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Li X, Armon C, Barkhaus P, Barnes B, Benatar M, Bertorini T, Bromberg M, Carter GT, Crayle J, Cudkowicz M, Dimachkie M, Feldman EL, Glass J, Goslinga J, Heiman-Patterson T, Jhooty S, Lichtenstein R, Lund I, Mcdermott C, Pattee G, Pierce K, Ratner D, Salmon K, Wicks P, Bedlack R. ALSUntangled #67: rituximab. Amyotroph Lateral Scler Frontotemporal Degener 2023; 24:544-547. [PMID: 36106861 DOI: 10.1080/21678421.2022.2122845] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Accepted: 09/04/2022] [Indexed: 11/01/2022]
Abstract
ALSUntangled reviews alternative and off-label treatments on behalf of people with ALS who ask about them. Here we review rituximab, a drug which specifically depletes B lymphocytes. We show a current lack of evidence for a role of these cells in ALS progression. The one patient we found who described using Rituximab for their ALS found no benefit. Given all this, and the known serious risks of rituximab, we advise against its use as an ALS treatment.
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Affiliation(s)
- Xiaoyan Li
- Department of Neurology, Duke University, Durham, NC, USA
| | - Carmel Armon
- Department of Neurology, Loma Linda University, Loma Linda, CA, USA
| | - Paul Barkhaus
- Department of Neurology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Benjamin Barnes
- Department of Neurology, Medical College of Georgia, Augusta, GA, USA
| | - Michael Benatar
- Department of Neurology, University of Miami, Miami, FL, USA
| | - Tulio Bertorini
- Neurology Department, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Mark Bromberg
- Department of Neurology, University of Utah, Salt Lake City, UT, USA
| | - Gregory T Carter
- Department of Rehabilitation, Elson S. Floyd College of Medicine, Washington State University, Spokane, WA, USA
| | - Jesse Crayle
- Neurology Department, Washington University, St. Louis, MO, USA
| | - Merit Cudkowicz
- Department of Neurology, Harvard Medical School, Boston, MA, USA
| | - Mazen Dimachkie
- Department of Neurology, University of Kansas, Kansas City, KS, USA
| | - Eva L Feldman
- Department of Neurology, University of Michigan, Ann Arbor, MI, USA
| | - Jonathan Glass
- Department of Neurology, Emory University, Atlanta, GA, USA
| | - Jill Goslinga
- Department of Neurology, University of California San Francisco, San Francisco, CA, USA
| | | | - Sartaj Jhooty
- University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Rachel Lichtenstein
- Avram and Stella Goren-Goldstein Biotechnology Engineering Department, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Isaac Lund
- Undergraduate, Green Hope High School, Cary, NC, USA
| | | | - Gary Pattee
- Department of Neurology, University of Nebraska Medical Center, Omaha, NE, USA
| | - Kaitlyn Pierce
- Department of Neuroscience, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Dylan Ratner
- Undergraduate, Longmeadow High School, Longmeadow, MA, USA
| | - Kristiana Salmon
- Department of Neurology, Montreal Neurological Institute, Montreal, CA and
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2
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Athni TS, Barmettler S. Hypogammaglobulinemia, late-onset neutropenia, and infections following rituximab. Ann Allergy Asthma Immunol 2023; 130:699-712. [PMID: 36706910 PMCID: PMC10247428 DOI: 10.1016/j.anai.2023.01.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 12/23/2022] [Accepted: 01/16/2023] [Indexed: 01/26/2023]
Abstract
Rituximab is a chimeric anti-CD20 monoclonal antibody that targets CD20-expressing B lymphocytes, has a well-defined efficacy and safety profile, and is broadly used to treat a wide array of diseases. In this review, we cover the mechanism of action of rituximab and focus on hypogammaglobulinemia and late-onset neutropenia-2 immune effects secondary to rituximab-and subsequent infection. We review risk factors and highlight key considerations for immunologic monitoring and clinical management of rituximab-induced secondary immune deficiencies. In patients treated with rituximab, monitoring for hypogammaglobulinemia and infections may help to identify the subset of patients at high risk for developing poor B cell reconstitution, subsequent infections, and adverse complications. These patients may benefit from early interventions such as vaccination, antibacterial prophylaxis, and immunoglobulin replacement therapy. Systematic evaluation of immunoglobulin levels and peripheral B cell counts by flow cytometry, both at baseline and periodically after therapy, is recommended for monitoring. In addition, in those patients with prolonged hypogammaglobulinemia and increased infections after rituximab use, immunologic evaluation for inborn errors of immunity may be warranted to further risk stratification, increase monitoring, and assist in therapeutic decision-making. As the immunologic effects of rituximab are further elucidated, personalized approaches to minimize the risk of adverse reactions while maximizing benefit will allow for improved care of patients with decreased morbidity and mortality.
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Affiliation(s)
| | - Sara Barmettler
- Allergy and Clinical Immunology Unit, Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Boston, Massachusetts.
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3
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Bhandari S, Baral MR, Barbery M, Rudinskaya A, Sostin O. Hematologic side effects of biologics and kinase inhibitors used in rheumatologic diseases: a review of the current evidence. Ann Hematol 2022; 101:1897-1904. [PMID: 35759025 PMCID: PMC9243812 DOI: 10.1007/s00277-022-04896-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Accepted: 06/13/2022] [Indexed: 11/24/2022]
Abstract
Treatment options for various rheumatologic diseases have been limited until the introduction of biologic agents and kinase inhibitor therapy in recent decades. Since their arrival, they have steadily been integrated into routine management. Given their wide use and overall successful outcomes, it becomes increasingly pertinent for clinicians to readily identify their side effects. Their effects can involve multiple organ systems, including hematologic. This review aims to identify and classify the range of hematologic effects associated with individual biologics and kinase inhibitors used for treatment of rheumatologic diseases.
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Affiliation(s)
| | - Maun Ranjan Baral
- Department of Medicine, Danbury Hospital-Nuvance Health, Danbury, CT, USA
| | - Matthew Barbery
- Department of Medicine, Danbury Hospital-Nuvance Health, Danbury, CT, USA
| | - Alla Rudinskaya
- Department of Rheumatology, Danbury Hospital-Nuvance Health, Danbury, CT, USA
| | - Oleg Sostin
- Department of Research, Danbury Hospital-Nuvance Health, Danbury, CT, USA
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4
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Tieu J, Smith R, Basu N, Brogan P, D'Cruz D, Dhaun N, Flossmann O, Harper L, Jones RB, Lanyon PC, Luqmani RA, McAdoo SP, Mukhtyar C, Pearce FA, Pusey CD, Robson JC, Salama AD, Smyth L, Watts RA, Willcocks LC, Jayne DRW. Rituximab for maintenance of remission in ANCA-associated vasculitis: expert consensus guidelines. Rheumatology (Oxford) 2020; 59:e24-e32. [PMID: 32096545 DOI: 10.1093/rheumatology/kez640] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Revised: 10/31/2019] [Indexed: 01/05/2023] Open
Affiliation(s)
- Joanna Tieu
- Department of Medicine, University of Cambridge, Cambridge, UK.,Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, Australia
| | - Rona Smith
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - Neil Basu
- Institute of Infection, Immunity and Inflammation, University of Glasgow, Glasgow
| | - Paul Brogan
- University College London Great Ormond Institute of Child Health.,Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - David D'Cruz
- Guy's and St Thomas' NHS Foundation Trust, London
| | - Neeraj Dhaun
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh.,Royal Infirmary of Edinburgh, Edinburgh
| | | | - Lorraine Harper
- Institute of Clinical Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham
| | - Rachel B Jones
- Department of Medicine, University of Cambridge, Cambridge, UK.,Department of Renal Medicine, Cambridge University Hospitals Trust, Cambridge
| | - Peter C Lanyon
- Department of Rheumatology, Nottingham University Hospitals NHS Trust.,Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, Nottingham
| | - Raashid A Luqmani
- Nuffield Department of Orthopaedics Rheumatology and Musculoskeletal Science, University of Oxford, Oxford
| | | | - Chetan Mukhtyar
- Norfolk and Norwich University Hospital.,University of East Anglia, Norwich
| | - Fiona A Pearce
- University of Nottingham.,Nottingham University Hospitals NHS Trust, Nottingham
| | | | - Joanna C Robson
- Faculty of Health and Applied Sciences, University of West of England.,Department of Rheumatology, University Hospitals Bristol NHS Trust, Bristol
| | - Alan D Salama
- University College London.,Department of Renal Medicine, Royal Free Hospital, London
| | - Lucy Smyth
- Exeter Kidney Unit, Royal Devon and Exeter Hospital, Exeter
| | - Richard A Watts
- Ipswich Hospital, Ipswich.,Norwich Medical School, University of East Anglia, Norwich, UK
| | - Lisa C Willcocks
- Department of Renal Medicine, Cambridge University Hospitals Trust, Cambridge
| | - David R W Jayne
- Department of Medicine, University of Cambridge, Cambridge, UK.,Vasculitis and Lupus Unit, Cambridge University Hospitals NHS Trust, Cambridge, UK
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5
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Malpica Castillo LE, Palmer S, Zhu A, Deal AM, Chen S, Moll S. Incidence and time course of neutropenia in patients treated with rituximab-based therapy for non-malignant immune-mediated hematologic diseases. Am J Hematol 2020; 95:E117-E120. [PMID: 32017201 DOI: 10.1002/ajh.25751] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Revised: 01/27/2020] [Accepted: 01/30/2020] [Indexed: 11/05/2022]
Affiliation(s)
- Luis E. Malpica Castillo
- Division of Hematology‐Oncology, Department of MedicineUniversity of North Carolina Chapel Hill North Carolina
| | - Shannon Palmer
- Department of PharmacyUniversity of North Carolina Chapel Hill North Carolina
| | - Anqi Zhu
- Biostatistics Shared Resource, Lineberger Comprehensive Cancer CenterUniversity of North Carolina Chapel Hill North Carolina
| | - Allison M. Deal
- Biostatistics Shared Resource, Lineberger Comprehensive Cancer CenterUniversity of North Carolina Chapel Hill North Carolina
| | - Sheh‐Li Chen
- Department of PharmacyUniversity of North Carolina Chapel Hill North Carolina
| | - Stephan Moll
- Division of Hematology‐Oncology, Department of MedicineUniversity of North Carolina Chapel Hill North Carolina
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6
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Malpica L, van Duin D, Moll S. Preventing infectious complications when treating non-malignant immune-mediated hematologic disorders. Am J Hematol 2019; 94:1396-1412. [PMID: 31571266 DOI: 10.1002/ajh.25642] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Revised: 09/11/2019] [Accepted: 09/16/2019] [Indexed: 01/19/2023]
Abstract
Immunosuppressants, targeted antibody therapies, and surgical splenectomy are amongst the treatment choices for immune-mediated non-malignant hematologic disorders, with infection being the most common non-hematological adverse event from these therapies. Corticosteroids are associated with a length-of-treatment and dose-dependent risk for infection, including opportunistic infections. Screening and antimicrobial prophylaxis against tuberculosis, Strongyloides stercoralis, and Pneumocystis jirovecii pneumonia, are indicated in selected patients on steroids and with certain risk factors for infection. Rituximab is associated with hepatitis B virus reactivation. All patients planned to be started on rituximab should be screened for hepatitis B surface antigen and total core antibody, with antiviral prophylaxis given depending on test results. In eculizumab treated patients, immunization against meningococcal serogroups ACWY and B is recommended. In addition, some guidelines suggest antibiotic prophylaxis for the duration of eculizumab treatment. In splenectomized patients, counseling and immunization are cornerstones of infection prevention. Several federal and society guidelines about immunizations and prophylactic antimicrobial therapies for patients treated with various immunosuppressive agents exist and are summarized in this manuscript in a clinical-focused table. In addition, management suggestions are made where no formal guidelines exist.
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Affiliation(s)
- Luis Malpica
- Department of Medicine, Division of Hematology and Oncology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - David van Duin
- Department of Medicine, Division of Infectious Diseases, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Stephan Moll
- Department of Medicine, Division of Hematology and Oncology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
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7
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Late-Onset Neutropenia after Rituximab Treatment for Adult-Onset Nephrotic Syndrome. Case Rep Nephrol 2019; 2019:3580941. [PMID: 30956827 PMCID: PMC6425356 DOI: 10.1155/2019/3580941] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Revised: 02/04/2019] [Accepted: 02/18/2019] [Indexed: 12/02/2022] Open
Abstract
A 41-year-old woman developed nephrotic syndrome at the age of 32 and was diagnosed with minimal change nephrotic syndrome based on a renal biopsy. Although remission was achieved with administration of prednisolone (PSL) and cyclosporine, the nephrotic syndrome recurred. She was also started on rituximab (RTX). She developed late-onset neutropenia after RTX treatment (R-LON) and improved 17 days later. Although the majority of R-LON cases undergo spontaneous remission, cases of death have been reported. This report is intended to warn about R-LON, since the use of RTX for adult-onset nephrotic syndrome is expected to increase in the future.
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8
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Whittam DH, Tallantyre EC, Jolles S, Huda S, Moots RJ, Kim HJ, Robertson NP, Cree BAC, Jacob A. Rituximab in neurological disease: principles, evidence and practice. Pract Neurol 2019; 19:5-20. [PMID: 30498056 DOI: 10.1136/practneurol-2018-001899] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Rituximab is a widely used B-cell-depleting monoclonal antibody. It is unlicensed for use in neurological disorders and there are no treatment guidelines. However, as a rapidly acting, targeted therapy with growing evidence of efficacy and tolerability in several neuroinflammatory disorders, it is an attractive alternative to conventional immunomodulatory medications. This practical review aims to explain the basic principles of B-cell depletion with therapeutic monoclonal antibodies. We present the evidence for using rituximab in neurological diseases, and describe the practical aspects of prescribing, including dosing, monitoring, safety, treatment failure and its use in special circumstances such as coexisting viral hepatitis, pregnancy and lactation. We provide an administration guide, checklist and patient information leaflet, which can be adapted for local use. Finally, we review the safety data of rituximab and ocrelizumab (a newer and recently licensed B-cell-depleting therapy for multiple sclerosis) and suggest monitoring and risk reduction strategies.
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Affiliation(s)
- Daniel H Whittam
- Department of Neurology, The Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Emma C Tallantyre
- Helen Durham Centre for Neuroinflammation, University Hospital or Wales, Cardiff, UK
- Division of Psychological Medicine and Clinical Neurosciences, School of Medicine, Cardiff University, Cardiff, UK
| | - Stephen Jolles
- Immunodeficiency Centre for Wales, University Hospital of Wales, Cardiff, UK
- School of Medicine, Cardiff University, Cardiff, UK
| | - Saif Huda
- Department of Neurology, The Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Robert J Moots
- Department of Musculoskeletal Diseases, Institute of Ageing and Chronic Diseases, University of Liverpool, Liverpool, UK
| | - Ho Jin Kim
- Department of Neurology, Research Institute and Hospital of National Cancer Center, Goyang, South Korea
| | - Neil P Robertson
- Helen Durham Centre for Neuroinflammation, University Hospital or Wales, Cardiff, UK
- Division of Psychological Medicine and Clinical Neurosciences, School of Medicine, Cardiff University, Cardiff, UK
| | - Bruce A C Cree
- Weill Institute for Neurosciences, University of California, San Francisco, California, USA
| | - Anu Jacob
- Department of Neurology, The Walton Centre NHS Foundation Trust, Liverpool, UK
- School of Medicine, University of Liverpool, Liverpool, UK
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9
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Jayashree S, Nirekshana K, Guha G, Bhakta-Guha D. Cancer chemotherapeutics in rheumatoid arthritis: A convoluted connection. Biomed Pharmacother 2018; 102:894-911. [PMID: 29710545 DOI: 10.1016/j.biopha.2018.03.123] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Revised: 03/20/2018] [Accepted: 03/20/2018] [Indexed: 12/11/2022] Open
Abstract
Chemotherapy is one of the most popular therapeutic strategies to treat cancer. However, cancer chemotherapeutics have often been associated with impairment of the immune system, which might consequently lead to an augmented risk of autoimmune disorders, such as rheumatoid arthritis. Though the accurate mechanistic facets of rheumatoid arthritis induction have not been interpreted yet, a conglomeration of genetic and environmental factors might promote its etiology. What makes the scenario more challenging is that patients with rheumatoid arthritis are at a significantly elevated risk of developing various types of cancer. It is intriguing to note that diverse cancer chemotherapy drugs are also commonly used to treat symptoms of rheumatoid arthritis. However, a colossal multitude of such cancer therapeutics has demonstrated highly varied results in rheumatoid arthritis patients, including both beneficial and adverse effects. Herein, we attempt to present a holistic account of the variegated modalities of this complex tripartite cross-talk between cancer, rheumatoid arthritis and chemotherapy drugs in order to decode the sinuous correlation between these two appalling pathological conditions.
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Affiliation(s)
- S Jayashree
- Cellular Dyshomeostasis Laboratory (CDHL), Department of Biotechnology, School of Chemical and Bio Technology, SASTRA University, Thanjavur, 613 401, Tamil Nadu, India
| | - K Nirekshana
- Cellular Dyshomeostasis Laboratory (CDHL), Department of Biotechnology, School of Chemical and Bio Technology, SASTRA University, Thanjavur, 613 401, Tamil Nadu, India
| | - Gunjan Guha
- Cellular Dyshomeostasis Laboratory (CDHL), Department of Biotechnology, School of Chemical and Bio Technology, SASTRA University, Thanjavur, 613 401, Tamil Nadu, India.
| | - Dipita Bhakta-Guha
- Cellular Dyshomeostasis Laboratory (CDHL), Department of Biotechnology, School of Chemical and Bio Technology, SASTRA University, Thanjavur, 613 401, Tamil Nadu, India.
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10
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AlDhaheri F, Almteri T, Dwid N, Majdali A, Janoudi N, Almoallim H. Rituximab Can Induce Remission in a Patient with Ankylosing Spondylitis Who Failed Anti-TNF-α Agent. AMERICAN JOURNAL OF CASE REPORTS 2017; 18:143-147. [PMID: 28179619 PMCID: PMC5315003 DOI: 10.12659/ajcr.900563] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Patient: Male, 38 Final Diagnosis: Ankylosing spondylitis Symptoms: Back pain • morning stiffness Medication: — Clinical Procedure: Not applicable Specialty: Rheuamatology
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Affiliation(s)
- Fahmi AlDhaheri
- Department of Internal Medicine, Dr. Soliman Fakeeh Hospital, Jeddah, Saudi Arabia
| | - Talal Almteri
- Department of Internal Medicine, Medical College, Umm-Al Qura University, Makkah, Saudi Arabia
| | - Naji Dwid
- Department of Internal Medicine, Dr. Soliman Fakeeh Hospital, Jeddah, Saudi Arabia
| | - Ahd Majdali
- Department of Internal Medicine, Medical College, Umm-Al Qura University, Makkah, Saudi Arabia
| | - Nahed Janoudi
- Internal medicine department, Dr.soliman Fakeeh hospital, Makkah, Saudi Arabia
| | - Hani Almoallim
- Department of Internal Medicine, Dr. Soliman Fakeeh Hospital, Jeddah, Saudi Arabia.,Department of Internal Medicine, Medical College, Umm-Al Qura University, Makkah, Saudi Arabia.,Alzaidi Chair of Research in Rheumatic Diseases, Medical College, Umm-Al Qura University, Makkah, Saudi Arabia
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11
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Ahmadi F, Dashti-Khavidaki S, Khatami MR, Lessan-Pezeshki M, Khalili H, Khosravi M. Rituximab-Related Late-Onset Neutropenia in Kidney Transplant Recipients Treated for Antibody-Mediated Acute Rejection. EXP CLIN TRANSPLANT 2016; 15:414-419. [PMID: 27796249 DOI: 10.6002/ect.2016.0027] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES Kidney transplant is a new area for use of rituximab, which is being used to treat acute antibody-mediated rejection or as an induction agent in ABO- or HLA-incompatible grafts. We report on late-onset neutropenia in rituximab-treated kidney transplant recipients with antibody-mediated rejection. MATERIALS AND METHODS This observational prospective study was performed on kidney transplant recipients with clinically suspicious or biopsy-proven antibody-mediated rejection treated with plasmapheresis plus intravenous immunoglobulin with (cases) or without (controls) rituximab. RESULTS Compared with none of the controls, 4 of 6 patients (66.7%) in the rituximab-treated group experienced late-onset neutropenia 35 to 93 days after the last dose of rituximab. The course of neutropenia was complicated by endocarditis in 1 patient, resulting in his death just because of a lack of valvular surgery. CONCLUSIONS Increased use of rituximab to treat antibody-mediated rejection among kidney transplant recipients requires attention to its late-onset adverse event, neutropenia. Although asymptomatic in some patients, kidney transplant recipients treated concomitantly with plasmapheresis and mycophenolate mofetil are predisposed to hypogammaglobulinemia, and monitoring of patients for infections is required.
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Affiliation(s)
- Fatemeh Ahmadi
- From the Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
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12
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