheumatology Unit, AOU Pisana, Pisa, Italy
- Rheumatology Unit, University of Pisa, Pisa, Italy
| | - Lorenzo Cavagna
- Division of Rheumatology, University and IRCCS Policlinico S. Matteo Foundation, Pavia, Italy
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14
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Long-Term Follow-Up after Intravenous Immunoglobulin Therapy in Patients with Severe Ocular Mucous Membrane Pemphigoid Unresponsive to Conventional Therapy. J Ophthalmol 2018; 2018:8372146. [PMID: 30327726 PMCID: PMC6169236 DOI: 10.1155/2018/8372146] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Accepted: 08/12/2018] [Indexed: 12/12/2022] Open
Abstract
Mucous membrane pemphigoid (MMP) is a heterogeneous group of rare, systemic, autoimmune subepidermal inflammatory disease that affects mucous membranes and the eye. In its most severe forms, this disease needs systemic therapy, usually based on steroids and immunosuppressant agents. In unresponsive cases or in the presence of contraindications or severe side effects due to conventional systemic corticosteroid and/or immunosuppressant therapy, a therapy shift to high-dose intravenous immunoglobulins (IVIg) has been recommended in other reports. This new therapy has proven to be effective in stopping ocular pemphigoid, but the data regarding the long-term effect on the disease activity or reactivation are extremely scarce, so the novel scientific aim of this study was to evaluate the clinical outcomes after a 9-year follow-up in 12 eyes (6 patients) affected by MMP with ocular involvement, successfully treated with IVIg therapy, as previously described in our report published in 2008. The evaluation of ocular and extraocular disease progression was performed at the end of IVIg therapy and at the end of the follow-up period. After 9 years, all the eyes enrolled showed a long-lasting remission of ocular and oral symptoms with a significant steroid-sparing effect. In conclusion, the IVIg has to be considered as a safe and successful alternative therapy in patients with severe ocular mucous membrane pemphigoid; furthermore, this kind of therapy seems to be effective in maintaining the clinical remission by the time.
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15
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Forbat E, Ali FR, Al-Niaimi F. Intravenous immunoglobulins in dermatology. Part 2: clinical indications and outcomes. Clin Exp Dermatol 2018; 43:659-666. [PMID: 29774587 DOI: 10.1111/ced.13552] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/04/2017] [Indexed: 11/29/2022]
Abstract
Intravenous immunoglobulin (IVIg) is a solution of human IgG, salt, sugars and solvents used to treat a multitude of diseases. Although IVIg has been known to treat many diseases safely and successfully, there are relatively few supporting randomized controlled trials. In part two of this review, we assess the clinical indications of IVIg in dermatological disorders and the outcomes of its use.
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Affiliation(s)
- E Forbat
- Chelsea and Westminster Hospital, London, UK
| | - F R Ali
- Dermatological Surgery and Laser Unit, St John's Institute of Dermatology, Guy's Hospital Cancer Centre, Guy's and St Thomas' NHS Foundation Trust, Great Maze Pond, London, UK
| | - F Al-Niaimi
- Dermatological Surgery and Laser Unit, St John's Institute of Dermatology, Guy's Hospital Cancer Centre, Guy's and St Thomas' NHS Foundation Trust, Great Maze Pond, London, UK
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16
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Navarro-Triviño F, Pérez-López I, Ruíz-Villaverde R. Dermatology and Immunoglobulin Therapy: Who to Treat and How to Administer Immunoglobulins. ACTAS DERMO-SIFILIOGRAFICAS 2018. [DOI: 10.1016/j.adengl.2018.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
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17
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Retrospektive, monozentrische Analyse des Managements schwerer Arzneimittelreaktionen. ALLERGO JOURNAL 2018. [DOI: 10.1007/s15007-018-1555-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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18
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Navarro-Triviño FJ, Pérez-López I, Ruíz-Villaverde R. Dermatology and Immunoglobulin Therapy: Who to Treat and How to Administer Immunoglobulins. ACTAS DERMO-SIFILIOGRAFICAS 2018; 109:323-330. [PMID: 29429551 DOI: 10.1016/j.ad.2017.11.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2017] [Revised: 10/16/2017] [Accepted: 11/05/2017] [Indexed: 12/23/2022] Open
Abstract
Intravenous immunoglobulin (IVIG) replacement therapy has been used in immune deficiency diseases for more than 50 years. The indications for this treatment have evolved, however, and IVIG therapy is now used in various diseases in which the immune system plays a prominent role. IVIG therapy has carved out a niche in dermatology for the treatment of such conditions as dermatomyositis, autoimmune bullous diseases, and toxic epidermal necrolysis. Special attention has been paid to this therapy in recent years. New guidelines have been published and should be taken into consideration in dermatology. This review provides a practical guide to IVIG use in our specialty.
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Affiliation(s)
- F J Navarro-Triviño
- Unidad de Dermatología Médico-Quirúrgica y Venereología, Hospital Comarcal Santa Ana, Motril, España.
| | - I Pérez-López
- Unidad de Gestión Clínica de Dermatología y Venereología, Complejo Hospitalario Universitario de Granada, Granada, España
| | - R Ruíz-Villaverde
- Unidad de Gestión Clínica de Dermatología y Venereología, Complejo Hospitalario Universitario de Granada, Granada, España
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19
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Pollmann R, Schmidt T, Eming R, Hertl M. Pemphigus: a Comprehensive Review on Pathogenesis, Clinical Presentation and Novel Therapeutic Approaches. Clin Rev Allergy Immunol 2018; 54:1-25. [DOI: 10.1007/s12016-017-8662-z] [Citation(s) in RCA: 94] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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20
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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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21
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A nursing protocol for safe IVIG administration. Nursing 2017; 47:15-19. [PMID: 28746095 DOI: 10.1097/01.nurse.0000521046.11691.0f] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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22
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Hodkinson JP. Considerations for dosing immunoglobulin in obese patients. Clin Exp Immunol 2017; 188:353-362. [PMID: 28263379 PMCID: PMC5422718 DOI: 10.1111/cei.12955] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/01/2017] [Indexed: 12/17/2022] Open
Abstract
Obesity is a very common condition; however, the effect of excess body weight on the appropriate dose of immunoglobulin has not been defined empirically. The proposed pharmacokinetic differences between lean and obese patients and the opportunity to reduce costs has led to the proposition that obese patients should receive proportionally lower doses of immunoglobulin once a certain threshold is reached. Here the theoretical factors which could affect dosing in obese patients are considered alongside the available empirical evidence. The available evidence indicates that obesity may affect the pharmacokinetics of immunoglobulin; however, the effect is likely to be too small to have a clinically important effect on dosing. Wide interpatient individuality and highly variable clinical need mean that obesity should not play a major factor in dosing considerations. However, patients who are obese are more likely to have multiple cardiovascular risk factors and their weight indicates a large dose. This puts these patients at a higher risk of adverse reactions, and therefore caution is advised.
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Affiliation(s)
- J P Hodkinson
- Corporate Medical Affairs, Biotest AG, Dreieich, Germany
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23
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Bağcı IS, Horváth ON, Ruzicka T, Sárdy M. Bullous pemphigoid. Autoimmun Rev 2017; 16:445-455. [DOI: 10.1016/j.autrev.2017.03.010] [Citation(s) in RCA: 79] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Accepted: 01/31/2017] [Indexed: 11/27/2022]
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24
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Harris V, Jackson C, Cooper A. Review of Toxic Epidermal Necrolysis. Int J Mol Sci 2016; 17:ijms17122135. [PMID: 27999358 PMCID: PMC5187935 DOI: 10.3390/ijms17122135] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2016] [Revised: 12/09/2016] [Accepted: 12/12/2016] [Indexed: 12/13/2022] Open
Abstract
Toxic epidermal necrolysis (TEN) is a rare but life threatening mucocutaneous reaction to drugs or their metabolites. It is characterised by widespread keratinocyte apoptosis and sloughing of the skin, erosions of the mucous membranes, painful blistering, and severe systemic disturbance. The pathophysiology of TEN is incompletely understood. Historically, it has been regarded as a drug-induced immune reaction initiated by cytotoxic lymphocytes via a human leukocyte antigen (HLA)-restricted pathway. Several mediators have been identified as contributors to the cell death seen in TEN, including; granulysin, soluble Fas ligand, perforin/granzyme, tumour necrosis factor-α (TNF-α), and TNF-related apoptosis-inducing ligand. Currently, granulysin is accepted as the most important mediator of T cell proliferation. There is uncertainty around the accepted management of TEN. The lack of definitive management guidelines for TEN is explained in part by the rarity of the disease and its high mortality rate, which makes it difficult to conduct randomised control trials on emerging therapies. Developments have been made in pharmacogenomics, with numerous HLA alleles identified; however, these have largely been ethnically specific. These associations have translated into screening recommendations for Han Chinese.
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Affiliation(s)
- Victoria Harris
- Sydney Medical School-Northern, University of Sydney, 2065 Sydney, Australia.
| | - Christopher Jackson
- Sutton Arthritis Research Laboratory, Kolling Institute, University of Sydney, 2065 Sydney, Australia.
| | - Alan Cooper
- Dermatology Department, Royal North Shore Hospital, 2065 Sydney, Australia.
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