1
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Le Quang M, Solé G, Martin-Négrier ML, Mathis S. Clinical and pathological aspects of toxic myopathies. J Neurol 2024:10.1007/s00415-024-12522-x. [PMID: 38907023 DOI: 10.1007/s00415-024-12522-x] [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: 04/17/2024] [Revised: 06/14/2024] [Accepted: 06/15/2024] [Indexed: 06/23/2024]
Abstract
As the most frequent cause of acquired myopathy, toxic myopathies are characterised by clinicopathological features that vary depending on the mode of action of the drugs or toxins involved. Although a large number of substances can induce myotoxicity, the main culprits are statins, alcohol, and corticosteroids. A rigorous, well-organised diagnostic approach is necessary to obtain a rapid diagnosis. For early diagnosis and management, it is important for clinicians to be aware that most toxic myopathies are potentially reversible, and the goal of treatment should be to avoid serious muscle damage.
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Affiliation(s)
- Mégane Le Quang
- Department of Pathology, University Hospital (CHU) of Bordeaux, Pellegrin Hospital, Place Amélie Raba Léon, 33000, Bordeaux, France
| | - Guilhem Solé
- Department of Neurology, Nerve-Muscle Unit, AOC Reference for Neuromuscular Disorders, University Hospital (CHU) of Bordeaux, Pellegrin Hospital, Place Amélie Raba Léon, 33000, Bordeaux, France
| | - Marie-Laure Martin-Négrier
- Department of Pathology, University Hospital (CHU) of Bordeaux, Pellegrin Hospital, Place Amélie Raba Léon, 33000, Bordeaux, France
| | - Stéphane Mathis
- Department of Neurology, Nerve-Muscle Unit, AOC Reference for Neuromuscular Disorders, University Hospital (CHU) of Bordeaux, Pellegrin Hospital, Place Amélie Raba Léon, 33000, Bordeaux, France.
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2
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Knapp S, Bolko L, Servettaz A, Didier K. [[Eosinophilic fasciitis: From pathophysiology to therapeutics]]. Rev Med Interne 2024:S0248-8663(24)00086-9. [PMID: 38519306 DOI: 10.1016/j.revmed.2024.03.006] [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: 11/23/2023] [Revised: 02/27/2024] [Accepted: 03/07/2024] [Indexed: 03/24/2024]
Abstract
Eosinophilic fasciitis (EF) is a rare connective tissue disorder characterized by painful edema and induration of the limbs and trunk, likely associated with hypereosinophilia and hypergammaglobulinemia. EF causes arthralgia and range of motion limitation, leading to significant functional impairment and poor quality of life. Since its description by Shulman in 1974, over 300 cases have been reported. We present here a review of the latest diagnostic, pathophysiological and therapeutic developments in this disease. Magnetic resonance imaging appears useful to guide diagnosis and biopsy. Diagnosis is based on a deep skin biopsy involving the fascia, which will reveal edema, sclerofibrosis of the muscular fascia and subcutaneous tissue, and an inflammatory infiltrate sometimes composed of eosinophilic polynuclear cells. EF may occur in patients treated with immune checkpoint inhibitors and the diagnosis should be raised in case of cutaneous sclerosis in these patients. The pathophysiology of the disease remains poorly understood, and its management lacks randomized, controlled, blinded trials. First-line treatment consists in oral corticosteroid therapy, sometimes combined with an immunosuppressant, mainly methotrexate. A better understanding of the pathophysiology has opened new therapeutic perspectives and clarified the role of targeted therapies in the management of EF, such as interleukin-6 inhibitors, whose efficacy has been reported in several cases.
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Affiliation(s)
- S Knapp
- Service de médecine interne, maladie infectieuse et immunologie clinique, hôpital Robert-Debré, CHU de Reims, rue du Général-Kœnig, 51092 Reims cedex, France
| | - L Bolko
- Service de rhumatologie, hôpital Maison Blanche, CHU de Reims, Reims, France
| | - A Servettaz
- Service de médecine interne, maladie infectieuse et immunologie clinique, hôpital Robert-Debré, CHU de Reims, rue du Général-Kœnig, 51092 Reims cedex, France; EA 7509 IRMAIC, université de Reims Champagne-Ardenne, Reims, France
| | - K Didier
- Service de médecine interne, maladie infectieuse et immunologie clinique, hôpital Robert-Debré, CHU de Reims, rue du Général-Kœnig, 51092 Reims cedex, France; EA 7509 IRMAIC, université de Reims Champagne-Ardenne, Reims, France.
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3
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Benzaquen M, Christ L, Sutter N, Özdemir BC. Nivolumab-induced eosinophilic fasciitis: An unusual immune-related adverse event that needs to be recognized by practitioners. Ann Dermatol Venereol 2023; 150:304-307. [PMID: 37821251 DOI: 10.1016/j.annder.2023.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 03/20/2023] [Accepted: 07/12/2023] [Indexed: 10/13/2023]
Affiliation(s)
- M Benzaquen
- Department of Dermatology, Inselspital - Bern University Hospital, University of Bern, CH-3010 Bern, Switzerland.
| | - L Christ
- Department of Rheumatology and Immunology, Inselspital - Bern University Hospital, University of Bern, CH-3010 Bern, Switzerland
| | - N Sutter
- Department of Internal Medicine, Inselspital - Bern University Hospital, University of Bern, CH-3010 Bern, Switzerland
| | - B C Özdemir
- Department of Oncology, Inselspital - Bern University Hospital, University of Bern, CH-3010 Bern, Switzerland
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4
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Angelopoulos A, Kouverianos I, Daoussis D. Is there a Role for Anti-IL-5 Therapies in Eosinophilic Fasciitis? Mediterr J Rheumatol 2023; 34:414-417. [PMID: 38282929 PMCID: PMC10815516 DOI: 10.31138/mjr.301223.itr] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 11/11/2023] [Accepted: 11/13/2023] [Indexed: 01/30/2024] Open
Abstract
Introduction Eosinophilic Fasciitis (EF) is a rare disease, originally proposed as "diffuse fasciitis with eosinophilia" by Shulman in 1974. Symptoms of EF include peripheral eosinophilia accompanied by symmetrical inflammation of the subcutaneous fascia and muscle, usually locating in the upper arms or thighs. There is no approved standard of care treatment. Methods Taking into account that eosinophils may be pathogenetically involved in EF, we performed a review on Medline focusing on anti-Interleukin-5 (IL-5) therapies in EF. Results Only one case of a patient with EF has been reported who was successfully treated with reslizumab, an anti-IL-5 therapy. The patient had EF refractory to the commonly used immunosuppressive treatment but when reslizumab was added, the patient experienced remission of her symptoms. Discussion The exact aetiology of EF is still unclear, and many therapeutic approaches have been tested. Commonly used immunosuppressive agents, such as corticosteroids are not always effective and associate with significant side effects. Eosinophils seem to have a role in the pathogenesis of the disease; anti-eosinophilic therapies targeting IL-5/IL-5 Receptor could be an attractive alternative for the treatment of the disease.
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Affiliation(s)
| | | | - Dimitrios Daoussis
- Department of Rheumatology, Patras University Hospital, University of Patras Medical School, Patras, Greece
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5
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Tasaki Y, Hamamoto S, Sugiyama Y, Tomiyama N, Naiki T, Etani T, Taguchi K, Matsuyama N, Sue Y, Mimura Y, Kubota H, Noda Y, Aoki M, Moritoki Y, Nozaki S, Kurokawa S, Okada A, Kawai N, Yasui T, Kimura K. Elevated eosinophils proportion as predictor of immune-related adverse events after ipilimumab and nivolumab treatment of advanced and metastatic renal cell carcinoma. Int J Urol 2023; 30:866-874. [PMID: 37278575 DOI: 10.1111/iju.15220] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Accepted: 05/22/2023] [Indexed: 06/07/2023]
Abstract
OBJECTIVES Ipilimumab and nivolumab treatment against advanced and metastatic renal cell carcinoma (RCC) causes severe and lethal immune-related adverse events (irAEs). Predicting irAEs might improve clinical outcomes, however no practical biomarkers exist. This study examined whether eosinophils could be effective biomarkers for ≥grade 2 irAEs in RCC. METHODS We retrospectively analyzed 75 patients with RCC treated with ipilimumab and nivolumab between August 2018 and March 2021 in a multicenter study. Eosinophils were examined before and 2 weeks after treatment, and immediately after irAEs development. The optimal cut-off value for ≥grade 2 irAEs was determined by a receiver operating characteristic (ROC) curve. Univariate and multivariate analyses were undertaken to identify predictors of ≥grade 2 irAEs. RESULTS Two weeks after treatment, eosinophils were significantly upregulated in patients who had experienced ≥grade 2 irAEs than in those who had not experienced irAEs (mean, 5.7% vs. 3.2%; p < 0.05). The optimal cut-off value for eosinophils against ≥grade 2 irAEs was 3.0% (area under the curve = 0.69). In multivariate analyses, an eosinophil level ≥ 3.0% was a risk factor for ≥grade 2 irAEs (odds ratio 4.18, 95% confidence interval 1.16-15.1). The eosinophil level 2 weeks after treatment was upregulated by the onset of any type of irAEs including endocrine, gastrointestinal, pulmonary and skin disorders. CONCLUSIONS An increased eosinophil level 2 weeks after treatment might be an effective biomarker for ≥grade 2 irAEs in patients with RCC treated with ipilimumab and nivolumab.
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Affiliation(s)
- Yoshihiko Tasaki
- Department of Clinical Pharmaceutics, Nagoya City University Graduate School of Medical Sciences, Nagoya, Aichi, Japan
| | - Shuzo Hamamoto
- Department of Nephro-urology, Nagoya City University Graduate School of Medical Sciences, Aichi, Nagoya, Japan
| | - Yosuke Sugiyama
- Department of Clinical Pharmaceutics, Nagoya City University Graduate School of Medical Sciences, Nagoya, Aichi, Japan
| | - Nami Tomiyama
- Department of Nephro-urology, Nagoya City University Graduate School of Medical Sciences, Aichi, Nagoya, Japan
| | - Taku Naiki
- Department of Nephro-urology, Nagoya City University Graduate School of Medical Sciences, Aichi, Nagoya, Japan
| | - Toshiki Etani
- Department of Nephro-urology, Nagoya City University Graduate School of Medical Sciences, Aichi, Nagoya, Japan
| | - Kazumi Taguchi
- Department of Nephro-urology, Nagoya City University Graduate School of Medical Sciences, Aichi, Nagoya, Japan
| | - Nayuka Matsuyama
- Department of Nephro-urology, Nagoya City University Graduate School of Medical Sciences, Aichi, Nagoya, Japan
| | - Yasuhito Sue
- Department of Nephro-urology, Nagoya City University Graduate School of Medical Sciences, Aichi, Nagoya, Japan
| | - Yoshihisa Mimura
- Department of Clinical Pharmaceutics, Nagoya City University Graduate School of Medical Sciences, Nagoya, Aichi, Japan
| | - Hiroki Kubota
- Department of Urology, Kainan Hospital, Yatomi, Aichi, Japan
| | - Yusuke Noda
- Department of Urology, Toyota Kosei Hospital, Toyota, Aichi, Japan
| | - Maria Aoki
- Department of Urology, Nagoya East Medical Center, Nagoya, Aichi, Japan
| | | | - Satoshi Nozaki
- Department of Urology, Nagoya Tokushukai General Hospital, Kasugai, Aichi, Japan
| | - Satoshi Kurokawa
- Department of Urology, Nagoya Tokushukai General Hospital, Kasugai, Aichi, Japan
| | - Atsushi Okada
- Department of Nephro-urology, Nagoya City University Graduate School of Medical Sciences, Aichi, Nagoya, Japan
| | - Noriyasu Kawai
- Department of Nephro-urology, Nagoya City University Graduate School of Medical Sciences, Aichi, Nagoya, Japan
| | - Takahiro Yasui
- Department of Nephro-urology, Nagoya City University Graduate School of Medical Sciences, Aichi, Nagoya, Japan
| | - Kazunori Kimura
- Department of Clinical Pharmaceutics, Nagoya City University Graduate School of Medical Sciences, Nagoya, Aichi, Japan
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6
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Martel J, Hanania HL, Patel AB. Immune checkpoint inhibitor-induced cutaneous toxicities: a review of histopathologic and clinical features. Hum Pathol 2023; 140:144-172. [PMID: 37141978 DOI: 10.1016/j.humpath.2023.04.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 04/25/2023] [Accepted: 04/26/2023] [Indexed: 05/06/2023]
Abstract
Immune checkpoint inhibitors (ICIs) represent an emerging treatment option for a variety of cancer types. Through inhibition of programmed cell death protein 1 (PD-1), programmed cell death ligand 1 (PD-L1), and/or cytotoxic lymphocyte-associated antigen-4 (CTLA-4), ICIs activate the host's immune system causing a heightened anti-tumor response. However, off-target effects of ICIs can result in numerous different immune-related cutaneous adverse events (irCAEs). Beyond impacting quality of life, irCAEs can lead to dose limitations or discontinuation of anti-cancer therapies. Correct diagnosis is necessary for expedient and appropriate management. Skin biopsies are often performed to increase diagnostic accuracy and guide clinical management. An extensive literature review was performed using the PubMed database to identify the reported clinical and histopathologic features of irCAEs. This comprehensive review primarily details the histopathologic features of various irCAEs reported to date. Clinical presentation and immunopathogenesis are also discussed in relation to histopathology.
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Affiliation(s)
- Julianna Martel
- Department of Dermatology, The University of Texas, MD Anderson Cancer Center, Houston, TX, 77030, USA
| | | | - Anisha B Patel
- Department of Dermatology, The University of Texas, MD Anderson Cancer Center, Houston, TX, 77030, USA.
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7
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Macklin M, Yadav S, Jan R, Reid P. Checkpoint Inhibitor-Associated Scleroderma and Scleroderma Mimics. Pharmaceuticals (Basel) 2023; 16:259. [PMID: 37259404 PMCID: PMC9962184 DOI: 10.3390/ph16020259] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Revised: 02/03/2023] [Accepted: 02/06/2023] [Indexed: 10/28/2023] Open
Abstract
Immune checkpoint inhibitors (ICI) are the standard of care for various malignancies and have been associated with a wide spectrum of complications that are phenotypically akin to primary autoimmune diseases. While the literature on these toxicities is growing, there is a paucity of data regarding ICI-associated scleroderma which can carry significant morbidity and limit the ability to continue effective ICI therapy. Our review aimed to analyze the current literature on ICI-associated systemic scleroderma (ICI-SSc) and key scleroderma mimics. Cases of ICI-SSc had notable differences from primary SSc, such as fewer vascular features and less seropositivity (such as scleroderma-specific antibodies and antinuclear antibodies). We found that patients with a diagnosis of SSc prior to the start of ICI can also experience flares of pre-existing disease after ICI treatment used for their cancer. Regarding scleroderma mimics, several cases of ICI-eosinophilic fasciitis have also been described with variable clinical presentations and courses. We found no cases of scleroderma mimics: ICI-scleromyxedema or ICI-scleroedema. There is a critical need for multi-institutional efforts to collaborate on developing a patient database and conducting robust, prospective research on ICI-scleroderma. This will ultimately facilitate more effective clinical evaluations and management for ICI-scleroderma.
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Affiliation(s)
- Michael Macklin
- Section of Rheumatology, Department of Medicine, University of Chicago Medical Center, Chicago, IL 60637, USA
| | - Sudeep Yadav
- Section of Rheumatology, Department of Medicine, University of Chicago Medical Center, Chicago, IL 60637, USA
| | - Reem Jan
- Section of Rheumatology, Department of Medicine, University of Chicago Medical Center, Chicago, IL 60637, USA
| | - Pankti Reid
- Section of Rheumatology, Department of Medicine, University of Chicago Medical Center, Chicago, IL 60637, USA
- Committee on Clinical Pharmacology and Pharmacogenomics, University of Chicago Medical Center, Chicago, IL 60637, USA
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8
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Shinozaki A, Hayashi S, Hongo T, Okamoto M, Ishikawa S, Igawa K. Efficacy of methotrexate for steroid-resistant eosinophilic fasciitis with delayed start of treatment: a case report. Int J Dermatol 2023; 62:e67-e68. [PMID: 35569104 DOI: 10.1111/ijd.16299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 04/27/2022] [Accepted: 05/05/2022] [Indexed: 01/20/2023]
Affiliation(s)
- Anju Shinozaki
- Department of Dermatology, Dokkyo Medical University School of Medicine, Mibu, Tochigi, Japan
| | - Shujiro Hayashi
- Department of Dermatology, Dokkyo Medical University School of Medicine, Mibu, Tochigi, Japan
| | - Takayuki Hongo
- Department of Dermatology, Dokkyo Medical University School of Medicine, Mibu, Tochigi, Japan
| | - Maki Okamoto
- Department of Dermatology, Dokkyo Medical University School of Medicine, Mibu, Tochigi, Japan
| | - Satoko Ishikawa
- Department of Dermatology, Dokkyo Medical University School of Medicine, Mibu, Tochigi, Japan
| | - Ken Igawa
- Department of Dermatology, Dokkyo Medical University School of Medicine, Mibu, Tochigi, Japan
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9
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Mazilu D, Boltașiu (Tătaru) LA, Mardale DA, Bijă MS, Ismail S, Zanfir V, Negoi F, Balanescu AR. Eosinophilic Fasciitis: Current and Remaining Challenges. Int J Mol Sci 2023; 24:ijms24031982. [PMID: 36768300 PMCID: PMC9916848 DOI: 10.3390/ijms24031982] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Revised: 01/09/2023] [Accepted: 01/14/2023] [Indexed: 01/20/2023] Open
Abstract
Eosinophilic fasciitis (EF), defined as diffuse fasciitis with eosinophilia by Shulman in 1974, is a disease with unknown etiology and whose pathogenesis is still being researched. The diagnosis is based on the clinical aspects (skin induration with an "orange peel" appearance), the lab results (eosinophilia, increased inflammatory markers), the skin biopsy with the pathognomonic histopathological result, as well as the typical MRI changes. The treatment includes glucocorticoids and immunosuppressive drugs. Due to severe refractory cases, the treatment remains a challenge. EF is still a disease with potential for further research.
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Affiliation(s)
- Diana Mazilu
- “Sfanta Maria” Clinical Hospital, Ion Mihalache blvd, 37-39, 011172 Bucharest, Romania
- “Carol Davila” University of Medicine, Dionisie Lupu Street, nr 37, 020021 Bucharest, Romania
- Correspondence: (D.M.); (L.A.B.)
| | - Laura Alina Boltașiu (Tătaru)
- “Sfanta Maria” Clinical Hospital, Ion Mihalache blvd, 37-39, 011172 Bucharest, Romania
- Correspondence: (D.M.); (L.A.B.)
| | - Denise-Ani Mardale
- “Sfanta Maria” Clinical Hospital, Ion Mihalache blvd, 37-39, 011172 Bucharest, Romania
- “Carol Davila” University of Medicine, Dionisie Lupu Street, nr 37, 020021 Bucharest, Romania
| | - Maria Silviana Bijă
- “Sfanta Maria” Clinical Hospital, Ion Mihalache blvd, 37-39, 011172 Bucharest, Romania
| | - Sermina Ismail
- “Sfanta Maria” Clinical Hospital, Ion Mihalache blvd, 37-39, 011172 Bucharest, Romania
| | - Violeta Zanfir
- “Sfanta Maria” Clinical Hospital, Ion Mihalache blvd, 37-39, 011172 Bucharest, Romania
| | - Florentina Negoi
- “Sfanta Maria” Clinical Hospital, Ion Mihalache blvd, 37-39, 011172 Bucharest, Romania
| | - Andra Rodica Balanescu
- “Sfanta Maria” Clinical Hospital, Ion Mihalache blvd, 37-39, 011172 Bucharest, Romania
- “Carol Davila” University of Medicine, Dionisie Lupu Street, nr 37, 020021 Bucharest, Romania
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10
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Abstract
Palmar fasciitis and polyarthritis syndrome (PFPAS) is a rare paraneoplastic rheumatic disease with characteristic features. We herein report a 77-year-old man with lung adenocarcinoma and contralateral pulmonary metastasis receiving chemotherapy who presented with progressive symmetrical flexion contractures associated with palmar fascial thickening and arthritis of both hands and shoulders. He was diagnosed with PFPAS as paraneoplastic manifestations. Salazosulfapyridine was not effective, but 15 mg/day of oral prednisolone improved his symptoms. Physicians should consider PFPAS and rule out malignancy in patients with arthritis in the extremities and flexion contractures associated with palmar fascial thickening.
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Affiliation(s)
- Hisatoshi Okumura
- Division of General Internal Medicine, North Medical Center Kyoto Prefectural University of Medicine, Japan
| | - Hidetaka Ishino
- Division of General Internal Medicine, North Medical Center Kyoto Prefectural University of Medicine, Japan
| | - Daisuke Yokoi
- Division of General Internal Medicine, North Medical Center Kyoto Prefectural University of Medicine, Japan
| | - Masami Matsumura
- Division of General Internal Medicine, Jichi Medical University, Japan
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11
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Naschitz JE. Clinical guide to eosinophilic fasciitis: straddling dermatology and rheumatology. Expert Rev Clin Immunol 2022; 18:649-651. [PMID: 35575016 DOI: 10.1080/1744666x.2022.2078309] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Jochanan E Naschitz
- Bait Balev Nesher and the Ruth and Bruce Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel
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12
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Haroon A, Tadros J, Smith EH. Eosinophilic Fasciitis with Concurrent Necrobiotic Granulomatous Dermatitis Related to Checkpoint Inhibition Therapy. JOURNAL OF IMMUNOTHERAPY AND PRECISION ONCOLOGY 2022; 5:48-51. [PMID: 35664087 PMCID: PMC9153248 DOI: 10.36401/jipo-21-19] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Revised: 11/18/2021] [Accepted: 11/22/2021] [Indexed: 12/02/2022]
Abstract
Immune checkpoint inhibitors (ICIs) have revolutionized cancer therapeutics. However, loss of physiologic tolerance in few cases has triggered rare and novel immune-related adverse events (irAEs). Eosinophilic fasciitis, an infrequently reported diffuse scleroderma-like entity, has been associated with ICI therapy. We report a case of a patient with metastatic melanoma treated with nivolumab who developed eosinophilic fasciitis with concurrent granulomatous dermatitis and lymphadenitis, the latter of which mimicked melanoma recurrence radiographically. Furthermore, this patient had a severe presentation that subsequently proved to be treatment-resistant to both corticosteroid and steroid-sparing therapies. To our knowledge, eosinophilic fasciitis has not been reported concurrently with granulomatous dermatitis in literature. We provide a narrative of this case and a review of therapeutic approaches for severe or refractory irAEs. With the increasing popularity of ICI therapy, we believe it is essential for clinicians to identify novel irAEs and be aware of treatments as late recognition could prove fatal.
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Affiliation(s)
- Adeeb Haroon
- Department of Dermatology, University of Missouri, Columbia, MO, USA
| | - Joseph Tadros
- Department of Dermatology, University of Missouri, Columbia, MO, USA
| | - Emily H. Smith
- Department of Dermatology, University of Missouri, Columbia, MO, USA
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13
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Abstract
Immune checkpoint inhibitors activate the immune system to combat cancer. In doing so, however, they can cause immune-related adverse events (irAEs), including rheumatic syndromes, such as inflammatory arthritis, polymyalgia rheumatica, and myositis. This article reviews rheumatic irAEs that may be encountered in the general medicine practice and provides guidance to support prompt recognition, referral, and treatment of these patients.
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Affiliation(s)
- Nilasha Ghosh
- Hospital for Special Surgery, Weill Cornell Medicine, New York, NY, USA
| | - Anne R Bass
- Hospital for Special Surgery, Weill Cornell Medicine, New York, NY, USA.
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14
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Amrane K, Le Meur C, Thuillier P, Alemany P, Niel C, Renault D, Abgral R. Case report: Eosinophilic fasciitis induced by pembrolizumab with high FDG uptake on 18F-FDG-PET/CT. Front Med (Lausanne) 2022; 9:1078560. [PMID: 36606046 PMCID: PMC9807755 DOI: 10.3389/fmed.2022.1078560] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 11/28/2022] [Indexed: 12/24/2022] Open
Abstract
Eosinophilic fasciitis (EF) is a rare connective tissue disorder causing inflammation and fibrosing of fascia. In this study, we present a very rare case of an immune checkpoint inhibitor (ICI)-induced EF revealed by 18F-fluorodesoxyglucose positron emission tomography (FDG-PET/CT) 20 months after the initiation of Pembrolizumab treatment of a relapsed non-small cell lung cancer (NSCLC). This study presents a 52-year-old Caucasian woman clinically presenting asthenia, inflammatory muscle, and joint pain associated with subcutaneous nodules and symmetrical edema of the lower limbs. Iterative 18FDG-PET/CT scans allow us to guide the therapeutic strategy due to this atypical ICI adverse event.
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Affiliation(s)
- Karim Amrane
- Department of Oncology, Centre Hospitalier des Pays de Morlaix, Morlaix, France.,Institut National de la Santé et de la Recherche Médicale UMR 1227, Lymphocytes B et Autoimmunité, Univ. Brest, Institut National de la Santé et de la Recherche Médicale, LabEx IGO, Brest, France
| | - Coline Le Meur
- Department of Oncology, Centre Hospitalier des Pays de Morlaix, Morlaix, France
| | - Philippe Thuillier
- Institut National de la Santé et de la Recherche Médicale UMR 1304 GETBO, University of Western Brittany, Brest, France.,Department of Endocrinology, University Hospital of Brest, Brest, France
| | - Pierre Alemany
- Department of Pathology, Ouest Pathologie, Brest, France
| | - Clémence Niel
- Department of Pneumology, Centre Hospitalier des Pays de Morlaix, Morlaix, France
| | - David Renault
- Department of Pneumology, Centre Hospitalier des Pays de Morlaix, Morlaix, France
| | - Ronan Abgral
- Department of Endocrinology, University Hospital of Brest, Brest, France.,Department of Nuclear Medicine, University Hospital of Brest, Brest, France
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15
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Boothby IC, Kinet MJ, Boda DP, Kwan EY, Clancy S, Cohen JN, Habrylo I, Lowe MM, Pauli M, Yates AE, Chan JD, Harris HW, Neuhaus IM, McCalmont TH, Molofsky AB, Rosenblum MD. Early-life inflammation primes a T helper 2 cell-fibroblast niche in skin. Nature 2021; 599:667-672. [PMID: 34707292 PMCID: PMC8906225 DOI: 10.1038/s41586-021-04044-7] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 09/20/2021] [Indexed: 12/18/2022]
Abstract
Inflammation early in life can prime the local immune milieu of peripheral tissues, which can cause lasting changes in immunological tone that confer disease protection or susceptibility1. The cellular and molecular mechanisms that prompt changes in immune tone in many nonlymphoid tissues remain largely unknown. Here we find that time-limited neonatal inflammation induced by a transient reduction in neonatal regulatory T cells causes a dysregulation of subcutaneous tissue in mouse skin. This is accompanied by the selective accumulation of type 2 helper T (TH2) cells within a distinct microanatomical niche. TH2 cells are maintained into adulthood through interactions with a fibroblast population in skin fascia that we refer to as TH2-interacting fascial fibroblasts (TIFFs), which expand in response to TH2 cytokines to form subcutaneous fibrous bands. Activation of the TH2-TIFF niche due to neonatal inflammation primes the skin for altered reparative responses to wounding. Furthermore, we identify fibroblasts in healthy human skin that express the TIFF transcriptional signature and detect these cells at high levels in eosinophilic fasciitis, an orphan disease characterized by inflammation and fibrosis of the skin fascia. Taken together, these data define a previously unidentified TH2 cell niche in skin and functionally characterize a disease-associated fibroblast population. The results also suggest a mechanism of immunological priming whereby inflammation early in life creates networks between adaptive immune cells and stromal cells to establish an immunological set-point in tissues that is maintained throughout life.
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Affiliation(s)
- Ian C. Boothby
- Department of Dermatology, University of California at San Franscisco, San Francisco, CA, USA.,Medical Scientist Training Program, University of California at San Franscisco, San Francisco, CA, USA
| | - Maxime J. Kinet
- Division of Rheumatology, Department of Medicine, University of California at San Franscisco, San Francisco, CA, USA
| | - Devi P. Boda
- Department of Dermatology, University of California at San Franscisco, San Francisco, CA, USA
| | - Elaine Y. Kwan
- Department of Dermatology, University of California at San Franscisco, San Francisco, CA, USA.,California Institute of Regenerative Medicine, San Francisco State University, San Francisco, CA, USA
| | - Sean Clancy
- Department of Dermatology, University of California at San Franscisco, San Francisco, CA, USA
| | - Jarish N. Cohen
- Department of Pathology, University of California at San Franscisco, San Francisco, CA, USA
| | - Ireneusz Habrylo
- Department of Dermatology, University of California at San Franscisco, San Francisco, CA, USA.,Medical Scientist Training Program, University of California at San Franscisco, San Francisco, CA, USA
| | - Margaret M. Lowe
- Department of Dermatology, University of California at San Franscisco, San Francisco, CA, USA
| | - Mariela Pauli
- Department of Dermatology, University of California at San Franscisco, San Francisco, CA, USA
| | - Ashley E. Yates
- Department of Dermatology, University of California at San Franscisco, San Francisco, CA, USA
| | - Jamie D. Chan
- Department of Pathology, University of California at San Franscisco, San Francisco, CA, USA
| | - Hobart W. Harris
- Department of Surgery, University of California at San Franscisco, San Francisco, CA, USA
| | - Isaac M. Neuhaus
- Department of Dermatology, University of California at San Franscisco, San Francisco, CA, USA
| | - Timothy H. McCalmont
- Department of Dermatology, University of California at San Franscisco, San Francisco, CA, USA.,Department of Pathology, University of California at San Franscisco, San Francisco, CA, USA
| | - Ari B. Molofsky
- Department of Laboratory Medicine, University of California at San Franscisco, San Francisco, CA, USA
| | - Michael D. Rosenblum
- Department of Dermatology, University of California at San Franscisco, San Francisco, CA, USA.,Correspondence and requests for materials should be addressed to Michael D. Rosenblum.
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16
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Krusche M, Schneider U, Geisler C, Keller S, Stenzel W, Ohrndorf S. [Myofasciitis under nivolumab treatment]. Z Rheumatol 2021; 80:884-888. [PMID: 33885949 PMCID: PMC8575749 DOI: 10.1007/s00393-021-01001-7] [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] [Accepted: 03/25/2021] [Indexed: 11/20/2022]
Abstract
We report the case of a 73-year-old female patient with malignant melanoma who developed rapidly progressive dermatosclerosis of the arms and legs as well as myalgia and flexion contractures during treatment with the immune checkpoint inhibitor nivolumab. The diagnosis of a myofasciitis was confirmed by imaging and biopsy. Following consultation with the treating dermato-oncologists nivolumab treatment was paused and treatment with methotrexate and prednisolone was initiated. Immune checkpoint inhibitors can induce a variety of immune-mediated side effects and can also imitate symptoms of rheumatological diseases. The occurrence of myofasciitis under immune checkpoint inhibition has been reported in the literature only in a few cases. Further oncological and rheumatological treatment management should be carried out in close interdisciplinary coordination.
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Affiliation(s)
- M Krusche
- Medizinische Klinik mit Schwerpunkt Rheumatologie und Klinische Immunologie, Charité - Universitätsmedizin, Charitéplatz 1, 10117, Berlin, Deutschland.
| | - U Schneider
- Medizinische Klinik mit Schwerpunkt Rheumatologie und Klinische Immunologie, Charité - Universitätsmedizin, Charitéplatz 1, 10117, Berlin, Deutschland
| | - C Geisler
- Klinik für Dermatologie, Venerologie und Allergologie, Charité - Universitätsmedizin, Charitéplatz 1, 10117, Berlin, Deutschland
| | - S Keller
- Klinik für Radiologie, Charité - Universitätsmedizin, Charitéplatz 1, 10117, Berlin, Deutschland
| | - W Stenzel
- Institut für Neuropathologie, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Deutschland
| | - S Ohrndorf
- Medizinische Klinik mit Schwerpunkt Rheumatologie und Klinische Immunologie, Charité - Universitätsmedizin, Charitéplatz 1, 10117, Berlin, Deutschland
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17
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Rea A, Anderson A, Moshiri A, Paulson K, Thompson JA, Kalus A. Eosinophilic fasciitis as a paraneoplastic syndrome in melanoma. JAAD Case Rep 2021; 17:49-51. [PMID: 34703864 PMCID: PMC8526906 DOI: 10.1016/j.jdcr.2021.09.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- Andrea Rea
- Division of Dermatology, University of Washington, Seattle, Washington
| | - Alexis Anderson
- School of Medicine, University of Washington, Seattle, Washington
| | - Ata Moshiri
- Division of Dermatology, University of Washington, Seattle, Washington
| | - Kelly Paulson
- Swedish Cancer Institute Medical Oncology, Edmonds, Washington
| | - John A Thompson
- Division of Oncology, University of Washington, Seattle, Washington
| | - Andrea Kalus
- Division of Dermatology, University of Washington, Seattle, Washington
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18
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Boppana SH, Dulla NR, Beutler BD, Gullapalli N, Kaur R. Drug-Associated Eosinophilic Fasciitis: A Case of Eosinophilic Fasciitis Secondary to Cemiplimab Therapy. AMERICAN JOURNAL OF CASE REPORTS 2021; 22:e932888. [PMID: 34403405 PMCID: PMC8380854 DOI: 10.12659/ajcr.932888] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Revised: 07/07/2021] [Accepted: 07/01/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND Eosinophilic fasciitis, also known as Shulman syndrome, is a rare inflammatory condition characterized by diffuse erythema and progressive collagenous thickening of the subcutaneous fascia. The underlying cause remains to be definitively established; however, several drugs have been linked to this uncommon clinical entity. We present a rare case of eosinophilic fasciitis secondary to immune checkpoint inhibitor therapy. CASE REPORT A 72-year-old woman with metastatic cutaneous squamous cell carcinoma presented to the rheumatology clinic for evaluation of joint pain that developed 3 weeks after beginning treatment with cemiplimab. The correlation of clinical history and physical examination was most consistent with osteoarthritis. Symptoms improved after a short course of low-dose prednisone. The patient continued cemiplimab therapy for approximately 1 year and was subsequently transitioned to carboplatin and radiation therapy. However, relapse occurred shortly thereafter, and cemiplimab was restarted. Two weeks later, the patient developed severe joint pain, morning stiffness, and extensive cutaneous discoloration and induration. A skin biopsy was performed. Microscopic examination of a tissue sample showed a mononuclear infiltrate with plasma cells and eosinophils. A diagnosis of eosinophilic fasciitis was established. Cemiplimab was held and the patient was treated with hydroxychloroquine, prednisone, and sulfasalazine. Symptoms improved within 1 week. CONCLUSIONS Eosinophilic fasciitis is a rare but important adverse effect of immune checkpoint inhibitors. Individuals receiving immunotherapy should be monitored closely for symptoms of eosinophilic fasciitis, as prompt treatment is essential to prevent long-term complications.
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Affiliation(s)
- Sri Harsha Boppana
- Department of Internal Medicine, Reno School of Medicine, University of Nevada, Reno, NV, USA
| | - Nageswara Rao Dulla
- Department of Internal Medicine, Mythri Multispecialty Hospital, Guntur, India
| | - Bryce D. Beutler
- Department of Radiology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Nageshwara Gullapalli
- Department of Internal Medicine, Reno School of Medicine, University of Nevada, Reno, NV, USA
| | - Ratinder Kaur
- Department of Internal Medicine, Reno School of Medicine, University of Nevada, Reno, NV, USA
- Department of Rheumatology, Arthritis Consultants, Reno, NV, USA
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19
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Ning C, Zhang X, Yang X, Zhao H, Wang H. Fasciitis induced by sintilimab in a patient with recurrent hepatocellular carcinoma. Eur J Cancer 2021; 155:296-298. [PMID: 34364744 DOI: 10.1016/j.ejca.2021.06.046] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 06/29/2021] [Indexed: 12/19/2022]
Affiliation(s)
- Cong Ning
- Department of Liver Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College (CAMS & PUMC), Beijing, 100730, China
| | - Xinmu Zhang
- Department of Pulmonary and Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College (CAMS & PUMC), Beijing, 100730, China
| | - Xiaobo Yang
- Department of Liver Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College (CAMS & PUMC), Beijing, 100730, China
| | - Haitao Zhao
- Department of Liver Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College (CAMS & PUMC), Beijing, 100730, China
| | - Hanping Wang
- Department of Pulmonary and Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College (CAMS & PUMC), Beijing, 100730, China.
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20
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Bourcier L, St-Hilaire È, LeBlanc M, Picard L. Complete reversibility of pembrolizumab-induced eosinophilic fasciitis without corticosteroids: A case report. SAGE Open Med Case Rep 2021; 9:2050313X211025111. [PMID: 34178352 PMCID: PMC8202265 DOI: 10.1177/2050313x211025111] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 04/05/2021] [Indexed: 12/29/2022] Open
Abstract
Checkpoint inhibitor immunotherapy has recently started to play a fundamental role in the management of metastatic melanoma. It is however accountable for many undesirable adverse effects involving many organ systems. Eosinophilic fasciitis is a rare immune-related adverse effect associated to checkpoint inhibitors such as pembrolizumab and nivolumab. We report the case of a 25-year-old male who received pembrolizumab as a second-line therapy for metastatic melanoma. Approximately 8 months after starting the treatment, the patient developed signs and symptoms of eosinophilic fasciitis, including edema of his hands and lower legs, as well as joint limitation. Pembrolizumab was discontinued after 15 cycles because of symptom progression. The patient experienced complete resolution of symptoms 4 months after cessation of pembrolizumab and without corticosteroids. This case illustrates the reversibility of this immune adverse effect by discontinuation of the treatment, speculating that corticotherapy may not be needed in all cases.
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Affiliation(s)
- Liane Bourcier
- Centre de Formation Médicale du Nouveau-Brunswick, Université de Sherbrooke, Moncton, NB, Canada
| | - Ève St-Hilaire
- Oncology Department, Dr. Georges-L.-Dumont University Hospital Centre, Vitalité Health Network, Moncton, NB, Canada
| | - Martin LeBlanc
- Dermatology Department, Dr. Georges-L.-Dumont University Hospital Centre, Vitalité Health Network, Moncton, NB, Canada
| | - Léo Picard
- Rheumatology Department, Dr. Georges-L.-Dumont University Hospital Centre, Vitalité Health Network, Moncton, NB, Canada
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21
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Rogers BB, Zawislak C, Wong V. Management of Hematologic Adverse Events Associated With Immune Checkpoint Inhibitors. J Adv Pract Oncol 2021; 12:392-404. [PMID: 34123476 PMCID: PMC8163252 DOI: 10.6004/jadpro.2021.12.4.4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Immune checkpoint inhibitors target suppressor receptors, including cytotoxic T-lymphocyte–associated antigen 4 (CTLA-4), programmed cell death protein 1 (PD-1), and programmed cell death ligand 1 (PD-L1). The activated T cells are not antigen specific; therefore, the blockade of the immune checkpoint may result in the development of autoimmune adverse events. The most common immune-related adverse events (irAEs) are rash, colitis, and endocrinopathies. However, irAEs that affect the hematologic system are rare and can affect red blood cells (e.g., autoimmune hemolytic anemia), white blood cells, and platelets (e.g., immune thrombocytopenia). Usually one cell line is affected; however, in some cases, multiple cell lines can be affected. Other changes in the hematologic system can also be affected (e.g., cryoglobulinemia, cytokine release syndrome). Due to the rarity and lack of recognition of these AEs, the timing, spectrum of events, and clinical presentation are poorly understood. Management of hematologic irAEs usually involves the use of steroids; however, other agents (e.g., IVIG, cyclosporine, rituximab) or procedures (e.g., plasma exchange, transfusions) can also be used.
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22
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Abstract
Immune checkpoint inhibitors activate the immune system to combat cancer. In doing so, however, they can cause immune-related adverse events (irAEs), including rheumatic syndromes, such as inflammatory arthritis, polymyalgia rheumatica, and myositis. This article reviews rheumatic irAEs that may be encountered in the general medicine practice and provides guidance to support prompt recognition, referral, and treatment of these patients.
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Affiliation(s)
- Nilasha Ghosh
- Hospital for Special Surgery, Weill Cornell Medicine, New York, NY, USA
| | - Anne R Bass
- Hospital for Special Surgery, Weill Cornell Medicine, New York, NY, USA.
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23
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Moreno-Arquieta IA, Cardenas-de la Garza JA, Esquivel-Valerio JA, Riega-Torres J, Cuellar-Barboza A, Herz-Ruelas ME, Ocampo-Candiani J, Galarza-Delgado DA. Mycophenolate mofetil and mycophenolic acid for the treatment of eosinophilic fasciitis: report of two cases and literature review. J DERMATOL TREAT 2021; 33:1765-1768. [PMID: 33615948 DOI: 10.1080/09546634.2021.1890682] [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: 10/22/2022]
Abstract
Eosinophilic fasciitis (EF) is an uncommon autoimmune connective tissue disorder characterized by edema, erythema, and subsequent induration of the extremities. It is commonly treated with corticosteroids but there is no treatment ladder for immunosuppressants or steroid-sparing agents. We report two EF cases treated effectively with mycophenolate mofetil (MMF) or mycophenolic acid (MPA) and present a literature review. We performed a MEDLINE search using the keywords 'eosinophilic fasciitis', 'Shulman syndrome', 'mycophenolic acid', or 'mofetil mycophenolate', and found 8 articles with 27 cases in which MMF or MPA was used. Twenty-nine cases were reviewed (2 reported herein and 27 from the literature search); all patients received a combination of systemic corticosteroids and MMF. MMF/MPA were given as a steroid-sparing agent in 27 (93.1%), in 1 (3.4%) as adjunctive therapy with other immunosuppressants, and in one, as monotherapy 1 (3.4%). Nineteen had a complete response, 6, a partial response, and 2 were unresponsive to diverse immunomodulators; in 2 cases, the outcome was not reported. MMF and MPA show promising therapeutic results and could be a treatment option to reduce corticosteroid related side effects.
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Affiliation(s)
- Ilse Andrea Moreno-Arquieta
- Rheumatology Department, Universidad Autónoma de Nuevo León, Facultad de Medicina y Hospital Universitario "Dr. José Eleuterio González", Monterrey, Mexico
| | - Jesus Alberto Cardenas-de la Garza
- Rheumatology Department, Universidad Autónoma de Nuevo León, Facultad de Medicina y Hospital Universitario "Dr. José Eleuterio González", Monterrey, Mexico
| | - Jorge Antonio Esquivel-Valerio
- Rheumatology Department, Universidad Autónoma de Nuevo León, Facultad de Medicina y Hospital Universitario "Dr. José Eleuterio González", Monterrey, Mexico
| | - Janett Riega-Torres
- Rheumatology Department, Universidad Autónoma de Nuevo León, Facultad de Medicina y Hospital Universitario "Dr. José Eleuterio González", Monterrey, Mexico
| | - Adrian Cuellar-Barboza
- Dermatology Department, Universidad Autónoma de Nuevo León, Facultad de Medicina y Hospital Universitario "Dr. José Eleuterio González", Monterrey, Mexico
| | - Maira Elizabeth Herz-Ruelas
- Dermatology Department, Universidad Autónoma de Nuevo León, Facultad de Medicina y Hospital Universitario "Dr. José Eleuterio González", Monterrey, Mexico
| | - Jorge Ocampo-Candiani
- Dermatology Department, Universidad Autónoma de Nuevo León, Facultad de Medicina y Hospital Universitario "Dr. José Eleuterio González", Monterrey, Mexico
| | - Dionicio Angel Galarza-Delgado
- Rheumatology Department, Universidad Autónoma de Nuevo León, Facultad de Medicina y Hospital Universitario "Dr. José Eleuterio González", Monterrey, Mexico
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24
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25
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Sechi E, Zekeridou A. Neurologic Complications of Immune Checkpoint Inhibitors in Thoracic Malignancies. J Thorac Oncol 2020; 16:381-394. [PMID: 33188910 DOI: 10.1016/j.jtho.2020.11.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 10/30/2020] [Accepted: 11/05/2020] [Indexed: 01/08/2023]
Abstract
Immune checkpoint inhibitors (ICIs) have transformed the prognosis of cancers previously considered lethal. The spectrum of therapeutic indications is rapidly expanding, including the vast majority of thoracic malignancies. By enhancing the immune responses against cancer, the ICI treatments lead to the development of immune-related adverse events (irAEs) that may affect any organ. Severity varies from mild to fatal clinical manifestations. Neurologic involvement is relatively rare and highly heterogeneous, including central and peripheral nervous system diseases associated with neural-specific autoantibodies or not, central nervous system vasculitis, and granulomatous and demyelinating disorders. Symptoms often manifest within the first four cycles of treatment and can develop regardless of the class of ICI used. An unfavorable outcome is found in up to one-third of patients and is generally associated with the patients' clinical characteristics (e.g., age, coexistence of systemic adverse events), cancer type (e.g., lung cancer versus other), and specific clinical setting (e.g., ICI treatment in patients with preexisting paraneoplastic neurologic autoimmunity, ICI rechallenge after a first neurologic irAE). Diagnosis should be suspected in patients with new-onset neurologic symptoms while on ICI treatment which are not explained by metastatic disease or other metabolic/infectious disorders. Recommended treatment is based on clinical severity and consists of ICI discontinuation with or without immunosuppressive/immunomodulatory therapy, although alternative approaches are reasonable depending on cancer status (e.g., aggressive immunosuppression without discontinuing ICI in patients with initial cancer response). Early recognition and appropriate treatment of these neurologic irAEs are crucial for improved patient outcomes and therapeutic planning.
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Affiliation(s)
- Elia Sechi
- Department of Neurology, Mayo Clinic, Rochester, Minnesota
| | - Anastasia Zekeridou
- Department of Neurology, Mayo Clinic, Rochester, Minnesota; Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota.
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26
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Salamaliki C, Solomou EE, Liossis SNC. Immune Checkpoint Inhibitor-Associated Scleroderma-Like Syndrome: A Report of a Pembrolizumab-Induced "Eosinophilic Fasciitis-Like" Case and a Review of the Literature. Rheumatol Ther 2020; 7:1045-1052. [PMID: 33067734 PMCID: PMC7695772 DOI: 10.1007/s40744-020-00246-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Accepted: 10/08/2020] [Indexed: 12/20/2022] Open
Abstract
Immune checkpoint inhibitors are a promising new therapeutic strategy in oncology that aims to eliminate cancer cells by enhancing patients' immune response against tumor antigens. Despite their beneficial effects, immune checkpoint inhibitors are also responsible for a plethora of autoimmune manifestations, known as immune-related adverse events. We present a case of eosinophilic fasciitis-like disorder in an 81-year-old patient treated with the programmed death cell protein 1 inhibitor pembrolizumab for non-small-cell lung cancer. The patient developed characteristic indurated skin lesions in his limbs after 1½ years of treatment with pembrolizumab and a typical “groove sign.” Raynaud’s syndrome was absent. A full-thickness biopsy confirmed the clinical diagnosis of an “EF-like” condition. Neither peripheral eosinophilia nor eosinophilic infiltrates in the skin biopsy were found. His symptoms improved after a 2.5-month CPI discontinuation and treatment with 16 mg of methylprednisolone slowly tapered to a dose of 4 mg. Eosinophilic fasciitis is a rare immune-related adverse event of CPI treatment; our literature search identified only 12 cases that fulfill the criteria of EF in patients receiving CPIs.
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Affiliation(s)
- Christina Salamaliki
- Division of Rheumatology, Department of Internal Medicine, University of Patras Medical School, Patras, Greece
| | - Elena E Solomou
- Department of Internal Medicine, University of Patras Medical School, Patras, Greece
| | - Stamatis-Nick C Liossis
- Division of Rheumatology, Department of Internal Medicine, University of Patras Medical School, Patras, Greece.
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27
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Kersh AE, Schuchter LM, Elenitsas R, Chu EY. Hypohidrosis as an immune-related adverse event of checkpoint inhibitor therapy. Immunotherapy 2020; 12:951-956. [PMID: 32772616 DOI: 10.2217/imt-2020-0002] [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] [Indexed: 11/21/2022] Open
Abstract
Background: Immune checkpoint blockade therapies including cytotoxic-T-lymphocyte antigen 4 (CTLA-4) and programmed cell death protein-1 (PD-1) inhibitors have become indispensable tools for treating melanoma and other cancers. An increasing number of diverse cutaneous adverse reactions to immunotherapy have been documented in the literature and have been reported to affect up to 40% of patients treated with targeted therapies. Method & results: Herein, we report a case of a patient with metastatic melanoma treated with checkpoint inhibitor therapy who developed vitiligo, gastritis and hepatitis, all identified as adverse immune events and attributable to his immunotherapy regimen. He subsequently developed acquired idiopathic generalized hypohidrosis with biopsy of lesional skin demonstrating a peri-eccrine lymphocytic infiltrate. Conclusion: These findings suggest this acquired generalized hypohidrosis represents a lymphocyte-mediated adverse immune event related to this patient's checkpoint inhibitor therapy.
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Affiliation(s)
- Anna E Kersh
- Department of Dermatology, Perelman School of Medicine at The University of Pennsylvania, Philadelphia, PA, USA
| | - Lynn M Schuchter
- Department of Medicine, Division of Hematology & Oncology, Perelman School of Medicine at The University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Rosalie Elenitsas
- Department of Dermatology, Perelman School of Medicine at The University of Pennsylvania, Philadelphia, PA, USA
| | - Emily Y Chu
- Department of Dermatology, Perelman School of Medicine at The University of Pennsylvania, Philadelphia, PA, USA
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28
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Bui ATN, Nelson CA, Lian CG, Canales AL, LeBoeuf NR. Eosinophilic fasciitis induced by nivolumab therapy managed without treatment interruption or systemic immunosuppression. JAAD Case Rep 2020; 6:693-696. [PMID: 32715051 PMCID: PMC7369459 DOI: 10.1016/j.jdcr.2020.04.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
| | - Caroline A Nelson
- Department of Dermatology, Yale School of Medicine, New Haven, Connecticut
| | - Christine G Lian
- Department of Pathology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Alvaro Laga Canales
- Department of Pathology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Nicole R LeBoeuf
- Department of Dermatology, Brigham and Women's Hospital, Boston, Massachusetts.,Center for Cutaneous Oncology, Department of Dermatology, Dana-Farber/Brigham and Women's Cancer Center, Boston, Massachusetts
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