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Brazel D, Grant C, Cabal A, Chen WP, Pinter-Brown L. Baseline immunoglobulin G and immune function in non-Hodgkin lymphoma: a retrospective analysis. Front Immunol 2024; 15:1334899. [PMID: 38745669 PMCID: PMC11091275 DOI: 10.3389/fimmu.2024.1334899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Accepted: 04/02/2024] [Indexed: 05/16/2024] Open
Abstract
Introduction Non-Hodgkin's lymphoma (NHL) encompasses a diverse group of lymphoma subtypes with a wide range in disease course. Previous studies show that hypogammaglobulinemia in treatment-naïve patients is associated with poorer survival in high grade B-cell non-Hodgkin's lymphomas, though it is not known how this applies across all B-cell lymphoid malignancies. Methods We conducted a retrospective study of immunoglobulin levels and clinical outcomes including survival, hospitalization, and infection rates in patients diagnosed with B-cell non-Hodgkin lymphomas of all grades at our institution. Results Two-hundred twenty-three adults (aged = 18 years) with available pre-treatment IgG levels were selected, with hypogammaglobulinemia defined as IgG< 500 mg/mL. For this analysis, we grouped DLBCL (n=90), Primary CNS (n=5), and Burkitt lymphoma (n=1) together as high-grade, while CLL (n=52), mantle cell (n=20), marginal zone (n=25), follicular (n=21), and Waldenstrom macroglobulinemia (n=5) were low-grade. The incidence of hypogammaglobulinemia in our cohort of both high and low-grade lymphoma patients was 13.5% (n=30). Across all NHL subtypes, individuals with baseline IgG< 500 mg/dL showed an increased rate of hospitalization (4.453, CI: 1.955-10.54, p= 0.0005) and higher mortality (3.325, CI: 1.258, 8.491, p= 0.013), yet no association in number of infections when compared with those with IgG=500 mg/dL. There was a higher hospitalization rate (3.237, CI: 1.77-6.051, p=0.0017) in those with high-grade lymphoma with hypogammaglobulinemia when compared with low-grade. There was no statistically significant difference in individuals who were alive after three years in those with baseline IgG<500 mg/dL. Discussion Our study is the first to analyze incidence of hypogammaglobulinemia at the time of diagnosis of NHL as a potential biomarker of interest for future outcomes including hospitalization and infection.
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Affiliation(s)
- Danielle Brazel
- Department of Hematology/Oncology, Scripps Clinic/Scripps Green Hospital, La Jolla, CA, United States
| | - Christopher Grant
- Department of Medicine, University of California Irvine Medical Center, Orange, CA, United States
| | - Angelo Cabal
- Department of Biostatistics, University of California Irvine Medical School, Irvine, CA, United States
| | - Wen-Pin Chen
- Chao Family Comprehensive Cancer Center, University of California Irvine, Orange, CA, United States
| | - Lauren Pinter-Brown
- Department of Medicine, University of California Irvine Medical Center, Orange, CA, United States
- Chao Family Comprehensive Cancer Center, University of California Irvine, Orange, CA, United States
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Clemente D, Cuadros EN, Lovillo MC, Hernández JC, Martín SG, Silveira LF, Cruz MJL, Tagarro A, Rueda RMA, López López A, Aritziturri MS, Calvo C. Position statement on infection screening, prophylaxis, and vaccination of pediatric patients with rheumatic diseases and immunosuppressive therapies, part 3: precautions in situations of surgery, fever, and opportunistic infections. Eur J Pediatr 2024; 183:915-927. [PMID: 38047962 PMCID: PMC10912362 DOI: 10.1007/s00431-023-05295-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Revised: 10/16/2023] [Accepted: 10/17/2023] [Indexed: 12/05/2023]
Abstract
The objective of this study is to provide practical recommendations on the management of pediatric patients with immune-mediated rheumatic diseases receiving immunosuppressive therapies. The recommendations specifically address the cases of surgery, fever, and opportunistic infections (varicella, herpes-zoster, tuberculosis, invasive fungal disease). A qualitative approach was applied. A narrative literature review was performed via Medline. Primary searches were conducted using MeSH terms and free text to identify publications on infections and vaccinations in pediatric patients with immune-mediated rheumatic diseases receiving immunosuppressive therapies. The results were presented and discussed in a nominal group meeting, comprising a committee of 12 pediatric rheumatologists from the Infection Prevention and Treatment Working Group of the Spanish Society of Pediatric Rheumatology. Several recommendations were generated. A consensus procedure was implemented via a Delphi process; this was extended to members of the Spanish Society of Pediatric Rheumatology and Spanish Society of Pediatric Infectious Disease of the Spanish Association of Pediatrics. Participants produced a score ranging from 0 (totally disagree) to 10 (totally agree). Agreement was defined as a vote ≥ 7 by at least 70% of participants. The literature review included more than 400 articles. Overall, 63 recommendations (19 on surgery, fever, and opportunistic infections) were generated and voted by 59 pediatric rheumatologists and other pediatric specialists. Agreement was reached for all 63 recommendations. The recommendations on special situations cover management in cases of surgery, fever, and opportunistic infections (varicella, herpes-zoster, tuberculosis, and invasive fungal disease). Conclusions: Hereby, we provided consensus and updated of recommendations about the management of special situations such as surgery, fever, and opportunistic in children with immune-mediated rheumatic diseases receiving immunosuppressive therapies. Several of the recommendations depend largely on clinical judgement and specific balance between risk and benefit for each individual and situation. To assess this risk, the clinician should have knowledge of the drugs, the patient's previous situation as well as the current infectious disease, in addition to experience. What is Known: • Infectious diseases and related complications are a major cause of morbidity and mortality in patients with immune-mediated rheumatic diseases. • Information on how to manage the treatment in situations of fever, opportunistic infections, and surgery in children is limited, and guidelines for action are often extrapolated from adults. What is New: • In the absence of strong evidence, a literature review and a Delphi survey were conducted to establish a series of expert recommendations that could support the clinical practice, providing a practical and simple day-to-day approach to be used by pediatric rheumatologists.
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Affiliation(s)
- Daniel Clemente
- Pediatric Rheumatology Unit, Hospital Infantil Universitario Niño Jesús, Madrid, Spain
| | - Esmeralda Núñez Cuadros
- Pediatric Rheumatology Unit, UGC Pediatría, Hospital Regional Universitario de Málaga, Instituto de investigación biomédica de Málaga (IBIMA), Málaga, Spain
| | - Marisol Camacho Lovillo
- Servicio de Inmunología, Hospital Universitario Virgen del Rocío, Reumatología e Infectología pediátricas, Seville, Spain
| | - Joan Calzada Hernández
- Unitat de Reumatologia Pediàtrica, Servei de Pediatria, Hospital Sant Joan de Déu, Esplugues de Llobregat, Barcelona, Spain
| | - Sara Guillén Martín
- Department of Pediatrics, Hospital Universitario de Getafe, CIBERINFEC ISCIII, Carretera de Toledo Km 12, 500, 28905, Getafe, Madrid, Spain.
| | - Laura Fernández Silveira
- Servicio de Inmunología, Hospital Universitario Virgen del Rocío/Instituto de Biomedicina de Sevilla (IBIS), Reumatología e Infectología pediátricas, Seville, Spain
| | | | - Alfredo Tagarro
- Pediatrics Department. Hospital Universitario Infanta Sofía, Instituto de Investigación 12 de Octubre (imas12), Universidad Europea, Madrid, Spain
| | | | - Agustín López López
- Department of Paediatrics, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain
| | | | - Cristina Calvo
- Department of Pediatrics, Infectious and Tropical Diseases, Hospital Universitario La Paz, La Paz Research Institute (IdiPaz), Translational Research Network of Pediatric Infectious Diseases (RITIP), CIBERINFEC ISCIII, Madrid, Spain
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3
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Clemente Garulo D, Núñez-Cuadros E, Camacho Lovillo M, Calzada-Hernández J, Guillén Martín S, Fernández Silveira L, Lirola Cruz MJ, Tagarro A, Alcobendas Rueda RM, López López A, Satrustegi Aritziturri M, Calvo C. Position statement on infection screening, prophylaxis, and vaccination in pediatric patients with rheumatic diseases and immunosuppressive therapies, part 2: infection prophylaxis. Eur J Pediatr 2023; 182:4271-4284. [PMID: 37439850 PMCID: PMC10570166 DOI: 10.1007/s00431-023-05080-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Revised: 06/18/2023] [Accepted: 06/21/2023] [Indexed: 07/14/2023]
Abstract
This study aims to provide practical recommendations on prophylaxis for infection in pediatric patients with immune-mediated rheumatic diseases receiving/scheduled to receive immunosuppressive therapy. A qualitative approach was applied. A narrative literature review was performed via Medline. Primary searches were conducted using MeSH terms and free text to identify articles that analyzed data on infections and vaccinations in pediatric patients with immune-mediated rheumatic diseases receiving immunosuppressive therapy. The results were presented and discussed in a nominal group meeting comprising a committee of 12 pediatric rheumatologists from the Prevention and Treatment of Infections Working Group of the Spanish Society of Pediatric Rheumatology. Several recommendations were generated. A consensus procedure was implemented via a Delphi process that was extended to members of the Spanish Society of Pediatric Rheumatology and the Vaccine Advisory Committee of the Spanish Association of Pediatrics. Participants produced a score ranging from 0 (completely disagree) to 10 (completely agree). Agreement was considered to have been reached if at least 70% of participants voted ≥ 7. The literature review included more than 400 articles. Overall, 63 recommendations were generated (23 on infection prophylaxis) and voted by 59 pediatric rheumatologists and other pediatric specialists, all of whom achieved the pre-established level of agreement. The recommendations on prophylaxis of infection cover vaccination and prophylaxis against varicella zoster virus, tuberculosis, Pneumocystis jiroveccii, and invasive fungal infections in pediatric patients with immune-mediated rheumatic diseases receiving/scheduled to receive immunosuppressive therapy. Conclusion: Based on current evidence and a Delphi process, we provided consensus and updated recommendations on prophylaxis and treatment of infections to guide those caring for pediatric rheumatology patients. What is Known: •Data largely derived from adults find that infectious diseases and related complications are a major cause of morbidity and mortality in patients with immune-mediated rheumatic diseases. •It is crucial to be aware of the preventive measures that should be implemented to prevent these infections in children, although most guidelines are often extrapolated from adult cases. What is New: •In the absence of evidence, a literature review and a Delphi survey were conducted to establish a series of expert recommendations that could prove useful in clinical practice, providing a practical and simple day-to-day approach to be used by pediatric rheumatologists. •The recommendations focus on tuberculosis, herpes zoster virus, fungal infections, and Pneumocystis jirovecii.
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Affiliation(s)
| | - Esmeralda Núñez-Cuadros
- Pediatric Rheumatology Unit, UGC Pediatría, Hospital Regional Universitario de Málaga, Instituto de Investigación Biomédica de Málaga (IBIMA), Av. del Arroyo de los Ángeles, S/N, 29011, Málaga, Spain.
| | - Marisol Camacho Lovillo
- Servicio de Inmunología, Hospital Universitario Virgen del Rocío/Instituto de Biomedicina de Sevilla (IBIS), Reumatología E Infectología Pediátricas, Seville, Spain
| | - Joan Calzada-Hernández
- Unitat de Reumatologia Pediàtrica, Servei de Pediatria, Hospital Sant Joan de Déu, Esplugues de Llobregat, Barcelona, Spain
| | - Sara Guillén Martín
- Department of Paediatrics, Hospital Universitario de Getafe, Getafe, Madrid, Spain
| | - Laura Fernández Silveira
- Servicio de Inmunología, Hospital Universitario Virgen del Rocío/Instituto de Biomedicina de Sevilla (IBIS), Reumatología E Infectología Pediátricas, Seville, Spain
| | - María José Lirola Cruz
- Department of Paediatric Rheumatology, Instituto Hispalense de Pediatría, Seville, Spain
| | - Alfredo Tagarro
- Pediatrics Department, Instituto de Investigación 12 de Octubre (imas12), Hospital Universitario Infanta Sofía, Universidad Europea, Hospital 12 de Octubre, Madrid, Spain
| | | | - Agustín López López
- Department of Paediatrics, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain
| | | | - Cristina Calvo
- Department of Pediatrics, Infectious and Tropical Diseases, Hospital Universitario La Paz, and La Paz Research Institute (IdiPaz), Madrid, Spain
- Translational Research Network of Pediatric Infectious Diseases (RITIP). Madrid, Madrid, Spain
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Kyriakidis I, Mantadakis E, Stiakaki E, Groll AH, Tragiannidis A. Infectious Complications of Targeted Therapies in Children with Leukemias and Lymphomas. Cancers (Basel) 2022; 14:cancers14205022. [PMID: 36291806 PMCID: PMC9599435 DOI: 10.3390/cancers14205022] [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: 09/19/2022] [Revised: 10/09/2022] [Accepted: 10/12/2022] [Indexed: 11/30/2022] Open
Abstract
Simple Summary Targeted therapies in children with hematological malignancies moderate the effects of cytotoxic therapy, thus improving survival rates. They have emerged over the last decade and are used in combination with or after the failure of conventional chemotherapy and as bridging therapy prior to hematopoietic stem cell transplantation (HSCT). Nowadays, there is a growing interest in their efficacy and safety in pediatric patients with refractory or relapsed disease. The compromised immune system, even prior to therapy, requires prompt monitoring and treatment. In children with hematological malignancies, targeted therapies are associated with a comparable incidence of infectious complications to adults. The exact impact of these agents that have different mechanisms of action and are used after conventional chemotherapy or HSCT is difficult to ascertain. Clinicians should be cautious of severe infections after the use of targeted therapies, especially when used in combination with chemotherapy. Abstract The aim of this review is to highlight mechanisms of immunosuppression for each agent, along with pooled analyses of infectious complications from the available medical literature. Rituximab confers no increase in grade ≥3 infectious risks, except in the case of patients with advanced-stage non-Hodgkin lymphoma. Gemtuzumab ozogamicin links with high rates of grade ≥3 infections which, however, are comparable with historical cohorts. Pembrolizumab exhibits a favorable safety profile in terms of severe infections. Despite high rates of hypogammaglobulinemia (HGG) with blinatumomab, low-grade ≥3 infection rates were observed, especially in the post-reinduction therapy of relapsed B-acute lymphoblastic leukemia. Imatinib and nilotinib are generally devoid of severe infectious complications, but dasatinib may slightly increase the risk of opportunistic infections. Data on crizotinib and pan-Trk inhibitors entrectinib and larotrectinib are limited. CAR T-cell therapy with tisagenlecleucel is associated with grade ≥3 infections in children and is linked with HGG and the emergence of immune-related adverse events. Off-label therapies inotuzumab ozogamicin, brentuximab vedotin, and venetoclax demonstrate low rates of treatment-related grade ≥3 infections, while the addition of bortezomib to standard chemotherapy in T-cell malignancies seems to decrease the infection risk during induction. Prophylaxis, immune reconstitution, and vaccinations for each targeted agent are discussed, along with comparisons to adult studies.
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Affiliation(s)
- Ioannis Kyriakidis
- Department of Pediatric Hematology-Oncology & Autologous Hematopoietic Stem Cell Transplantation Unit, University Hospital of Heraklion & Laboratory of Blood Diseases and Childhood Cancer Biology, School of Medicine, University of Crete, 70013 Heraklion, Greece
| | - Elpis Mantadakis
- Department of Paediatrics, Paediatric Hematology/Oncology Unit, Faculty of Medicine, Democritus University of Thrace, 68100 Alexandroupolis, Greece
| | - Eftichia Stiakaki
- Department of Pediatric Hematology-Oncology & Autologous Hematopoietic Stem Cell Transplantation Unit, University Hospital of Heraklion & Laboratory of Blood Diseases and Childhood Cancer Biology, School of Medicine, University of Crete, 70013 Heraklion, Greece
| | - Andreas H. Groll
- Infectious Disease Research Program, Center for Bone Marrow Transplantation and Department of Pediatric Hematology and Oncology, University Children’s Hospital Münster, D-48149 Münster, Germany
| | - Athanasios Tragiannidis
- Pediatric and Adolescent Hematology-Oncology Unit, 2nd Department of Pediatrics, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, AHEPA Hospital, 54636 Thessaloniki, Greece
- Correspondence: ; Fax: +30-2310-994803
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Kyriakidis I, Vasileiou E, Rossig C, Roilides E, Groll AH, Tragiannidis A. Invasive Fungal Diseases in Children with Hematological Malignancies Treated with Therapies That Target Cell Surface Antigens: Monoclonal Antibodies, Immune Checkpoint Inhibitors and CAR T-Cell Therapies. J Fungi (Basel) 2021; 7:186. [PMID: 33807678 PMCID: PMC7999508 DOI: 10.3390/jof7030186] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 02/27/2021] [Accepted: 03/02/2021] [Indexed: 12/12/2022] Open
Abstract
Since 1985 when the first agent targeting antigens on the surface of lymphocytes was approved (muromonab-CD3), a multitude of such therapies have been used in children with hematologic malignancies. A detailed literature review until January 2021 was conducted regarding pediatric patient populations treated with agents that target CD2 (alefacept), CD3 (bispecific T-cell engager [BiTE] blinatumomab), CD19 (denintuzumab mafodotin, B43, BiTEs blinatumomab and DT2219ARL, the immunotoxin combotox, and chimeric antigen receptor [CAR] T-cell therapies tisagenlecleucel and axicabtagene ciloleucel), CD20 (rituximab and biosimilars, 90Y-ibritumomab tiuxetan, ofatumumab, and obinutuzumab), CD22 (epratuzumab, inotuzumab ozogamicin, moxetumomab pasudotox, BiTE DT2219ARL, and the immunotoxin combotox), CD25 (basiliximab and inolimomab), CD30 (brentuximab vedotin and iratumumab), CD33 (gemtuzumab ozogamicin), CD38 (daratumumab and isatuximab), CD52 (alemtuzumab), CD66b (90Y-labelled BW 250/183), CD248 (ontuxizumab) and immune checkpoint inhibitors against CTLA-4 (CD152; abatacept, ipilimumab and tremelimumab) or with PD-1/PD-L1 blockade (CD279/CD274; atezolizumab, avelumab, camrelizumab, durvalumab, nivolumab and pembrolizumab). The aim of this narrative review is to describe treatment-related invasive fungal diseases (IFDs) of each category of agents. IFDs are very common in patients under blinatumomab, inotuzumab ozogamicin, basiliximab, gemtuzumab ozogamicin, alemtuzumab, and tisagenlecleucel and uncommon in patients treated with moxetumomab pasudotox, brentuximab vedotin, abatacept, ipilimumab, pembrolizumab and avelumab. Although this new era of precision medicine shows promising outcomes of targeted therapies in children with leukemia or lymphoma, the results of this review stress the necessity for ongoing surveillance and suggest the need for antifungal prophylaxis in cases where IFDs are very common complications.
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Affiliation(s)
- Ioannis Kyriakidis
- Pediatric and Adolescent Hematology-Oncology Unit, 2nd Department of Pediatrics, Faculty of Health Sciences, School of Medicine, Aristotle University of Thessaloniki, AHEPA Hospital, 54636 Thessaloniki, Greece; (I.K.); (E.V.)
| | - Eleni Vasileiou
- Pediatric and Adolescent Hematology-Oncology Unit, 2nd Department of Pediatrics, Faculty of Health Sciences, School of Medicine, Aristotle University of Thessaloniki, AHEPA Hospital, 54636 Thessaloniki, Greece; (I.K.); (E.V.)
| | - Claudia Rossig
- Department of Pediatric Hematology and Oncology, University Children’s Hospital Münster, D-48149 Münster, Germany;
| | - Emmanuel Roilides
- Infectious Diseases Unit, Basic and Translational Research Unit, Special Unit for Biomedical Research and Education, 3rd Department of Pediatrics, Faculty of Health Sciences, School of Medicine, Aristotle University of Thessaloniki, Hippokration General Hospital, 54642 Thessaloniki, Greece;
| | - Andreas H. Groll
- Center for Bone Marrow Transplantation and Department of Pediatric Hematology and Oncology, Infectious Disease Research Program, University Children’s Hospital Münster, D-48149 Münster, Germany;
| | - Athanasios Tragiannidis
- Pediatric and Adolescent Hematology-Oncology Unit, 2nd Department of Pediatrics, Faculty of Health Sciences, School of Medicine, Aristotle University of Thessaloniki, AHEPA Hospital, 54636 Thessaloniki, Greece; (I.K.); (E.V.)
- Center for Bone Marrow Transplantation and Department of Pediatric Hematology and Oncology, Infectious Disease Research Program, University Children’s Hospital Münster, D-48149 Münster, Germany;
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Mantadakis E. Pneumocystis jirovecii Pneumonia in Children with Hematological Malignancies: Diagnosis and Approaches to Management. J Fungi (Basel) 2020; 6:jof6040331. [PMID: 33276699 PMCID: PMC7761543 DOI: 10.3390/jof6040331] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 12/01/2020] [Accepted: 12/01/2020] [Indexed: 12/21/2022] Open
Abstract
Pneumocystis jirovecii pneumonia (PJP) is an opportunistic infection that mostly affects children with suppressed cellular immunity. PJP was the most common cause of infectious death in children with acute lymphoblastic leukemia prior to the inclusion of cotrimoxazole prophylaxis as part of the standard medical care in the late 1980s. Children with acute leukemia, lymphomas, and those undergoing hematopoietic stem cell transplantation, especially allogeneic transplantation, are also at high risk of PJP. Persistent lymphopenia, graft versus host disease, poor immune reconstitution, and lengthy use of corticosteroids are significant risk factors for PJP. Active infection may be due to reactivation of latent infection or recent acquisition from environmental exposure. Intense hypoxemia and impaired diffusing capacity of the lungs are hallmarks of PJP, while computerized tomography of the lungs is the diagnostic technique of choice. Immunofluorescence testing with monoclonal antibodies followed by fluorescent microscopy and polymerase chain reaction testing of respiratory specimens have emerged as the best diagnostic methods. Measurement of (1-3)-β-D-glucan in the serum has a high negative predictive value in ruling out PJP. Oral cotrimoxazole is effective for prophylaxis, but in intolerant patients, intravenous and aerosolized pentamidine, dapsone, and atovaquone are effective alternatives. Ιntravenous cotrimoxazole is the treatment of choice, but PJP has a high mortality even with appropriate therapy.
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Affiliation(s)
- Elpis Mantadakis
- Department of Pediatrics, Hematology/Oncology Unit, University General Hospital of Alexandroupolis, Democritus University of Thrace, 68 100 Alexandroupolis, Thrace, Greece
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Infectious Complications of Biological and Small Molecule Targeted Immunomodulatory Therapies. Clin Microbiol Rev 2020; 33:33/3/e00035-19. [PMID: 32522746 DOI: 10.1128/cmr.00035-19] [Citation(s) in RCA: 63] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
The past 2 decades have seen a revolution in our approach to therapeutic immunosuppression. We have moved from relying on broadly active traditional medications, such as prednisolone or methotrexate, toward more specific agents that often target a single receptor, cytokine, or cell type, using monoclonal antibodies, fusion proteins, or targeted small molecules. This change has transformed the treatment of many conditions, including rheumatoid arthritis, cancers, asthma, and inflammatory bowel disease, but along with the benefits have come risks. Contrary to the hope that these more specific agents would have minimal and predictable infectious sequelae, infectious complications have emerged as a major stumbling block for many of these agents. Furthermore, the growing number and complexity of available biologic agents makes it difficult for clinicians to maintain current knowledge, and most review articles focus on a particular target disease or class of agent. In this article, we review the current state of knowledge about infectious complications of biologic and small molecule immunomodulatory agents, aiming to create a single resource relevant to a broad range of clinicians and researchers. For each of 19 classes of agent, we discuss the mechanism of action, the risk and types of infectious complications, and recommendations for prevention of infection.
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8
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Lora V, Graceffa D, De Felice C, Morrone A, Bonifati C. Treatment of severe psoriasis with ixekizumab in a liver transplant recipient with concomitant hepatitis B virus infection. Dermatol Ther 2019; 32:e12909. [PMID: 30964590 DOI: 10.1111/dth.12909] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Revised: 04/01/2019] [Accepted: 04/05/2019] [Indexed: 12/16/2022]
Abstract
Treatment of severe psoriasis (PsO) in organ transplant (OT) patients is difficult. In fact, systemic drugs used for PsO therapy can be detrimental to transplanted organs and/or can increase the risk of serious infections in subjects already taking antireject medicines. Current guidelines fail to give indications on how to manage PsO OT subjects. Moreover, only a few cases of patients with the above-cited characteristics treated with systemic therapies have been published so far. Here, we report our experience concerning a liver transplant patient successfully treated with ixekizumab for his psoriasis throughout 1 year.
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Affiliation(s)
- Viviana Lora
- Department of Clinical Dermatology, Centre for the Study and Treatment of Psoriasis, San Gallicano Dermatological Institute, IRCCS, Rome, Italy
| | - Dario Graceffa
- Department of Clinical Dermatology, Centre for the Study and Treatment of Psoriasis, San Gallicano Dermatological Institute, IRCCS, Rome, Italy
| | - Catia De Felice
- Department of Clinical Dermatology, Centre for the Study and Treatment of Psoriasis, San Gallicano Dermatological Institute, IRCCS, Rome, Italy
| | - Aldo Morrone
- Scientific Direction, San Gallicano Dermatological Institute, IRCCS, Rome, Italy
| | - Claudio Bonifati
- Department of Clinical Dermatology, Centre for the Study and Treatment of Psoriasis, San Gallicano Dermatological Institute, IRCCS, Rome, Italy
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Abstract
Fungal diseases became a major medical problem in the second half of the 20th century when advances in modern medicine together with the HIV epidemic resulted in large numbers of individuals with impaired immunity. Fungal diseases are difficult to manage because they tend to be chronic, hard to diagnose, and difficult to eradicate with antifungal drugs. This essay considers the future of medical mycology in the 21st century, extrapolating from current trends. In the near horizon, the prevalence of fungal diseases is likely to increase, as there will be more hosts with impaired immunity and drug resistance will inevitably increase after selection by antifungal drug use. We can expect progress in the development of new drugs, diagnostics, vaccines, and immunotherapies. In the far horizon, humanity may face new fungal diseases in association with climate change. Some current associations between chronic diseases and fungal infections could lead to the establishment of fungi as causative agents, which will greatly enhance their medical importance. All trends suggest that the importance of fungal diseases will increase in the 21st century, and enhanced human preparedness for this scourge will require more research investment in this group of infectious diseases.
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Affiliation(s)
- Arturo Casadevall
- Department of Molecular Microbiology and Immunology, The Johns Hopkins School of Public Health, Baltimore, Maryland
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10
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Lionakis MS, Levitz SM. Host Control of Fungal Infections: Lessons from Basic Studies and Human Cohorts. Annu Rev Immunol 2017; 36:157-191. [PMID: 29237128 DOI: 10.1146/annurev-immunol-042617-053318] [Citation(s) in RCA: 133] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
In the last few decades, the AIDS pandemic and the significant advances in the medical management of individuals with neoplastic and inflammatory conditions have resulted in a dramatic increase in the population of immunosuppressed patients with opportunistic, life-threatening fungal infections. The parallel development of clinically relevant mouse models of fungal disease and the discovery and characterization of several inborn errors of immune-related genes that underlie inherited human susceptibility to opportunistic mycoses have significantly expanded our understanding of the innate and adaptive immune mechanisms that protect against ubiquitous fungal exposures. This review synthesizes immunological knowledge derived from basic mouse studies and from human cohorts and provides an overview of mammalian antifungal host defenses that show promise for informing therapeutic and vaccination strategies for vulnerable patients.
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Affiliation(s)
- Michail S Lionakis
- Fungal Pathogenesis Section, Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland 20892;
| | - Stuart M Levitz
- Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts 01655;
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