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Mahdizade Ari M, Amini ME, Sholeh M, Zahedi Bialvaei A. The effect of polyclonal and monoclonal based antibodies as promising potential therapy for treatment of sepsis: A systematic review. New Microbes New Infect 2024; 60-61:101435. [PMID: 38860003 PMCID: PMC11163170 DOI: 10.1016/j.nmni.2024.101435] [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: 12/27/2023] [Revised: 03/23/2024] [Accepted: 05/14/2024] [Indexed: 06/12/2024] Open
Abstract
While mortality caused by sepsis remains an unsolved problem, studies showed conflicting results about effectiveness of monoclonal and polyclonal antibodies in patients suffering sepsis. For this reason, this current study provides an update of review clinical randomized trial studies until March 2024. The main object of this study is to determine effects of monoclonal and polyclonal antibodies on mortality rate and hospitalization of patients suffering sepsis. Search of Scopus, Web of science, EMBASE, PubMed and Cochrane were performed and randomized controlled trials which conducted in patients with septic shock or bacterial sepsis were included. Two reviewers assessed all searched trials for eligibility according to already defined criteria and did data collection and analyses afterwards. Present study showed monoclonal and polyclonal antibodies are a safe strategy with mild-to-moderate adverse effects. However, most studies indicate no significant change among inter-and intra-group comparison (p > 0.05) and further studies are needed, results showed an increase in survival rate, ventilator-and ICU-free days, resolve organ dysfunction, mediating inflammation related cytokines.
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Affiliation(s)
- Marzie Mahdizade Ari
- Department of Microbiology, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Mohammad Esmaeil Amini
- Department of Microbiology, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Mohammad Sholeh
- Department of Bacteriology, Pasteur Institute of Iran, Tehran, Iran
| | - Abed Zahedi Bialvaei
- Microbial Biotechnology Research Center, Iran University of Medical Sciences, Tehran, Iran
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2
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Schmidt C, Weißmüller S, Heinz CC. Multifaceted Tissue-Protective Functions of Polyvalent Immunoglobulin Preparations in Severe Infections-Interactions with Neutrophils, Complement, and Coagulation Pathways. Biomedicines 2023; 11:3022. [PMID: 38002022 PMCID: PMC10669904 DOI: 10.3390/biomedicines11113022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 10/30/2023] [Accepted: 11/08/2023] [Indexed: 11/26/2023] Open
Abstract
Severe infections induce immune defense mechanisms and initial tissue damage, which produce an inflammatory neutrophil response. Upon dysregulation of these responses, inflammation, further tissue damage, and systemic spread of the pathogen may occur. Subsequent vascular inflammation and activation of coagulation processes may cause microvascular obstruction at sites distal to the primary site of infection. Low immunoglobulin (Ig) M and IgG levels have been detected in patients with severe infections like sCAP and sepsis, associated with increased severity and mortality. Based on Ig's modes of action, supplementation with polyvalent intravenous Ig preparations (standard IVIg or IgM/IgA-enriched Ig preparations) has long been discussed as a treatment option for severe infections. A prerequisite seems to be the timely administration of Ig preparations before excessive tissue damage has occurred and coagulopathy has developed. This review focuses on nonclinical and clinical studies that evaluated tissue-protective activities resulting from interactions of Igs with neutrophils, complement, and the coagulation system. The data indicate that coagulopathy, organ failure, and even death of patients can possibly be prevented by the timely combined interactions of (natural) IgM, IgA, and IgG with neutrophils and complement.
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Affiliation(s)
- Carolin Schmidt
- Department of Corporate Clinical Research and Development, Biotest AG, 63303 Dreieich, Germany
| | | | - Corina C Heinz
- Department of Corporate Clinical Research and Development, Biotest AG, 63303 Dreieich, Germany
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Singer M, Torres A, Heinz CC, Weißmüller S, Staus A, Kistner S, Jakubczyk K, Häder T, Langohr P, Wartenberg-Demand A, Schüttrumpf J, Vincent JL, Welte T. The immunomodulating activity of trimodulin (polyvalent IgM, IgA, IgG solution): a post hoc analysis of the phase II CIGMA trial. Crit Care 2023; 27:436. [PMID: 37946226 PMCID: PMC10634136 DOI: 10.1186/s13054-023-04719-9] [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: 09/11/2023] [Accepted: 11/01/2023] [Indexed: 11/12/2023] Open
Abstract
BACKGROUND The phase II CIGMA trial performed in 160 patients with severe community-acquired pneumonia (sCAP) found treatment with trimodulin (human polyvalent immunoglobulin [Ig]: ~ 23% IgM, ~ 21% IgA, ~ 56% IgG) was associated with a lower mortality in those patients with elevated baseline serum levels of C-reactive protein (CRP) and/or subnormal IgM. METHODS In this post hoc analysis, the pharmacodynamic effects of trimodulin treatment (182.6 mg/kg/day for 5 days) were investigated on Ig replenishment, cellular markers of inflammation (absolute neutrophil [ANC] and lymphocyte [ALC] count, neutrophil-to-lymphocyte ratio [NLR]), and soluble markers of inflammation (procalcitonin [PCT] and CRP). The impact of these pharmacodynamic effects on mortality was also evaluated. RESULTS Compared with healthy subjects, baseline serum levels of IgM, IgG, and ALC were significantly lower, and ANC, NLR, PCT and CRP significantly higher in sCAP patients (p < 0.0001). Low Ig concentrations increased with trimodulin. Normalization of ANC (analysis of variance [ANOVA] p = 0.016) and PCT (ANOVA p = 0.027) was more rapid with trimodulin compared with placebo. These and other effects were more evident in patients with low baseline IgM levels. Normalization of PCT and CRP levels was both steadier and faster with trimodulin treatment. In patients with low baseline ALC, trimodulin was associated with a lower 28-day all-cause mortality rate (14.5% vs 32.1% in placebo, p = 0.043) and more ventilator-free days ([VFD]; median VFD: 3.5 vs 11 in placebo, p = 0.043). These numerical differences were greater if baseline IgM was also low (low ALC, low IgM: 8.1% mortality vs 34.1% placebo, p = 0.006; 3 VFD vs 15 VFD, p = 0.009, respectively). Results were consistent in patients with high baseline CRP (low ALC, high CRP: 10.9% mortality vs 34.1% placebo, p = 0.011). CONCLUSIONS This post hoc pharmacodynamic analysis of a blinded phase II trial suggests that trimodulin compensates for, and more rapidly modifies, the dysregulated inflammatory response seen in sCAP patients. Trimodulin was associated with significantly lower mortality and more VFD in subgroups with high CRP and low ALC. This effect was particularly marked in patients who also had low baseline IgM values. These findings require confirmation in prospective trials.
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Affiliation(s)
- Mervyn Singer
- Division of Medicine, Bloomsbury Institute of Intensive Care Medicine, University College London, London, UK
| | - Antoni Torres
- Hospital Clínic, Servei de Pneumologia I Allèrgia Respiratòria, Catedràtic de Medicina, Universitat de Barcelona, Barcelona, Spain.
- IDIBAPS, ICREA, CIBER de Enfermedades Respiratorias, Barcelona, Spain.
| | - Corina C Heinz
- Biotest AG, Landsteinerstraße 5, 63303, Dreieich, Germany
| | | | | | | | | | - Thomas Häder
- Biotest AG, Landsteinerstraße 5, 63303, Dreieich, Germany
| | | | | | | | - Jean-Louis Vincent
- Department of Intensive Care, Erasme University Hospital, Brussels, Belgium
| | - Tobias Welte
- Klinik für Pneumologie, Medizinische Hochschule Hannover, Hannover, Germany
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Belousoviene E, Pranskuniene Z, Vaitkaitiene E, Pilvinis V, Pranskunas A. Effect of high-dose intravenous ascorbic acid on microcirculation and endothelial glycocalyx during sepsis and septic shock: a double-blind, randomized, placebo-controlled study. BMC Anesthesiol 2023; 23:309. [PMID: 37700249 PMCID: PMC10496271 DOI: 10.1186/s12871-023-02265-z] [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: 05/21/2023] [Accepted: 08/30/2023] [Indexed: 09/14/2023] Open
Abstract
Previous studies indicate supplemental vitamin C improves microcirculation and reduces glycocalyx shedding in septic animals. Our randomized, double-blind, placebo-controlled trial aimed to investigate whether a high dose of intravenous ascorbic acid (AA) might improve microcirculation and affect glycocalyx in septic patients. In our study, 23 septic patients were supplemented with a high dose (50 mg/kg every 6 h) of intravenous AA or placebo for 96 h. Sublingual microcirculation was examined using a handheld Cytocam-incident dark field (IDF) video microscope. A sidestream dark field video microscope (SDF), connected to the GlycoCheck software (GlycoCheck ICU®; Maastricht University Medical Center, Maastricht, the Netherlands), was employed to observe glycocalyx. We found a significantly higher proportion of perfused small vessels (PPV) 6 h after the beginning of the trial in the experimental group compared with placebo. As an indicator of glycocalyx thickness, the perfused boundary region was lower in capillaries of the 5-9 μm diameter in the AA group than placebo after the first dose of AA. Our data suggest that high-dose parenteral AA tends to improve microcirculation and glycocalyx in the early period of septic shock. The study was retrospectively registered in the clinicaltrials.gov database on 26/02/2021 (registration number NCT04773717).
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Affiliation(s)
- Egle Belousoviene
- Department of Intensive Care Medicine, Lithuanian University of Health Sciences, Eiveniu g. 2, Kaunas, LT-50161, Lithuania
| | - Zivile Pranskuniene
- Department of Drug Technology and Social Pharmacy, Lithuanian University of Health Sciences, Sukileliu pr.13, Kaunas, LT-50162, Lithuania
- Institute of Pharmaceutical Technologies, Lithuanian University of Health Sciences, Sukileliu pr.13, Kaunas, LT-50162, Lithuania
| | - Egle Vaitkaitiene
- Department of Disaster Medicine and Health Research Institute, Lithuanian University of Health Sciences, Eiveniu g. 4, Kaunas, LT-50161, Lithuania
| | - Vidas Pilvinis
- Department of Intensive Care Medicine, Lithuanian University of Health Sciences, Eiveniu g. 2, Kaunas, LT-50161, Lithuania
| | - Andrius Pranskunas
- Department of Intensive Care Medicine, Lithuanian University of Health Sciences, Eiveniu g. 2, Kaunas, LT-50161, Lithuania.
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Damiani E, Carsetti A, Casarotta E, Domizi R, Scorcella C, Donati A, Adrario E. Microcirculation-guided resuscitation in sepsis: the next frontier? Front Med (Lausanne) 2023; 10:1212321. [PMID: 37476612 PMCID: PMC10354242 DOI: 10.3389/fmed.2023.1212321] [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: 04/26/2023] [Accepted: 06/20/2023] [Indexed: 07/22/2023] Open
Abstract
Microcirculatory dysfunction plays a key role in the pathogenesis of tissue dysoxia and organ failure in sepsis. Sublingual videomicroscopy techniques enable the real-time non-invasive assessment of microvascular blood flow. Alterations in sublingual microvascular perfusion were detected during sepsis and are associated with poor outcome. More importantly, sublingual videomicroscopy allowed to explore the effects of commonly applied resuscitative treatments in septic shock, such as fluids, vasopressors and inotropes, and showed that the optimization of macro-hemodynamic parameters may not be accompanied by an improvement in microvascular perfusion. This loss of "hemodynamic coherence," i.e., the concordance between the response of the macrocirculation and the microcirculation, advocates for the integration of microvascular monitoring in the management of septic patients. Nonetheless, important barriers remain for a widespread use of sublingual videomicroscopy in the clinical practice. In this review, we discuss the actual limitations of this technique and future developments that may allow an easier and faster evaluation of the microcirculation at the bedside, and propose a role for sublingual microvascular monitoring in guiding and titrating resuscitative therapies in sepsis.
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Affiliation(s)
- Elisa Damiani
- Anesthesia and Intensive Care Unit, Azienda Ospedaliero Universitaria delle Marche, Ancona, Italy
- Department of Biomedical Sciences and Public Health, Università Politecnica delle Marche, Ancona, Italy
| | - Andrea Carsetti
- Anesthesia and Intensive Care Unit, Azienda Ospedaliero Universitaria delle Marche, Ancona, Italy
- Department of Biomedical Sciences and Public Health, Università Politecnica delle Marche, Ancona, Italy
| | - Erika Casarotta
- Department of Biomedical Sciences and Public Health, Università Politecnica delle Marche, Ancona, Italy
| | - Roberta Domizi
- Anesthesia and Intensive Care Unit, Azienda Ospedaliero Universitaria delle Marche, Ancona, Italy
| | - Claudia Scorcella
- Anesthesia and Intensive Care Unit, Azienda Ospedaliero Universitaria delle Marche, Ancona, Italy
| | - Abele Donati
- Anesthesia and Intensive Care Unit, Azienda Ospedaliero Universitaria delle Marche, Ancona, Italy
- Department of Biomedical Sciences and Public Health, Università Politecnica delle Marche, Ancona, Italy
| | - Erica Adrario
- Anesthesia and Intensive Care Unit, Azienda Ospedaliero Universitaria delle Marche, Ancona, Italy
- Department of Biomedical Sciences and Public Health, Università Politecnica delle Marche, Ancona, Italy
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Aggarwal R, Dewan A, Pandey A, Trehan N, Majid MA. Efficacy of high-dose intravenous immunoglobulin in severe and critical COVID-19: A retrospective cohort study. Int Immunopharmacol 2022; 106:108615. [PMID: 35168081 PMCID: PMC8825318 DOI: 10.1016/j.intimp.2022.108615] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2021] [Revised: 01/26/2022] [Accepted: 02/06/2022] [Indexed: 01/08/2023]
Abstract
Background Methods Results Conclusion
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Affiliation(s)
- Ritesh Aggarwal
- Department of Critical Care, Max Smart Super Speciality Hospital, New Delhi 110017, India.
| | - Arun Dewan
- Department of Critical Care, Max Smart Super Speciality Hospital, New Delhi 110017, India
| | - Ankita Pandey
- Department of Internal Medicine, Max Smart Super Speciality Hospital, New Delhi 110017, India
| | - Nikita Trehan
- Department of Critical Care, Max Smart Super Speciality Hospital, New Delhi 110017, India
| | - Muhammad Aamir Majid
- Department of Critical Care, Max Smart Super Speciality Hospital, New Delhi 110017, India
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Abram N, Baretta V, Mercolini F, De Bortoli M, Chinello M, Balter R, Bonetti E, Zaccaron A, Vitale V, Caddeo G, Mauro M, Battisti L, Tridello G, Cesaro S. Outcome and Risk Factors of Febrile Episodes Treated with Broad Spectrum Antibiotics and Polyclonal IgM–Enriched Immunoglobulin in Pediatric Oncology Hematology Patients: A Retrospective Study. J PEDIAT INF DIS-GER 2021. [DOI: 10.1055/s-0041-1741122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Abstract
Objective Preparations with high-titer immunoglobulin-M (HT-IgM) have been used to treat neonatal and adult sepsis as adjuvant to antibiotics. Limited data are available of this use in pediatric oncohematological patients. We retrospectively assessed the characteristics and outcome of febrile episodes treated with broad-spectrum antibiotics and HT-IgM.
Methods This study included febrile episodes diagnosed after chemotherapy or hematopoietic stem cell transplantation (HSCT) treated with antibiotics and HT-IgM. Study period was from January 2011 to March 2019.
Results Seventy febrile episodes in 63 patients were eligible. In 40% of episodes (n = 28), blood cultures identified a causative organism: Gram-negative (n = 15), Gram-positive (n = 8), polybacterial (n = 4), fungi (n = 1). Twenty-six percent of Gram-negatives were extend spectrum β-lactamase (ESBL)-producers. In 44% of episodes, a deep-organ localization was present, mostly pulmonary. Severe or profound neutropenia, hypotension, and hypoxemia were present in 89, 26, and 21% of episodes, respectively; 20% of episodes required intensive care and 20% of episodes required the use of inotropes. Overall, 90-day mortality was 13% and infection-attributable mortality resulted 8.6%. More than half of the patients received HT-IgM within 24 hours from fever onset. HT-IgM-related allergic reactions occurred in three episodes. Risk factors for 90-day mortality were as follows: hypotension and hypoxemia at fever presentation, admission to intensive care unit (ICU), use of inotropes, presence of deep-organ infection, and escalation of antibiotic therapy within 5 days.
Conclusion The combination of broad-spectrum antibiotics and HT-IgM was feasible, tolerated, and promising, being associated with a limited infectious mortality. Further prospective controlled studies are needed to assess the efficacy of this combination over a standard antibiotic approach.
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Affiliation(s)
- Nicoletta Abram
- Department of Mother and Child, Division of Pediatric Hematology Oncology, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Valentina Baretta
- Department of Mother and Child, Division of Pediatric Hematology Oncology, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Federico Mercolini
- Division of Pediatric Hematology Oncology, Hospital of Bolzano, Bolzano, Italy
| | - Massimiliano De Bortoli
- Department of Mother and Child, Division of Pediatric Hematology Oncology, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Matteo Chinello
- Department of Mother and Child, Division of Pediatric Hematology Oncology, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Rita Balter
- Department of Mother and Child, Division of Pediatric Hematology Oncology, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Elisa Bonetti
- Department of Mother and Child, Division of Pediatric Hematology Oncology, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Ada Zaccaron
- Department of Mother and Child, Division of Pediatric Hematology Oncology, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Virginia Vitale
- Department of Mother and Child, Division of Pediatric Hematology Oncology, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Giulia Caddeo
- Department of Mother and Child, Division of Pediatric Hematology Oncology, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Margherita Mauro
- Department of Mother and Child, Division of Pediatric Hematology Oncology, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Laura Battisti
- Division of Pediatric Hematology Oncology, Hospital of Bolzano, Bolzano, Italy
| | - Gloria Tridello
- Department of Mother and Child, Division of Pediatric Hematology Oncology, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Simone Cesaro
- Department of Mother and Child, Division of Pediatric Hematology Oncology, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
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Danieli MG, Piga MA, Paladini A, Longhi E, Mezzanotte C, Moroncini G, Shoenfeld Y. Intravenous immunoglobulin as an important adjunct in the prevention and therapy of coronavirus 2019 disease. Scand J Immunol 2021; 94:e13101. [PMID: 34940980 PMCID: PMC8646640 DOI: 10.1111/sji.13101] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 08/31/2021] [Accepted: 09/08/2021] [Indexed: 12/15/2022]
Abstract
The coronavirus disease-19 (COVID-19) pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) challenged globally with its morbidity and mortality. A small percentage of affected patients (20%) progress into the second stage of the disease clinically presenting with severe or fatal involvement of lung, heart and vascular system, all contributing to multiple-organ failure. The so-called 'cytokines storm' is considered the pathogenic basis of severe disease and it is a target for treatment with corticosteroids, immunotherapies and intravenous immunoglobulin (IVIg). We provide an overview of the role of IVIg in the therapy of adult patients with COVID-19 disease. After discussing the possible underlying mechanisms of IVIg immunomodulation in COVID-19 disease, we review the studies in which IVIg was employed. Considering the latest evidence that show a link between new coronavirus and autoimmunity, we also discuss the use of IVIg in COVID-19 and anti-SARS-CoV-2 vaccination related autoimmune diseases and the post-COVID-19 syndrome. The benefit of high-dose IVIg is evident in almost all studies with a rapid response, a reduction in mortality and improved pulmonary function in critically ill COVID-19 patients. It seems that an early administration of IVIg is crucial for a successful outcome. Studies' limitations are represented by the small number of patients, the lack of control groups in some and the heterogeneity of included patients. IVIg treatment can reduce the stay in ICU and the demand for mechanical ventilation, thus contributing to attenuate the burden of the disease.
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Affiliation(s)
- Maria Giovanna Danieli
- Clinica Medica, Dipartimento di Medicina Interna, AOU Ospedali Riuniti di Ancona and DISCLIMOUniversità Politecnica delle Marche, Clinica MedicaAnconaItaly
- School of Specialisation in Allergology and Clinical Immunology, Dipartimento di Medicina Interna, AOU Ospedali Riuniti di AnconaUniversità Politecnica delle MarcheAnconaItaly
| | - Mario Andrea Piga
- School of Specialisation in Allergology and Clinical Immunology, Dipartimento di Medicina Interna, AOU Ospedali Riuniti di AnconaUniversità Politecnica delle MarcheAnconaItaly
| | - Alberto Paladini
- School of Specialisation in Internal Medicine, Dipartimento di Medicina Interna, AOU Ospedali Riuniti di AnconaUniversità Politecnica delle MarcheAnconaItaly
| | - Eleonora Longhi
- Scuola di Medicina e ChirurgiaAlma Mater StudiorumUniversità degli Studi di BolognaBolognaItaly
| | - Cristina Mezzanotte
- School of Specialisation in Internal Medicine, Dipartimento di Medicina Interna, AOU Ospedali Riuniti di AnconaUniversità Politecnica delle MarcheAnconaItaly
| | - Gianluca Moroncini
- Clinica Medica, Dipartimento di Medicina Interna, AOU Ospedali Riuniti di Ancona and DISCLIMOUniversità Politecnica delle Marche, Clinica MedicaAnconaItaly
- School of Specialisation in Internal Medicine, Dipartimento di Medicina Interna, AOU Ospedali Riuniti di AnconaUniversità Politecnica delle MarcheAnconaItaly
| | - Yehuda Shoenfeld
- Ariel UniversityArielIsrael
- The Zabludowicz Center for Autoimmune DiseasesSheba Medical CenterRamat GanIsrael
- Saint Petersburg State UniversitySt. PetersburgRussia
- I.M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation (Sechenov University)MoscowRussia
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Corona A, Richini G, Simoncini S, Zangrandi M, Biasini M, Russo G, Pasqua M, Santorsola C, Gregorini C, Giordano C. Treating Critically Ill Patients Experiencing SARS-CoV-2 Severe Infection with Ig-M and Ig-A Enriched Ig-G Infusion. Antibiotics (Basel) 2021; 10:antibiotics10080930. [PMID: 34438980 PMCID: PMC8388937 DOI: 10.3390/antibiotics10080930] [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: 05/20/2021] [Revised: 07/15/2021] [Accepted: 07/28/2021] [Indexed: 11/16/2022] Open
Abstract
SARS-CoV-2 in patients who need intensive care unit (ICU) is associated with a mortality rate ranging from 10 to 40–45%, with an increase in morbidity and mortality in presence of sepsis. We hypothesized that IgM and IgA enriched immunoglobulin G may support the sepsis-related phase improving patient outcome. We conducted a retrospective case–control study on 47 consecutive patients admitted to our ICU. At the time of admission, patients received anticoagulants (heparin sodium) together with the standard supportive treatment. We decided to add IgM and IgA enriched immunoglobulin G to the standard therapy. Patients receiving IgM and IgA enriched immunoglobulin G were compared with patients with similar baseline characteristics and treatment, receiving only standard therapy. The mortality resulted significantly higher in patients treated with standard therapy only (56.5 vs. 37.5%, p < 0.01) and, at day 7, the probability of dying was 3 times higher in this group. Variable life adjustment display (VLAD) was 2.4 and −2.2 (in terms of lives saved in relation with those expected and derived from Simplified Acute Physiology Score II) in the treated and not treated group, respectively. The treatment based on IgM and IgA enriched immunoglobulin G infusion seems to give an advantage on survival in SARS-CoV-2 severe infection.
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Pneumolysin induces platelet destruction, not platelet activation, which can be prevented by immunoglobulin preparations in vitro. Blood Adv 2021; 4:6315-6326. [PMID: 33351126 DOI: 10.1182/bloodadvances.2020002372] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 11/05/2020] [Indexed: 01/08/2023] Open
Abstract
Community-acquired pneumonia by primary or superinfections with Streptococcus pneumoniae can lead to acute respiratory distress requiring mechanical ventilation. The pore-forming toxin pneumolysin alters the alveolar-capillary barrier and causes extravasation of protein-rich fluid into the interstitial pulmonary tissue, which impairs gas exchange. Platelets usually prevent endothelial leakage in inflamed pulmonary tissue by sealing inflammation-induced endothelial gaps. We not only confirm that S pneumoniae induces CD62P expression in platelets, but we also show that, in the presence of pneumolysin, CD62P expression is not associated with platelet activation. Pneumolysin induces pores in the platelet membrane, which allow anti-CD62P antibodies to stain the intracellular CD62P without platelet activation. Pneumolysin treatment also results in calcium efflux, increase in light transmission by platelet lysis (not aggregation), loss of platelet thrombus formation in the flow chamber, and loss of pore-sealing capacity of platelets in the Boyden chamber. Specific anti-pneumolysin monoclonal and polyclonal antibodies inhibit these effects of pneumolysin on platelets as do polyvalent human immunoglobulins. In a post hoc analysis of the prospective randomized phase 2 CIGMA trial, we show that administration of a polyvalent immunoglobulin preparation was associated with a nominally higher platelet count and nominally improved survival in patients with severe S pneumoniae-related community-acquired pneumonia. Although, due to the low number of patients, no definitive conclusion can be made, our findings provide a rationale for investigation of pharmacologic immunoglobulin preparations to target pneumolysin by polyvalent immunoglobulin preparations in severe community-acquired pneumococcal pneumonia, to counteract the risk of these patients becoming ventilation dependent. This trial was registered at www.clinicaltrials.gov as #NCT01420744.
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Intravenous Immunoglobulin for Treatment of Patients with COVID-19: A Case-control Study. ARCHIVES OF CLINICAL INFECTIOUS DISEASES 2021. [DOI: 10.5812/archcid.108068] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Background: It seems that the risk of developing complications associated with coronavirus disease 2019 (COVID-19) is higher among individuals with weakened immune systems. Objectives: Therefore, this study was carried out to determine the effectiveness of intravenous immunoglobulin (IVIG) for the treatment of patients not entering the intubation phase compared to those entering the intubation phase. Methods: This descriptive case-control study was performed on 26 patients with COVID-19 referring to Imam Reza hospital in Mashhad, Iran, in March 2020. For subjects with COVID-19 not responding to the standard three-drug protocol (i.e., ribavirin, hydroxychloroquine, and lopinavir/ritonavir), three doses of IVIG (0.4 g/kg/day) were added to the protocol. The patients were divided into two groups of subjects not entering the intubation phase and those entering the intubation phase and compared in terms of different variables. Results: The comparison of laboratory findings showed a significant difference before and after receiving IVIG regarding oxygen saturation (P < 0.005), white blood cell (P = 0.001), hemoglobin level (P = 0.0002), lymphocyte count (P = 0.03), and C-reactive protein (P = 0.001). In general, 53.8% and 46.2% of the patients were discharged and expired, respectively. All the subjects not entering the intubation phase were recovered; nevertheless, only one case entering the intubation phase was recovered, and 92.3% of the patients expired. A significant difference was observed between the patients not entering the intubation phase and those entering the intubation phase in terms of mortality (χ2 = 22.28; P < 0.005). Conclusions: In summary, the obtained results of the current study confirmed the therapeutic effects of IVIG on patients with COVID-19. Moreover, better treatment results, shorter hospital stay, and lower mortality rates were observed among COVID-19 patients who did not enter the intubation phase in comparison with those entering the intubation phase.
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Abstract
PURPOSE OF REVIEW The aim of this study was to discuss the implication of microvascular dysfunction in septic shock. RECENT FINDINGS Resuscitation of sepsis has focused on systemic haemodynamics and, more recently, on peripheral perfusion indices. However, central microvascular perfusion is altered in sepsis and these alterations often persist despite normalization of various macro haemodynamic resuscitative goals. Endothelial dysfunction is a key element in sepsis pathophysiology. It is responsible for the sepsis-induced hypotension. In addition, endothelial dysfunction is also implicated involved in the activation of inflammation and coagulation processes leading to amplification of the septic response and development of organ dysfunction. It also promotes an increase in permeability, mostly at venular side, and impairs microvascular perfusion and hence tissue oxygenation.Microvascular alterations are characterized by heterogeneity in blood flow distribution, with adequately perfused areas in close vicinity to not perfused areas, thus characterizing the distributive nature of septic shock. Such microvascular alterations have profound implications, as these are associated with organ dysfunction and unfavourable outcomes. Also, the response to therapy is highly variable and cannot be predicted by systemic hemodynamic assessment and hence cannot be detected by classical haemodynamic tools. SUMMARY Microcirculation is a key element in the pathophysiology of sepsis. Even if microcirculation-targeted therapy is not yet ready for the prime time, understanding the processes implicated in microvascular dysfunction is important to prevent chasing systemic hemodynamic variables when this does not contribute to improve tissue perfusion.
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13
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Busani S, Roat E, Tosi M, Biagioni E, Coloretti I, Meschiari M, Gelmini R, Brugioni L, De Biasi S, Girardis M. Adjunctive Immunotherapy With Polyclonal Ig-M Enriched Immunoglobulins for Septic Shock: From Bench to Bedside. The Rationale for a Personalized Treatment Protocol. Front Med (Lausanne) 2021; 8:616511. [PMID: 33681248 PMCID: PMC7930614 DOI: 10.3389/fmed.2021.616511] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 01/27/2021] [Indexed: 01/19/2023] Open
Abstract
Septic shock still has a high mortality rate which has not hinted at decreasing in recent years. Unfortunately, randomized trials failed mainly because the septic patient was considered as a homogeneous entity. All this creates a sort of therapeutic impotence in everyday clinical practice in treating patients with septic shock. The need to customize therapy on each patient with sepsis has now become an established necessity. In this scenario, adjuvant therapies can help if interpreted as modulators of the immune system. Indeed, the host's immune response differs from patient to patient based on the virulence of the pathogen, comorbidity, infection site, and prolonged hospitalization. In this review, we summarize the rationale for using immunoglobulins as an adjunctive treatment. Furthermore, we would like to suggest a possible protocol to personalize treatment in the different clinical scenarios of the host's response to serious infectious events.
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Affiliation(s)
- Stefano Busani
- Intensive Care Unit, University Hospital Policlinico di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Erika Roat
- Intensive Care Unit, University Hospital Policlinico di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Martina Tosi
- Intensive Care Unit, University Hospital Policlinico di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Emanuela Biagioni
- Intensive Care Unit, University Hospital Policlinico di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Irene Coloretti
- Intensive Care Unit, University Hospital Policlinico di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Marianna Meschiari
- Infectious Diseases Unit, University Hospital Policlinico di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Roberta Gelmini
- Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Lucio Brugioni
- Internal Medicine Department, Azienda Ospedaliero-Universitaria Policlinico of Modena, Modena, Italy
| | - Sara De Biasi
- Department of Medical and Surgical Sciences for Children and Adults, University of Modena and Reggio Emilia School of Medicine, Modena, Italy
| | - Massimo Girardis
- Intensive Care Unit, University Hospital Policlinico di Modena, University of Modena and Reggio Emilia, Modena, Italy
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14
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Soltani S, Zandi M, Shiri Aghbash P, Rezaei M, Mohammadzadeh N, Afsharifar A, Poortahmasebi V. A review of COVID-19 vaccines and major considerations for diabetic patients. Biotechnol Appl Biochem 2020; 69:30-40. [PMID: 33179788 DOI: 10.1002/bab.2076] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 11/05/2020] [Indexed: 01/08/2023]
Abstract
The necessity and impact of SARS-CoV2 on the world's health have led to developing and producing practical and useful vaccines for this deadly respiratory virus. Since April 2020, a vaccine for the virus has been developed. Given that comorbidities such as diabetes, hypertension, and cardiovascular disease are more prone to viruses and the risk of infection, vaccines should be designed to protect against high-risk respiratory illnesses. Including SARS, MERS, influenza, and the SARS-CoV-2 provide a safe immune response. Here, we review the information and studies that have been done to help develop strategies and perspectives for producing a safe and ideal vaccine to prevent COVID-19 in normal people, especially at high-risk groups such as diabetes patients.
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Affiliation(s)
- Saber Soltani
- Department of Virology, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran.,Research Center for Clinical Virology, Tehran University of Medical Sciences, Tehran, Iran
| | - Milad Zandi
- Department of Virology, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran.,Research Center for Clinical Virology, Tehran University of Medical Sciences, Tehran, Iran
| | - Parisa Shiri Aghbash
- Department of Bacteriology and Virology, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Masoud Rezaei
- Department of Plant Protection, Shiraz University, Shiraz, Iran
| | - Nader Mohammadzadeh
- Health Reference Laboratory, Tabriz University of Medical Sciences, Tabriz, Iran
| | | | - Vahdat Poortahmasebi
- Department of Bacteriology and Virology, Tabriz University of Medical Sciences, Tabriz, Iran
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15
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Casarotta E, Damiani E, Domizi R, Carsetti A, Scorcella C, Adrario E, Bolognini S, Di Falco D, Pantanetti S, Vannicola S, Damia Paciarini A, Donati A. Variation in the Outcome of Norepinephrine-Dependent Septic Patients After the Institution of a Patient-Tailored Therapy Protocol in an Italian Intensive Care Unit: Retrospective Observational Study. Front Med (Lausanne) 2020; 7:592282. [PMID: 33251238 PMCID: PMC7674935 DOI: 10.3389/fmed.2020.592282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Accepted: 10/13/2020] [Indexed: 11/13/2022] Open
Abstract
Objective: To evaluate the outcome of patients with septic shock after the institution of a patient tailored therapy protocol in our Intensive Care Unit (ICU). Methods: Single-center retrospective observational study including 100 consecutive septic patients (≥ 16 years) requiring norepinephrine infusion, admitted to our ICU between 2018 and 2019 after the institution of a patient-tailored therapy protocol, compared with a historical control group of 100 patients admitted between 2010 and 2013 (historical controls). The patient-tailored therapy protocol included the use of IgM-enriched immunoglobulins for patients with low plasma IgM levels, blood purification strategies for patients with high plasma levels of cytokines or endotoxin, albumin correction and modulation of vasoactive agents. Clinical and therapeutic parameters were noted at the time of initiation of norepinephrine infusion and for the 1st 24 h. The primary outcome was ICU mortality. Results: ICU-mortality was lower in the patient-tailored therapy cohort as compared to historical controls (32 vs. 57%, p < 0.001). Patient-tailored therapy was associated with a lower risk of ICU-mortality even after adjusting for the main clinical severity indices (adjusted odds ratio 0.331 [95% confidence interval 0.166–0.658], p = 0.002). After propensity score matching, 48 patients in historical control group and 48 patients in the patient-tailored therapy cohort with similar general characteristics were selected. ICU-mortality was lower in the patient-tailored therapy matched subgroup as compared to historical controls (40 vs. 60%, p = 0.037). Conclusions: An individualized therapeutic approach in septic patients may be associated with a survival benefit. However, the use of an historical control group of patients admitted between 2010 and 2013 may introduce substantial bias. Further adequately designed studies are needed to demonstrate the impact of patient-tailored therapy on outcome.
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Affiliation(s)
- Erika Casarotta
- Anesthesia and Intensive Care Unit, Department of Biomedical Sciences and Public Health, Università Politecnica Delle Marche, Ancona, Italy
| | - Elisa Damiani
- Anesthesia and Intensive Care Unit, Department of Biomedical Sciences and Public Health, Università Politecnica Delle Marche, Ancona, Italy
| | - Roberta Domizi
- Anesthesia and Intensive Care Unit, Department of Biomedical Sciences and Public Health, Università Politecnica Delle Marche, Ancona, Italy
- Anesthesia and Intensive Care Unit, Azienda Ospedaliera Universitaria “Ospedali Riuniti” of Ancona, Ancona, Italy
| | - Andrea Carsetti
- Anesthesia and Intensive Care Unit, Department of Biomedical Sciences and Public Health, Università Politecnica Delle Marche, Ancona, Italy
- Anesthesia and Intensive Care Unit, Azienda Ospedaliera Universitaria “Ospedali Riuniti” of Ancona, Ancona, Italy
| | - Claudia Scorcella
- Anesthesia and Intensive Care Unit, Azienda Ospedaliera Universitaria “Ospedali Riuniti” of Ancona, Ancona, Italy
| | - Erica Adrario
- Anesthesia and Intensive Care Unit, Department of Biomedical Sciences and Public Health, Università Politecnica Delle Marche, Ancona, Italy
- Anesthesia and Intensive Care Unit, Azienda Ospedaliera Universitaria “Ospedali Riuniti” of Ancona, Ancona, Italy
| | - Sandra Bolognini
- Anesthesia and Intensive Care Unit, Department of Biomedical Sciences and Public Health, Università Politecnica Delle Marche, Ancona, Italy
| | - Domenico Di Falco
- Anesthesia and Intensive Care Unit, Department of Biomedical Sciences and Public Health, Università Politecnica Delle Marche, Ancona, Italy
| | - Simona Pantanetti
- Anesthesia and Intensive Care Unit, Azienda Ospedaliera Universitaria “Ospedali Riuniti” of Ancona, Ancona, Italy
| | - Sara Vannicola
- Anesthesia and Intensive Care Unit, Department of Biomedical Sciences and Public Health, Università Politecnica Delle Marche, Ancona, Italy
| | - Agnese Damia Paciarini
- Anesthesia and Intensive Care Unit, Department of Biomedical Sciences and Public Health, Università Politecnica Delle Marche, Ancona, Italy
| | - Abele Donati
- Anesthesia and Intensive Care Unit, Department of Biomedical Sciences and Public Health, Università Politecnica Delle Marche, Ancona, Italy
- Anesthesia and Intensive Care Unit, Azienda Ospedaliera Universitaria “Ospedali Riuniti” of Ancona, Ancona, Italy
- *Correspondence: Abele Donati
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16
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Nierhaus A, Berlot G, Kindgen-Milles D, Müller E, Girardis M. Best-practice IgM- and IgA-enriched immunoglobulin use in patients with sepsis. Ann Intensive Care 2020; 10:132. [PMID: 33026597 PMCID: PMC7538847 DOI: 10.1186/s13613-020-00740-1] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Accepted: 09/06/2020] [Indexed: 12/20/2022] Open
Abstract
Background Sepsis is a life-threatening organ dysfunction caused by a dysregulated host response to infection. Despite treatment being in line with current guidelines, mortality remains high in those with septic shock. Intravenous immunoglobulins represent a promising therapy to modulate both the pro- and anti-inflammatory processes and can contribute to the elimination of pathogens. In this context, there is evidence of the benefits of immunoglobulin M (IgM)- and immunoglobulin A (IgA)-enriched immunoglobulin therapy for sepsis. This manuscript aims to summarize current relevant data to provide expert opinions on best practice for the use of an IgM- and IgA-enriched immunoglobulin (Pentaglobin) in adult patients with sepsis. Main text Sepsis patients with hyperinflammation and patients with immunosuppression may benefit most from treatment with IgM- and IgA-enriched immunoglobulin (Pentaglobin). Patients with hyperinflammation present with phenotypes that manifest throughout the body, whilst the clinical characteristics of immunosuppression are less clear. Potential biomarkers for hyperinflammation include elevated procalcitonin, interleukin-6, endotoxin activity and C-reactive protein, although thresholds for these are not well-defined. Convenient biomarkers for identifying patients in a stage of immune-paralysis are still matter of debate, though human leukocyte antigen–antigen D related expression on monocytes, lymphocyte count and viral reactivation have been proposed. The timing of treatment is potentially more critical for treatment efficacy in patients with hyperinflammation compared with patients who are in an immunosuppressed stage. Due to the lack of evidence, definitive dosage recommendations for either population cannot be made, though we suggest that patients with hyperinflammation should receive an initial bolus at a rate of up to 0.6 mL (30 mg)/kg/h for 6 h followed by a continuous maintenance rate of 0.2 mL (10 mg)/kg/hour for ≥ 72 h (total dose ≥ 0.9 g/kg). For immunosuppressed patients, dosage is more conservative (0.2 mL [10 mg]/kg/h) for ≥ 72 h, without an initial bolus (total dose ≥ 0.72 g/kg). Conclusions Two distinct populations that may benefit most from Pentaglobin therapy are described in this review. However, further clinical evidence is required to strengthen support for the recommendations given here regarding timing, duration and dosage of treatment.
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Affiliation(s)
- Axel Nierhaus
- University Medical Center Hamburg, Hamburg, Germany. .,Dep. of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.
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17
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Jarczak D, Kluge S, Nierhaus A. Use of Intravenous Immunoglobulins in Sepsis Therapy-A Clinical View. Int J Mol Sci 2020; 21:ijms21155543. [PMID: 32756325 PMCID: PMC7432410 DOI: 10.3390/ijms21155543] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Revised: 07/29/2020] [Accepted: 07/30/2020] [Indexed: 12/29/2022] Open
Abstract
Sepsis is a life-threatening organ dysfunction, defined by a dysregulated host immune response to infection. During sepsis, the finely tuned system of immunity, inflammation and anti-inflammation is disturbed in a variety of ways. Both pro-inflammatory and anti-inflammatory pathways are upregulated, activation of the coagulation cascade and complement and sepsis-induced lymphopenia occur. Due to the manifold interactions in this network, the use of IgM-enriched intravenous immunoglobulins seems to be a promising therapeutic approach. Unfortunately, there is still a lack of evidence-based data to answer the important questions of appropriate patient populations, optimal timing and dosage of intravenous immunoglobulins. With this review, we aim to provide an overview of the role of immunoglobulins, with emphasis on IgM-enriched formulations, in the therapy of adult patients with sepsis and septic shock.
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18
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Carannante N, Fiorentino G, Corcione A, Di Sarno R, Spatarella M, Maturo N, Fragranza F, Di Micco P. Administration of Immunoglobulins in SARS-CoV-2-Positive Patient Is Associated With Fast Clinical and Radiological Healing: Case Report. Front Med (Lausanne) 2020; 7:388. [PMID: 32766266 PMCID: PMC7378528 DOI: 10.3389/fmed.2020.00388] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 06/22/2020] [Indexed: 01/16/2023] Open
Abstract
Polyclonal preparation of IgM as an adjuvant therapy has been reported as a relevant immunomodulant therapy in several infectious diseases, exhibiting, in most cases, improvement of the clinical course. No drug has demonstrated therapeutic efficacy for COVID-19. Immunomodulatory treatment with hydroxychloroquine and biologics as tocilizumab, in fact, has not proven to show satisfactory results in several reports. We therefore treated a selected patient with interstitial multifocal pneumonia, positive to COVID-19, with polyclonal preparation of immunoglobulins as an adjuvant therapy, obtaining in few days clinical remission and improvements in radiological findings. Based on this case report, we suggest that clinical trials are conducted to test the efficacy and safety of polyclonal immunoglobulins for adjunctive therapy of COVID-19.
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Affiliation(s)
- Novella Carannante
- Emergency Infectious Disease p.o. Cotugno-Monaldi, A.O. dei Colli, Naples, Italy.,UOC Medicina, Ospedale Fatebenefratelli di Naples, Naples, Italy
| | - Giuseppe Fiorentino
- Emergency Infectious Disease p.o. Cotugno-Monaldi, A.O. dei Colli, Naples, Italy.,UOC Medicina, Ospedale Fatebenefratelli di Naples, Naples, Italy
| | - Antonio Corcione
- Emergency Infectious Disease p.o. Cotugno-Monaldi, A.O. dei Colli, Naples, Italy.,UOC Medicina, Ospedale Fatebenefratelli di Naples, Naples, Italy
| | - Raffaele Di Sarno
- Emergency Infectious Disease p.o. Cotugno-Monaldi, A.O. dei Colli, Naples, Italy.,UOC Medicina, Ospedale Fatebenefratelli di Naples, Naples, Italy
| | - Micaela Spatarella
- Emergency Infectious Disease p.o. Cotugno-Monaldi, A.O. dei Colli, Naples, Italy.,UOC Medicina, Ospedale Fatebenefratelli di Naples, Naples, Italy
| | - Nicola Maturo
- Emergency Infectious Disease p.o. Cotugno-Monaldi, A.O. dei Colli, Naples, Italy.,UOC Medicina, Ospedale Fatebenefratelli di Naples, Naples, Italy
| | - Fiorentino Fragranza
- Emergency Infectious Disease p.o. Cotugno-Monaldi, A.O. dei Colli, Naples, Italy.,UOC Medicina, Ospedale Fatebenefratelli di Naples, Naples, Italy
| | - Pierpaolo Di Micco
- Emergency Infectious Disease p.o. Cotugno-Monaldi, A.O. dei Colli, Naples, Italy.,UOC Medicina, Ospedale Fatebenefratelli di Naples, Naples, Italy
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19
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Shoenfeld Y. Corona (COVID-19) time musings: Our involvement in COVID-19 pathogenesis, diagnosis, treatment and vaccine planning. Autoimmun Rev 2020; 19:102538. [PMID: 32268212 PMCID: PMC7131471 DOI: 10.1016/j.autrev.2020.102538] [Citation(s) in RCA: 156] [Impact Index Per Article: 39.0] [Reference Citation Analysis] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 03/31/2020] [Indexed: 12/14/2022]
Affiliation(s)
- Yehuda Shoenfeld
- Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, affiliated to Tel-Aviv University, Israel; Laboratory of the Mosaics of Autoimmunity, Saint Petersburg State University, Saint-Petersburg, Russian Federation.
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