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Li X, Paccoud O, Chan KH, Yuen KY, Manchon R, Lanternier F, Slavin MA, van de Veerdonk FL, Bicanic T, Lortholary O. Cryptococcosis Associated With Biologic Therapy: A Narrative Review. Open Forum Infect Dis 2024; 11:ofae316. [PMID: 38947739 PMCID: PMC11212009 DOI: 10.1093/ofid/ofae316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Accepted: 06/17/2024] [Indexed: 07/02/2024] Open
Abstract
Cryptococcus is an opportunistic fungal pathogen that can cause disseminated infection with predominant central nervous system involvement in patients with compromised immunity. Biologics are increasingly used in the treatment of neoplasms and autoimmune/inflammatory conditions and the prevention of transplant rejection, which may affect human defense mechanisms against cryptococcosis. In this review, we comprehensively investigate the association between cryptococcosis and various biologics, highlighting their risks of infection, clinical manifestations, and clinical outcomes. Clinicians should remain vigilant for the risk of cryptococcosis in patients receiving biologics that affect the Th1/macrophage activation pathways, such as tumor necrosis factor α antagonists, Bruton tyrosine kinase inhibitors, fingolimod, JAK/STAT inhibitors (Janus kinase/signal transducer and activator of transcription), and monoclonal antibody against CD52. Other risk factors-such as age, underlying condition, and concurrent immunosuppressants, especially corticosteroids-should also be taken into account during risk stratification.
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Affiliation(s)
- Xin Li
- Department of Infectious Diseases and Tropical Medicine, Université Paris Cité, Necker-Enfants Malades University Hospital, Assistance Publique–Hôpitaux de Paris, IHU Imagine, Paris, France
- Department of Microbiology, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Pokfulam, Hong Kong SAR, China
| | - Olivier Paccoud
- Department of Infectious Diseases and Tropical Medicine, Université Paris Cité, Necker-Enfants Malades University Hospital, Assistance Publique–Hôpitaux de Paris, IHU Imagine, Paris, France
| | - Koon-Ho Chan
- Department of Medicine, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Pokfulam, Hong Kong SAR, China
| | - Kwok-Yung Yuen
- Department of Microbiology, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Pokfulam, Hong Kong SAR, China
| | - Romain Manchon
- Department of Infectious Diseases and Tropical Medicine, Université Paris Cité, Necker-Enfants Malades University Hospital, Assistance Publique–Hôpitaux de Paris, IHU Imagine, Paris, France
| | - Fanny Lanternier
- Department of Infectious Diseases and Tropical Medicine, Université Paris Cité, Necker-Enfants Malades University Hospital, Assistance Publique–Hôpitaux de Paris, IHU Imagine, Paris, France
- Institut Pasteur, National Reference Center for Invasive Mycoses and Antifungals, Mycology Translational Research Group, Mycology Department, Université Paris Cité, Paris, France
| | - Monica A Slavin
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Australia
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Australia
- Victorian Infectious Diseases Service, Royal Melbourne Hospital, Melbourne, Australia
| | - Frank L van de Veerdonk
- Department of Internal Medicine, Radboud Center for Infectious Diseases, Radboudumc, Nijmegen, the Netherlands
| | - Tihana Bicanic
- Institute of Infection and Immunity, St George's University of London, London, UK
| | - Olivier Lortholary
- Department of Infectious Diseases and Tropical Medicine, Université Paris Cité, Necker-Enfants Malades University Hospital, Assistance Publique–Hôpitaux de Paris, IHU Imagine, Paris, France
- Institut Pasteur, National Reference Center for Invasive Mycoses and Antifungals, Mycology Translational Research Group, Mycology Department, Université Paris Cité, Paris, France
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Nasir M, Galea I, Neligan A, Chung K. Cryptococcal meningoencephalitis in multiple sclerosis treated with fingolimod. Pract Neurol 2023; 23:512-515. [PMID: 37802650 DOI: 10.1136/pn-2023-003691] [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] [Accepted: 06/27/2023] [Indexed: 10/08/2023]
Abstract
A 21-year-old woman with multiple sclerosis (taking regular fingolimod) developed sudden-onset severe headache with nausea and malaise. Neurological examination was normal and she was afebrile. Blood results showed lymphocytes 0.53 x 109/L and C reactive protein 19 mg/L. CT scan of head and venogram were normal. CSF showed an opening pressure of 33 cm H2O and an incidental light growth of Cryptococcus neoformans, confirmed with positive India Ink stain and a positive cryptococcal antigen (1:100). She was treated for cryptococcal meningoencephalitis with amphotericin and flucytosine. Her presenting symptoms had closely mimicked subarachnoid haemorrhage. This atypical presentation of cryptococcal CNS infection highlights the need for vigilance in immunosuppressed patients.
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Affiliation(s)
- Moneeb Nasir
- The Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Ian Galea
- Wessex Neurological Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK
- Clinical Neurosciences, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Aidan Neligan
- Neurology department, Homerton University Hospital NHS Foundation Trust, London, UK
- UCL Queen Square Institute of Neurology, London, UK
| | - Karen Chung
- Neurology department, Homerton University Hospital NHS Foundation Trust, London, UK
- National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Foundation Trust, London, UK
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Silva BA, Carnero Contentti E, Becker J, Carranza JI, Correa-Díaz PE, Galleguillos Goiry L, Garcea O, Gracia F, Hamuy F, Macías MA, Navas C, Nuñez S, Rojas JI, Farez MF, Alonso R, López P. Latin American consensus recommendations on the risk of infections in people with multiple sclerosis treated with disease modifying drugs. Mult Scler Relat Disord 2023; 77:104840. [PMID: 37399673 DOI: 10.1016/j.msard.2023.104840] [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: 01/08/2023] [Revised: 05/14/2023] [Accepted: 06/16/2023] [Indexed: 07/05/2023]
Abstract
INTRODUCTION The emergence of several therapeutic options in multiple sclerosis (MS), which significantly modify the immune system functioning, has led to the need for the consideration of additional factors, such as risk of infections, in the decision-making process. The aim of these consensus recommendations was to discuss and perform a practical guide to Latin American neurologists on the risk of infections at diagnosis, follow-up and prior to initiation of DMDs. METHODS A panel of Latin American neurologists, experts in demyelinating diseases and dedicated to management and care of MS patients, gathered during 2021 and 2022 to make consensus recommendations on the risk of infections in PwMS treated with DMDs in Latin America. The RAND/UCLA methodology was developed to synthesize the scientific evidence and expert opinions on health care topics and was used for reaching a formal agreement. RESULTS Recommendations were established based on relevant published evidence and expert opinion, focusing on: 1- baseline infection disease and vaccination status; 2- opportunistic infections; 3- progressive multifocal leukoencephalopathy; 4- genitourinary system infections; 5- respiratory tract infections; 6- digestive system infections, 7-others local infections and 8- COVID-19. CONCLUSION The recommendations of this consensus seek to optimize the care, management and treatment of PwMS in Latin America. The standardized evidence-based care of pwMS infections will allow better outcomes.
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Affiliation(s)
- Berenice A Silva
- Centro Universitario de Esclerosis Múltiple (CUEM), Hospital JM Ramos Mejía, Buenos Aires, Argentina; Sección Enfermedades Desmielinizantes, Hospital Italiano de Buenos Aires, Argentina.
| | - Edgar Carnero Contentti
- Unidad de Neuroinmunología, Departamento de Neurociencias, Hospital Alemán de Buenos Aires, Argentina
| | - Jefferson Becker
- Hospital São Lucas - Pontifícia Universidade Católica do Rio Grande do Sul, Brazil
| | - José I Carranza
- Sección Zoopatología y Parasitología Médica, Hospital Muñiz, Buenos Aires, Argentina
| | | | | | - Orlando Garcea
- Centro Universitario de Esclerosis Múltiple (CUEM), Hospital JM Ramos Mejía, Buenos Aires, Argentina
| | | | - Fernando Hamuy
- Departamento de Neurología, Hospital IMT, Paraguay; Departamento de Neurología de Diagnostico, Codas Thompson, Paraguay
| | | | - Carlos Navas
- Clínica Enfermedad Desmielinizantes, Clinica Universitaria Colombia, Colombia
| | - Sebastián Nuñez
- Servicio de Infectología, Sanatorio Güemes, Buenos Aires, Argentina
| | - Juan I Rojas
- Service of Neurology, Hospital Universitario CEMIC, Buenos Aires, Argentina; Centro de Esclerosis Múltiple de Buenos Aires (CEMBA), Buenos Aires, Argentina
| | | | - Ricardo Alonso
- Centro Universitario de Esclerosis Múltiple (CUEM), Hospital JM Ramos Mejía, Buenos Aires, Argentina; Servicio de Neurología, Sanatorio Güemes, Buenos Aires, Argentina
| | - Pablo López
- Unidad de Neuroinmunología, Departamento de Neurociencias, Hospital Alemán de Buenos Aires, Argentina
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Chey SY, O’Sullivan NA, Beer T, Leong WK, Kermode AG. Cutaneous presentation of cryptococcal infection with subclinical central nervous system involvement secondary to fingolimod therapy. Mult Scler J Exp Transl Clin 2023; 9:20552173231197132. [PMID: 37674981 PMCID: PMC10478555 DOI: 10.1177/20552173231197132] [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: 05/29/2023] [Accepted: 08/08/2023] [Indexed: 09/08/2023] Open
Abstract
Fingolimod is a multiple sclerosis disease-modifying therapy which sequestrates lymphocytes in the lymph nodes, thereby reducing peripheral blood lymphocytes. Cryptococcal infection is an important adverse effect which should be recognised. We report a case of cutaneous and central nervous system infection who presented with isolated cutaneous symptoms in the absence of neurological or systemic manifestations.
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Affiliation(s)
- Shin Yee Chey
- Department of Neurology, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
- Perron Institute for Neurological and Translational Sciences, QE II Medical Centre, Perth, Australia
| | | | - Trevor Beer
- Clinipath Pathology, Osborne Park, Australia
| | - Wai K Leong
- Department of Neurology, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Allan G Kermode
- Perron Institute for Neurological and Translational Sciences, QE II Medical Centre, Perth, Australia
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Varghese JA, Guhan S, Zheng L. Emerging Fungal Infections and Cutaneous Manifestations in Immunosuppressed Patients. CURRENT DERMATOLOGY REPORTS 2023. [DOI: 10.1007/s13671-023-00386-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/08/2023]
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Zhao Y, Ye L, Zhao F, Zhang L, Lu Z, Chu T, Wang S, Liu Z, Sun Y, Chen M, Liao G, Ding C, Xu Y, Liao W, Wang L. Cryptococcus neoformans, a global threat to human health. Infect Dis Poverty 2023; 12:20. [PMID: 36932414 PMCID: PMC10020775 DOI: 10.1186/s40249-023-01073-4] [Citation(s) in RCA: 42] [Impact Index Per Article: 42.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 02/27/2023] [Indexed: 03/18/2023] Open
Abstract
BACKGROUND Emerging fungal pathogens pose important threats to global public health. The World Health Organization has responded to the rising threat of traditionally neglected fungal infections by developing a Fungal Priority Pathogens List (FPPL). Taking the highest-ranked fungal pathogen in the FPPL, Cryptococcus neoformans, as a paradigm, we review progress made over the past two decades on its global burden, its clinical manifestation and management of cryptococcal infection, and its antifungal resistance. The purpose of this review is to drive research efforts to improve future diagnoses, therapies, and interventions associated with fungal infections. METHODS We first reviewed trends in the global burden of HIV-associated cryptococcal infection, mainly based on a series of systematic studies. We next conducted scoping reviews in accordance with the guidelines described in the Preferred Reporting Items for Systematic Reviews and Meta-analyses extension for Scoping Reviews using PubMed and ScienceDirect with the keyword Cryptococcus neoformans to identify case reports of cryptococcal infections published since 2000. We then reviewed recent updates on the diagnosis and antifungal treatment of cryptococcal infections. Finally, we summarized knowledge regarding the resistance and tolerance of C. neoformans to approved antifungal drugs. RESULTS There has been a general reduction in the estimated global burden of HIV-associated cryptococcal meningitis since 2009, probably due to improvements in highly active antiretroviral therapies. However, cryptococcal meningitis still accounts for 19% of AIDS-related deaths annually. The incidences of CM in Europe and North America and the Latin America region have increased by approximately two-fold since 2009, while other regions showed either reduced or stable numbers of cases. Unfortunately, diagnostic and treatment options for cryptococcal infections are limited, and emerging antifungal resistance exacerbates the public health burden. CONCLUSION The rising threat of C. neoformans is compounded by accumulating evidence for its ability to infect immunocompetent individuals and the emergence of antifungal-resistant variants. Emphasis should be placed on further understanding the mechanisms of pathogenicity and of antifungal resistance and tolerance. The development of novel management strategies through the identification of new drug targets and the discovery and optimization of new and existing diagnostics and therapeutics are key to reducing the health burden.
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Affiliation(s)
- Youbao Zhao
- College of Veterinary Medicine, Henan Agricultural University, Zhengzhou, 450046, Henan, China.
| | - Leixin Ye
- State Key Laboratory of Mycology, Institute of Microbiology, Chinese Academy of Sciences, Beijing, 100101, China
- University of Chinese Academy of Sciences, Beijing, 100039, China
| | - Fujie Zhao
- College of Veterinary Medicine, Henan Agricultural University, Zhengzhou, 450046, Henan, China
| | - Lanyue Zhang
- State Key Laboratory of Mycology, Institute of Microbiology, Chinese Academy of Sciences, Beijing, 100101, China
- University of Chinese Academy of Sciences, Beijing, 100039, China
| | - Zhenguo Lu
- College of Veterinary Medicine, Henan Agricultural University, Zhengzhou, 450046, Henan, China
| | - Tianxin Chu
- College of Veterinary Medicine, Henan Agricultural University, Zhengzhou, 450046, Henan, China
| | - Siyu Wang
- College of Veterinary Medicine, Henan Agricultural University, Zhengzhou, 450046, Henan, China
| | - Zhanxiang Liu
- College of Veterinary Medicine, Henan Agricultural University, Zhengzhou, 450046, Henan, China
| | - Yukai Sun
- College of Veterinary Medicine, Henan Agricultural University, Zhengzhou, 450046, Henan, China
| | - Min Chen
- Department of Dermatology, Shanghai Key Laboratory of Molecular Medical Mycology, Changzheng Hospital, Shanghai, 200003, China
| | - Guojian Liao
- The Medical Research Institute, College of Pharmaceutical Sciences, Southwest University, Chongqing, 400715, China
| | - Chen Ding
- College of Life and Health Sciences, Northeastern University, Shenyang, 110819, Liaoning, China
| | - Yingchun Xu
- Department of Laboratory Medicine, and Beijing Key Laboratory for Mechanisms Research and Precision Diagnosis of Invasive Fungal Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Wanqing Liao
- Department of Dermatology, Shanghai Key Laboratory of Molecular Medical Mycology, Changzheng Hospital, Shanghai, 200003, China
| | - Linqi Wang
- State Key Laboratory of Mycology, Institute of Microbiology, Chinese Academy of Sciences, Beijing, 100101, China.
- University of Chinese Academy of Sciences, Beijing, 100039, China.
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7
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Constantinescu V, Akgün K, Ziemssen T. Current status and new developments in sphingosine-1-phosphate receptor antagonism: fingolimod and more. Expert Opin Drug Metab Toxicol 2022; 18:675-693. [PMID: 36260948 DOI: 10.1080/17425255.2022.2138330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Fingolimod was the first oral disease-modifying treatment approved for relapsing-remitting multiple sclerosis (MS) that serves as a sphingosine-1-phosphate receptor (S1PR) agonist. The efficacy is primarily mediated by S1PR subtype 1 activation, leading to agonist-induced down-modulation of receptor expression and further functional antagonism, blocking the egression of auto-aggressive lymphocytes from the lymph nodes in the peripheral compartment. The role of S1P signaling in the regulation of other pathways in human organisms through different S1PR subtypes has received much attention due to its immune-modulatory function and its significance for the regeneration of the central nervous system (CNS). The more selective second-generation S1PR modulators have improved safety and tolerability profiles. AREAS COVERED This review has been carried out based on current data on S1PR modulators, emphasizing the benefits of recent advances in this emergent class of immunomodulatory treatment for MS. EXPERT OPINION Ongoing clinical research suggests that S1PR modulators represent an alternative to first-line therapies in selected cases of MS. A better understanding of the relevance of selective S1PR pathways and the ambition to optimize selective modulation has improved the safety and tolerability of S1PR modulators in MS therapy and opened new perspectives for the treatment of other diseases.
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Affiliation(s)
- Victor Constantinescu
- Center of Clinical Neuroscience, University Hospital, Fetscher Str. 74, 01307 Dresden, Germany
| | - Katja Akgün
- Center of Clinical Neuroscience, University Hospital, Fetscher Str. 74, 01307 Dresden, Germany
| | - Tjalf Ziemssen
- Center of Clinical Neuroscience, University Hospital, Fetscher Str. 74, 01307 Dresden, Germany
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Carpenter K, Etemady-Deylamy A, Costello V, Khasawneh M, Chamberland R, Tian K, Donlin M, Moreira-Walsh B, Reisenbichler E, Abate G. Cryptococcal chest wall mass and rib osteomyelitis associated with the use of fingolimod: A case report and literature review. Front Med (Lausanne) 2022; 9:942751. [PMID: 36160166 PMCID: PMC9491343 DOI: 10.3389/fmed.2022.942751] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Accepted: 08/08/2022] [Indexed: 11/18/2022] Open
Abstract
Being introduced in 2010, fingolimod was among the first oral therapies for relapsing multiple sclerosis (MS). Since that time, postmarketing surveillance has noted several case reports of various cryptococcal infections associated with fingolimod use. To date, approximately 15 such case reports have been published. We present the first and unique case of cryptococcal chest wall mass and rib osteomyelitis associated with fingolimod use. The patient presented with left-side chest pain and was found to have a lower left chest wall mass. Computerized tomography (CT) showed chest wall mass with the destruction of left 7th rib. Aspirate from the mass grew Cryptococcus neoformans. The isolate was serotype A. Fingolimod was stopped. The patient received liposomal amphotericin B for 2 weeks and started on fluconazole with a plan to continue for 6–12 months. The follow-up CT in 6 weeks showed a marked decrease in the size of the chest wall mass. In conclusion, our case highlights the atypical and aggressive form of cryptococcal infection possibly related to immunosuppression from fingolimod use.
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Affiliation(s)
- Kent Carpenter
- Department of Internal Medicine, Saint Louis University, Saint Louis, MO, United States
| | - Ali Etemady-Deylamy
- Department of Internal Medicine, Saint Louis University, Saint Louis, MO, United States
| | - Victoria Costello
- Department of Internal Medicine, Saint Louis University, Saint Louis, MO, United States
| | - Mohammad Khasawneh
- Department of Internal Medicine, Saint Louis University, Saint Louis, MO, United States
| | - Robin Chamberland
- SSM Saint Louis Network Microbiology, Saint Louis, MO, United States
- Department of Pathology, Saint Louis University, Saint Louis, MO, United States
| | - Katherine Tian
- Department of Internal Medicine, Saint Louis University, Saint Louis, MO, United States
| | - Maureen Donlin
- Department of Molecular Microbiology and Immunology, Saint Louis University, Saint Louis, MO, United States
| | - Brenda Moreira-Walsh
- Department of Molecular Microbiology and Immunology, Saint Louis University, Saint Louis, MO, United States
| | - Emily Reisenbichler
- Department of Pathology, Saint Louis University, Saint Louis, MO, United States
| | - Getahun Abate
- Department of Internal Medicine, Saint Louis University, Saint Louis, MO, United States
- *Correspondence: Getahun Abate
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Darazam IA, Rabiei MM, Moradi O, Gharehbagh FJ, Roozbeh M, Nourinia R, Hatami F, Shojaei M, Lotfollahi L. A Case of Fingolimod-associated Cryptococcal Meningitis. Curr HIV Res 2022; 20:337-342. [PMID: 35770404 DOI: 10.2174/1570162x20666220629124225] [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: 01/20/2022] [Revised: 04/10/2022] [Accepted: 05/05/2022] [Indexed: 01/27/2023]
Abstract
BACKGROUND Leukopenia, a rare adverse effect of Fingolimod therapy, paves the way for opportunistic infections. In this study, we reported rare fingolimod associated cryptococcal meningitis. CASE PRESENTATION A 39-year-old woman with RRMS was referred to the emergency department. The patient's major complaints were headache, fever, weakness, and progressive loss of consciousness within the last two days prior to the referral. The patient had a history of hospitalization due to RRMS [two times]. In the second hospitalization, interferon Beta-1a was replaced with Fingolimod. Using polymerase chain reaction, Cryptococcus neoformans was detected in CSF. Liposomal amphotericin B and fluconazole [800 mg per day] were started. Six weeks later, the patient was discharged without any major complaints. CONCLUSION Albeit fingolimod associated cryptococcal meningitis is a rare event, Fingolimod therapy in patients with MS should be performed cautiously. Regular follow-ups may give rise to a timely diagnosis of probable fingolimod associated cryptococcal meningitis. Fingolimod therapy can lead to lymphocytopenia and various infections. We, therefore, suggest that intermittent blood lymphocyte counts as well as monitoring of clinical manifestations among MS patients treated with Fingolimod to avoid additional neurological and physical disabilities in these patients.
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Affiliation(s)
- Ilad Alavi Darazam
- Infectious Diseases and Tropical Medicine Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran.,Department of Infectious Diseases and Tropical Medicine, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohammad Mahdi Rabiei
- Infectious Diseases and Tropical Medicine Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran.,Department of Infectious Diseases and Tropical Medicine, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Omid Moradi
- Department of Clinical Pharmacy, School of Pharmacy, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Farid Javandoust Gharehbagh
- Infectious Diseases and Tropical Medicine Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran.,Department of Infectious Diseases and Tropical Medicine, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mehrdad Roozbeh
- Brain Mapping Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Ramin Nourinia
- Ophthalmic Research Center, Shahid Beheshti University of Medical Science, Tehran, Iran
| | - Firouze Hatami
- Infectious Diseases and Tropical Medicine Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran.,Department of Infectious Diseases and Tropical Medicine, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Maziar Shojaei
- Department of Neurology, Loghman Hakim Hospital, Kamali, Iran
| | - Legha Lotfollahi
- Department of Nephrology, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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A comprehensive review of varicella-zoster virus, herpes simplex virus and cryptococcal infections associated with sphingosine-1-phosphate receptor modulators in multiple sclerosis patients. Mult Scler Relat Disord 2022; 59:103675. [DOI: 10.1016/j.msard.2022.103675] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 01/22/2022] [Accepted: 02/06/2022] [Indexed: 12/30/2022]
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11
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Long-term real-world effectiveness and safety of fingolimod over 5 years in Germany. J Neurol 2022; 269:3276-3285. [PMID: 34982201 PMCID: PMC9120082 DOI: 10.1007/s00415-021-10931-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 12/02/2021] [Accepted: 12/03/2021] [Indexed: 11/03/2022]
Abstract
Objective To evaluate the 5-year real-world benefit–risk profile of fingolimod in patients with relapsing–remitting MS (RRMS) in Germany. Methods Post-Authorization Non-interventional German sAfety study of GilEnyA (PANGAEA) is a non-interventional real-world study to prospectively assess the effectiveness and safety of fingolimod in routine clinical practice in Germany. The follow-up period comprised 5 years. Patients were included if they had been diagnosed with RRMS and had been prescribed fingolimod as part of clinical routine. There were no exclusion criteria except the contraindications for fingolimod as defined in the European label. The effectiveness and safety analysis set comprised 4032 and 4067 RRMS patients, respectively. Results At the time of the 5-year follow-up of PANGAEA, 66.57% of patients still continued fingolimod therapy. Annualized relapse rates decreased from baseline 1.5 ± 1.15 to 0.42 ± 0.734 at year 1 and 0.21 ± 0.483 at year 5, and the disability status remained stable, as demonstrated by the Expanded Disability Status Scale mean change from baseline (0.1 ± 2.51), the decrease of the Multiple Sclerosis Severity Score from 5.1 ± 2.59 at baseline to 3.9 ± 2.31 at the 60-months follow-up, and the percentage of patients with ‘no change’ in the Clinical Global Impression scale at the 60-months follow-up (78.11%). Adverse events (AE) occurring in 75.04% of patients were in line with the known safety profile of fingolimod and were mostly non-serious AE (33.62%) and non-serious adverse drug reactions (50.59%; serious AE 4.98%; serious ADR 10.82%). Conclusions PANGAEA demonstrated the sustained beneficial effectiveness and safety of fingolimod in the long-term real-world treatment of patients with RRMS. Supplementary Information The online version contains supplementary material available at 10.1007/s00415-021-10931-w.
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12
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Gressler AE, Volke D, Firacative C, Schnabel CL, Müller U, Krizsan A, Schulze-Richter B, Brock M, Brombacher F, Escandón P, Hoffmann R, Alber G. Identification of Disease-Associated Cryptococcal Proteins Reactive With Serum IgG From Cryptococcal Meningitis Patients. Front Immunol 2021; 12:709695. [PMID: 34367172 PMCID: PMC8342929 DOI: 10.3389/fimmu.2021.709695] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Accepted: 06/21/2021] [Indexed: 01/16/2023] Open
Abstract
Cryptococcus neoformans, an opportunistic fungal pathogen ubiquitously present in the environment, causes cryptococcal meningitis (CM) mainly in immunocompromised patients, such as AIDS patients. We aimed to identify disease-associated cryptococcal protein antigens targeted by the human humoral immune response. Therefore, we used sera from Colombian CM patients, with or without HIV infection, and from healthy individuals living in the same region. Serological analysis revealed increased titers of anti-cryptococcal IgG in HIV-negative CM patients, but not HIV-positive CM patients, compared to healthy controls. In contrast, titers of anti-cryptococcal IgM were not affected by CM. Furthermore, we detected pre-existing IgG and IgM antibodies even in sera from healthy individuals. The observed induction of anti-cryptococcal IgG but not IgM during CM was supported by analysis of sera from C. neoformans-infected mice. Stronger increase in IgG was found in wild type mice with high lung fungal burden compared to IL-4Rα-deficient mice showing low lung fungal burden. To identify the proteins targeted by human anti-cryptococcal IgG antibodies, we applied a quantitative 2D immunoproteome approach identifying cryptococcal protein spots preferentially recognized by sera from CM patients or healthy individuals followed by mass spectrometry analysis. Twenty-three cryptococcal proteins were recombinantly expressed and confirmed to be immunoreactive with human sera. Fourteen of them were newly described as immunoreactive proteins. Twelve proteins were classified as disease-associated antigens, based on significantly stronger immunoreactivity with sera from CM patients compared to healthy individuals. The proteins identified in our screen significantly expand the pool of cryptococcal proteins with potential for (i) development of novel anti-cryptococcal agents based on implications in cryptococcal virulence or survival, or (ii) development of an anti-cryptococcal vaccine, as several candidates lack homology to human proteins and are localized extracellularly. Furthermore, this study defines pre-existing anti-cryptococcal immunoreactivity in healthy individuals at a molecular level, identifying target antigens recognized by sera from healthy control persons.
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Affiliation(s)
- A Elisabeth Gressler
- Institute of Immunology, Faculty of Veterinary Medicine, Leipzig University, Leipzig, Germany
| | - Daniela Volke
- Institute of Bioanalytical Chemistry, Leipzig University, Leipzig, Germany
| | - Carolina Firacative
- Studies in Translational Microbiology and Emerging Diseases (MICROS) Research Group, School of Medicine and Health Sciences, Universidad del Rosario, Bogota, Colombia
| | - Christiane L Schnabel
- Institute of Immunology, Faculty of Veterinary Medicine, Leipzig University, Leipzig, Germany
| | - Uwe Müller
- Institute of Immunology, Faculty of Veterinary Medicine, Leipzig University, Leipzig, Germany
| | - Andor Krizsan
- Institute of Bioanalytical Chemistry, Leipzig University, Leipzig, Germany
| | - Bianca Schulze-Richter
- Institute of Immunology, Faculty of Veterinary Medicine, Leipzig University, Leipzig, Germany
| | - Matthias Brock
- Fungal Genetics and Biology Group, School of Life Sciences, University of Nottingham, Nottingham, United Kingdom
| | - Frank Brombacher
- International Centre for Genetic Engineering and Biotechnology (ICGEB), Cape Town Component, Cape Town, South Africa
| | | | - Ralf Hoffmann
- Institute of Bioanalytical Chemistry, Leipzig University, Leipzig, Germany
| | - Gottfried Alber
- Institute of Immunology, Faculty of Veterinary Medicine, Leipzig University, Leipzig, Germany
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13
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Cuascut FX, Alkabie S, Hutton GJ. Fingolimod-related cryptococcal meningoencephalitis and immune reconstitution inflammatory syndrome in a patient with multiple sclerosis. Mult Scler Relat Disord 2021; 53:103072. [PMID: 34139459 DOI: 10.1016/j.msard.2021.103072] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 04/12/2021] [Accepted: 05/31/2021] [Indexed: 11/17/2022]
Abstract
Fingolimod is an oral medication for multiple sclerosis that sequesters certain subsets of lymphocytes in lymph nodes, reducing egress into blood and their subsequent CNS migration. The initial multi-site randomized Phase III controlled trials found rates of infection similar to those in control groups. However, post-marketing surveillance has revealed an association with several opportunistic infections, including cryptococcosis. We report a case of fingolimod-related cryptococcal meningoencephalitis and IRIS after drug discontinuation and suggest a surveillance and risk mitigation strategy.
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Affiliation(s)
- Fernando X Cuascut
- Maxine Mesinger Multiple Sclerosis Comprehensive Care Center, Department of Neurology, Baylor College of Medicine, Houston, Texas, United States.
| | - Samir Alkabie
- Maxine Mesinger Multiple Sclerosis Comprehensive Care Center, Department of Neurology, Baylor College of Medicine, Houston, Texas, United States
| | - George J Hutton
- Maxine Mesinger Multiple Sclerosis Comprehensive Care Center, Department of Neurology, Baylor College of Medicine, Houston, Texas, United States
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14
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Scotto R, Reia A, Buonomo AR, Moccia M, Viceconte G, Pisano E, Zappulo E, Brescia Morra V, Gentile I. Risk of invasive fungal infections among patients treated with disease modifying treatments for multiple sclerosis: a comprehensive review. Expert Opin Drug Saf 2021; 20:925-936. [PMID: 33880975 DOI: 10.1080/14740338.2021.1918673] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Introduction: Disease modifying treatments are commonly used in the treatment of multiple sclerosis. As different opportunistic infections have been reported, concerns are also raised regarding the risk of invasive fungal infections.Areas covered: Both clinical trials and observational studies on safety and efficacy of diseases modifying treatment for multiple sclerosis were reviewed and data regarding the occurrence of invasive fungal infections were reported. Papers evaluating the following drugs were reviewed: rituximab, ocrelizumab, alemtuzumab, fingolimod, natalizumab, dimethyl fumarate, interferon, glatiramer acetate, cladribine, teriflunomide.Expert opinion: Overall, the occurrence of invasive fungal infections was low, with most infective events reported among patients treated with monoclonal antibodies and fingolimod. Aspergillosis and cryptococcal meningitidis were the most representative fungal infections. Although not common, these infections may be difficult to diagnose and their fatality rate is often high. For this reason, screening protocols for fungal infections must be implemented in the clinical practice when managing patients with MS.
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Affiliation(s)
- R Scotto
- Department of Clinical Medicine and Surgery, Section of Infectious Diseases, University of Naples Federico II, Naples, Italy
| | - A Reia
- Department of Neuroscience, Reproductive Science and Odontostomatology, Multiple Sclerosis Clinical Care and Research Centre, University of Naples Federico II, Italy
| | - A R Buonomo
- Department of Clinical Medicine and Surgery, Section of Infectious Diseases, University of Naples Federico II, Naples, Italy
| | - M Moccia
- Department of Neuroscience, Reproductive Science and Odontostomatology, Multiple Sclerosis Clinical Care and Research Centre, University of Naples Federico II, Italy
| | - G Viceconte
- Department of Clinical Medicine and Surgery, Section of Infectious Diseases, University of Naples Federico II, Naples, Italy
| | - E Pisano
- Department of Neuroscience, Reproductive Science and Odontostomatology, Multiple Sclerosis Clinical Care and Research Centre, University of Naples Federico II, Italy
| | - E Zappulo
- Department of Clinical Medicine and Surgery, Section of Infectious Diseases, University of Naples Federico II, Naples, Italy
| | - V Brescia Morra
- Department of Neuroscience, Reproductive Science and Odontostomatology, Multiple Sclerosis Clinical Care and Research Centre, University of Naples Federico II, Italy
| | - I Gentile
- Department of Clinical Medicine and Surgery, Section of Infectious Diseases, University of Naples Federico II, Naples, Italy
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15
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Otero-Romero S, Sánchez-Montalvá A, Vidal-Jordana A. Assessing and mitigating risk of infection in patients with multiple sclerosis on disease modifying treatment. Expert Rev Clin Immunol 2021; 17:285-300. [PMID: 33543657 DOI: 10.1080/1744666x.2021.1886924] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Introduction: The important development that the multiple sclerosis (MS) treatment field has experienced in the last years comes along with the need of dealing with new adverse events such as the increase risk of infections. In the shared therapeutic decision-making process, the MS expert neurologist should also balance the risks of specific infections under each particular treatment and be familiar with new mitigation strategies.Areas covered: In this review, the authors provide an up-to-date review of the infection risk associated with MS treatments with a specific focus on risk mitigating strategies. The search was conducted using Pubmed® database (2000 - present) to identify publications that reported infection rates and infection complications for each treatment (interferon beta, glatiramer acetate, teriflunomide, dimethyl fumarate, fingolimod, cladribine, natalizumab, alemtuzumab, rituximab, and ocrelizumab).Expert opinion: Since the emergence of the first natalizumab-related PML case, the arrival of new MS therapies has come hand in hand with new infectious complications. MS-specialist neurologist has to face new challenges regarding the management of immunosuppression-related infectious complications. The implementation of patient-centered management focus on preventive and mitigating strategies with a multidisciplinary approach should be seen in the future as a marker of excellence of MS management.
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Affiliation(s)
- Susana Otero-Romero
- Department of Preventive Medicine and Epidemiology, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Adrián Sánchez-Montalvá
- Department of Infectious Diseases. Hospital Universitari Vall d'Hebron, International Health Program Catalan Institute of Health (PROSICS), Universitat Autònoma De Barcelona, Barcelona, Spain.,Micobacteria Infections Study Group (GEIM) of the Spanish Society of Infectious Diseases (SEIMC), Spain
| | - Angela Vidal-Jordana
- Department of Neurology-Neuroimmunology and Multiple Sclerosis Centre of Catalonia (Cemcat). Hospital Universitari Vall d'Hebron, Universitat Autònoma De Barcelona, Barcelona, Spain
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16
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Wijburg MT, Warnke C, McGuigan C, Koralnik IJ, Barkhof F, Killestein J, Wattjes MP. Pharmacovigilance during treatment of multiple sclerosis: early recognition of CNS complications. J Neurol Neurosurg Psychiatry 2021; 92:177-188. [PMID: 33229453 DOI: 10.1136/jnnp-2020-324534] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 09/27/2020] [Accepted: 10/05/2020] [Indexed: 12/22/2022]
Abstract
An increasing number of highly effective disease-modifying therapies for people with multiple sclerosis (MS) have recently gained marketing approval. While the beneficial effects of these drugs in terms of clinical and imaging outcome measures is welcomed, these therapeutics are associated with substance-specific or group-specific adverse events that include severe and fatal complications. These adverse events comprise both infectious and non-infectious complications that can occur within, or outside of the central nervous system (CNS). Awareness and risk assessment strategies thus require interdisciplinary management, and robust clinical and paraclinical surveillance strategies. In this review, we discuss the current role of MRI in safety monitoring during pharmacovigilance of patients treated with (selective) immune suppressive therapies for MS. MRI, particularly brain MRI, has a pivotal role in the early diagnosis of CNS complications that potentially are severely debilitating and may even be lethal. Early recognition of such CNS complications may improve functional outcome and survival, and thus knowledge on MRI features of treatment-associated complications is of paramount importance to MS clinicians, but also of relevance to general neurologists and radiologists.
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Affiliation(s)
- Martijn T Wijburg
- Department of Neurology, MS Center Amsterdam, Neuroscience Amsterdam, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands .,Department of Radiology & Nuclear Medicine, MS Center Amsterdam, Neuroscience Amsterdam, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
| | - Clemens Warnke
- Department of Neurology, University Hospital Köln, University of Cologne, Köln, Germany.,Department of Neurology, Medical Faculty, Heinrich Heine University, Dusseldorf, Germany
| | - Christopher McGuigan
- Department of Neurology, St Vincent's University Hospital & University College Dublin, Dublin, Ireland
| | - Igor J Koralnik
- Department of Neurological Sciences, Division of Neuroinfectious Diseases, Rush University Medical Center, Chicago, Illinois, USA
| | - Frederik Barkhof
- Department of Radiology & Nuclear Medicine, MS Center Amsterdam, Neuroscience Amsterdam, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands.,Institutes of Neurology and Healthcare Engineering, UCL, London, UK
| | - Joep Killestein
- Department of Neurology, MS Center Amsterdam, Neuroscience Amsterdam, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
| | - Mike P Wattjes
- Department of Radiology & Nuclear Medicine, MS Center Amsterdam, Neuroscience Amsterdam, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands.,Department of Diagnostic and Interventional Neuroradiology, Hannover Medical School, Hannover, Germany
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17
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Kaur P, Lewis A, Basit A, Cyr NS, Muhammad Z. Increased risk of disseminated cryptococcal infection in a patient with multiple sclerosis on fingolimod. IDCases 2020; 22:e00961. [PMID: 32995275 PMCID: PMC7516047 DOI: 10.1016/j.idcr.2020.e00961] [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: 07/24/2020] [Revised: 09/15/2020] [Accepted: 09/15/2020] [Indexed: 12/21/2022] Open
Abstract
Multiple sclerosis (MS) is the most common autoimmune disease of the central nervous system (CNS), with an estimated 2.3 million people being affected globally, and is a major cause of permanent disability. About 90 % of the affected patients with MS have relapsing-remitting type. Fingolimod became the first FDA approved oral drug in 2010 with an immunomodulating mechanism to control the relapse rates. However, since its introduction, increased cases of cryptococcal infections have been reported including meningoencephalitis and disseminated infections. Herein, we present the case of a 34-year-old-male with disseminated Cryptococcal and localized varicella zoster virus (VZV) coinfection to highlight the risk of opportunistic infections associated with the long-term use of fingolimod. The objective of this literature review is for clinicians to have a high index of suspicion for cryptococcal infections when dealing with MS patients on Fingolimod, especially those who present with neurological symptoms, as this mimics MS relapse.
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Affiliation(s)
- Pushpinder Kaur
- Department of Internal Medicine, Coney Island Hospital, Brooklyn, USA
| | - Alana Lewis
- Department of Internal Medicine, Coney Island Hospital, Brooklyn, USA
| | - Abdul Basit
- Department of Internal Medicine, Coney Island Hospital, Brooklyn, USA
| | - Nikolas St Cyr
- Department of Internal Medicine, Coney Island Hospital, Brooklyn, USA
| | - Zaman Muhammad
- Department of Infectious Disease, Coney Island Hospital, Brooklyn, USA
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