Interferon alpha sensitisation induced fatal renal insufficiency in a patient with chronic myeloid leukaemia: case report and review of literature

Immune checkpoint inhibitor-related pancreatitis: What is known and what is not

A 47-year-old man presented with a 1 week history of progressive fatigue and decreased appetite. He had stage IV oral squamous cell carcinoma and was treated with sintilimab, a programmed cell death protein 1 inhibitor, 22 months earlier. Laboratory work-up revealed significant elevation of bilirubin, liver enzymes, glucose, and lipase. Ultrasound examination and magnetic resonance cholangiopancreatography showed severe stenosis and occlusion of the pancreatic segment of the common bile duct, and PET/CT revealed swelling of the pancreas with diffuse increase in glucose metabolism. He was diagnosed with immune checkpoint inhibitor (ICI)-related pancreatitis and the treatment with sintilimab was permanently discontinued. He was administered systemic methylprednisolone at a dose of 2 mg/kg/day and subcutaneous insulin injection, without intravenous fluid or protease inhibitor. He improved quickly and received oral methylprednisolone for 10 months in gradually decreasing doses. He maintained well at 20 month follow-up. ICI-related pancreatitis is rare and varied. Further studies are needed to investigate the differences in the two types of ICI-related pancreatitis: acute pancreatitis and autoimmune pancreatitis-like cases.

Severe immune thrombocytopenia following diphtheria, tetanus, pertussis and polio vaccination in a 36-year-old Caucasian woman: a case report

Background

Immune thrombocytopenia (ITP) is a rare autoimmune disorder characterized by low platelet counts and increased bleeding risk. The disease may be induced by other disorders, including malignancies, autoimmune diseases, infectious agents or drugs. However, ITP has also been described following vaccinations, such as the measles–mumps–rubella vaccination. In rare cases, ITP may occur in children who received a DTaP-IP (diphtheria, tetanus, acellular pertussis vaccine and inactivated poliovirus) vaccine. Hereinafter, we report the first well-documented cases of ITP in an adult patient in the temporal context of a DTaP-IP vaccination.

Case presentation

This case report attempts to capture the life-threatening picture of a 36-year-old otherwise healthy Caucasian woman with newly diagnosed severe immune thrombocytopenia in the temporal context of a DTaP-IP vaccination. Four days after receiving the vaccine, the women presented to her primary care physician with malaise, fever and recurrent epistaxis. Clinical examination revealed oral petechiae, ecchymoses, and non-palpable petechiae on both legs. The patient was immediately referred to a local hematology unit where she developed hematuria and an intestinal bleeding (WHO Bleeding Grade III) requiring multiple transfusions. After receiving oral corticosteroids and intravenous immunoglobulins, her platelets gradually recovered. Common causes of secondary ITP were ruled out by laboratory investigations, bone marrow and peripheral blood examinations. This raises the possibility of a (secondary) vaccination-associated thrombocytopenia. To the best of our knowledge, this is the first well-documented case of a DTaP-IP vaccination-related ITP in an adult patient in the English literature.

Conclusion

Although a causal connection between both entities may not be established, we would like to raise awareness in clinicians that ITP following DTaP-IP vaccinations is potentially not limited to children, but may also occur in adults. Users of DTaP-IP booster vaccines should be alert of the possibility of such adverse reactions.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40001-022-00686-z.

Nephrotoxic Chemotherapy Agents: Old and New

In the last several decades, advancements in chemotherapy have improved the overall survival of cancer patients. These agents, however, are associated with adverse effects, including various kidney lesions. This review summarizes the nephrotoxic potential of chemotherapy agents, old and new, as well as the different factors that contribute to kidney injury. Provided for each class of chemotherapy agent is the associated kidney lesion and a brief discussion of clinical manifestation, mechanism of action, and possible treatment when available. Understanding the nephrotoxic potential of these agents have on the kidneys is imperative for both the oncologist and the nephrologist to properly care for cancer patients and ensure their best outcomes.

Discontinuation of Imatinib Mesylate could Improve Renal Impairment in Chronic Myeloid Leukemia

We aim to report a CML case that had fluid retention and serum creatinine increase under long-term imatinib mesylate (IM) treatment. A 68-year-old woman was diagnosed with chronic myeloid leukemia, and IM was started in 2002 with a dose of 400 mg/day. She had achieved complete hematological, molecular and cytogenetic remission under IM treatment. In September 2015, her creatinine level was 1.7 mg/dl. In May 2016, she was admitted to our hospital with dyspnea. Hypervolemia secondary to fluid retention was detected in our patient. Her laboratory tests results showed hemoglobin 9.7 gr/dl, white blood cell 7.6x103/μl, platelet 157x103/μl, creatinine 3.2 mg/dl, blood urea nitrogen (BUN) 88 mg/dl. In her X-ray chest film, bilateral pleural effusion was detected. The effusion was detected as transuda. The other reasons of pleural effusion were excluded and the development of pleural effusion was considered secondary to IM. IM was also considered responsible for the acute rise of serum creatinine levels of our patient. Therefore for these two reasons IM was stopped. After the discontinuation of IM, her creatinine levels decreased to 1.6 mg/dl and her pleural effusions disappeared. IM treatment was considered as the reason of serum creatinine elevation since serum creatinine levels decreased after the discontinuation of IM. All of the side-effects disappeared after discontinuation of IM.

Onco-nephrology: renal toxicities of chemotherapeutic agents

Despite dramatic improvements in patient survival and drug tolerability, nephrotoxicity remains an important complication of chemotherapy. Adverse renal effects occur because of innate drug toxicity and a number of patient- and drug-related factors. To provide cutting edge care for these patients, nephrologists and oncologists must be familiar with the nephrotoxicity of these drugs, particularly their associated clinical and laboratory manifestations. Rapid diagnosis, targeted treatment, and supportive care are critical to improving care for these patients. Unfortunately, some patients who develop nephrotoxicity will be left with long-term complications such as chronic tubulopathies and CKD. Onco-Nephrology is a new area that is rapidly expanding and requires a close working relationship between oncologists and nephrologists.

Nephrotoxicity from chemotherapeutic agents: clinical manifestations, pathobiology, and prevention/therapy

Nephrotoxicity remains a vexing complication of chemotherapeutic agents. A number of kidney lesions can result from these drugs, including primarily tubular-limited dysfunction, glomerular injury with proteinuria, full-blown acute kidney injury, and long-term chronic kidney injury. In most cases, these kidney lesions develop from innate toxicity of these medications, but underlying host risk factors and the renal handling of these drugs clearly increase the likelihood of nephrotoxicity. This article reviews some of the classic nephrotoxic chemotherapeutic agents and focuses on examples of the clinical and histopathologic kidney lesions they cause as well as measures that may prevent or treat drug-induced nephrotoxicity.

Recurrent imatinib-induced hepatotoxicity in a chronic myeloid leukaemia patient successfully managed with prednisone

Imatinib, the frontline tyrosine kinase inhibitor (TKI), has revolutionised the management of chronic myeloid leukaemia (CML). Severe hepatotoxicity, although uncommon, can occur with this drug. This tends to subside with dose reduction or cessation, but can recur with reintroduction of the drug. Recurrent severe hepatotoxicity mandates permanent discontinuation of imatinib. This can cause difficulties in the management of CML, more so if the patient cannot afford or get access to alternate therapy. Furthermore, alternate therapy, for example, second-line TKIs, can impose a huge economic burden on a healthcare system. Here, the authors report the case of 20-year-old CML patient who developed recurrent hepatotoxicity with the use of imatinib. Introduction of corticosteroids enabled successful reintroduction of imatinib therapy.

The role of cytokine in regulation of the natural killer cell activity

Natural killer (NK) cells are characterized by a CD3-CD16+ CD56+ immunophenotype and have a central role in the innate immune system. They are defined by their capacity to kill certain tumor-target cells or virus infected cells without prior sensitization or MHC-restriction. The activity of the NK cells is determined by the balance between activation and inhibitory receptor molecules expressed on the surface of NK cells. However, several cytokines and chemokines can significantly modulate their activity, inducing increase of NK cell activity. Immunomodulation mediated by NK cells is very important mechanism in tumor immunity, as well as in other immunodepressions of the immune system. In this study, we summarize the role of several cytokines, including IFN, IL-1, IL-2, IL-4, IL-7, IL-12 and IL-17, on NK cell function. The NK cells, after activation, depending on cytokine environment, can differentiate into NK1 cells that produce Th1 cytokine type (IFN-?, IL-2, IL-12) or NK2 cells that produce Th2 type cytokines, enhance exocytosis and release of previously formed molecules from NK cells (granzyme, perforin). We also describe that the release of cytokines and mediators show local or distance effects, or induce apoptosis (mostly by secreted TNF-?) after binding appropriated killer cell receptors from TNF receptor superfamily.

Immunomodulators: interleukins, interferons, and IV immunoglobulin

The outstanding progress in immunology and the development of new technologies have resulted in the introduction of new immunotherapies, the so-called “immunomodulators”, for autoimmune diseases, inflammatory disorders, allograft rejection, and cancer. These immunomodulators comprise recombinant cytokines and specific blocking or depleting antibodies. Many of these therapies achieve their effect by stimulating the release of cytokines. The term cytokines includes interleukins (IL-), chemokines, growth factors, interferons (IFN), colony stimulating factors (CSF), and tumor necrosis factors (TNF). These molecules are involved in inflammation, cell proliferation and apoptosis, tissue injury and repair.

These new therapeutic tools can be associated with side effects among which nephrotoxicity. The most common immunomodulators associated with nephrotoxicity are described in Table 1. The nephrotoxic side effects of immunomodulators can be roughly divided into (ischemic) tubular necrosis, thrombotic microangiopathy, serum sickness, and autoimmune disorders.