Hypogammaglobulinaemia in low grade B cell tumours; significance and therapy

Treated Follicular Lymphoma, Recurrent Invasive Pneumococcal Disease, Nonresponsiveness to Vaccination, and a Unique Pneumococcus

A nonneutropenic patient with treated low-grade non-Hodgkin's (Follicular) lymphoma and secondary hypogammaglobulinemia recovered from pneumococcal pneumonia and septicemia (serotype 7F; ST191) subsequent to influenza A H1N1 (2009). Both infections were potentially vaccine preventable. The patient then developed pneumococcal meningitis due to a serotype 35F pneumococcus with a unique Multilocus Sequence Type (ST7004) which was not vaccine preventable. Patient management was influenced by host predisposition to pneumococcal infection, antibiotic intolerance, and poor response to polysaccharide pneumococcal vaccine. Indirect immunofluorescence with anti-human immunoglobulin confirmed a poor or intermediate response to Pneumovax II. Prophylactic erythromycin was initiated, and immunoglobulin transfusions were also commenced as a preventive strategy. ST7004 is a single locus variant of ST1635 which has been associated with the serotype 35F capsule in England. The spi gene in ST7004, which differentiates it from ST1635, is the same as the spi gene present in ST191 which could have arisen from the first disease episode suggesting that horizontal gene transfer may have occurred between different populations of pneumococci present within the patient in an attempt to evade vaccination selection pressure.

Evidence for the use of intravenous immunoglobulins--a review of the literature

Intravenous immunoglobulins (IVIg) were first introduced in the middle of the twentieth century for the treatment of primary immunodeficiencies. In 1981, Paul Imbach noticed an improvement of immune-mediated thrombocytopenia, in patients receiving IVIg for immunodeficiencies. This opened a new era for the treatment of autoimmune conditions with IVIg. Since then, IVIg has become an important treatment option in a wide spectrum of diseases, including autoimmune and acute inflammatory conditions, most of them off-label (not included in the US Food and Drug Administration recommendation). A panel of immunologists and internists with experience in IVIg therapy reviewed the medical literature for published data concerning treatment with IVIg. The quality of evidence was assessed, and a summary of the available relevant literature in each disease was given. To our knowledge, this is the first all-inclusive comprehensive review, developed to assist the clinician when considering the use of IVIg in autoimmune diseases, immune deficiencies, and other conditions.

Anti-inflammatory actions of intravenous immunoglobulin

The remarkable success story of the therapeutic application of pooled immunoglobulin G (IgG) preparations from thousands of donors, the so-called intravenous IgG (IVIG) therapy, to patients with a variety of hematological and immunological disorders began more than half a century ago. Since then, the use of this primary blood product has increased constantly, resulting in the serious danger of shortages in supply. Despite its widespread use and therapeutic success, the mechanisms of action, especially of the anti-inflammatory activity, are only beginning to be understood. In this review, we summarize the clinical use of IVIG for different diseases and discuss recent data on the molecular mechanisms that might explain how this potent drug mediates its activity in vivo.

Intravenous immunoglobulin: an update on the clinical use and mechanisms of action

Initially used as a replacement therapy for immunodeficiency diseases, intravenous immunoglobulin (IVIg) is now widely used for a number of autoimmune and inflammatory diseases. Considerable progress has been made in understanding the mechanisms by which IVIg exerts immunomodulatory effects in autoimmune and inflammatory disorders. The mechanisms of action of IVIg are complex, involving modulation of expression and function of Fc receptors, interference with activation of complement and the cytokine network and of idiotype network, regulation of cell growth, and effects on the activation, differentiation, and effector functions of dendritic cells, and T and B cells.

Developing practice guidelines for the administration of intravenous immunoglobulin

As the use of intravenous immunoglobulin (IGIV) continues to expand, infusion nurses have a greater need for a comprehensive understanding of the product, patient risk factors, and comorbidities when developing guidelines for administering IGIV. Because immunoglobulin therapy is a blood derivative product, many nurses may not have as much experience administering this type of infusion. This article provides an in-depth overview of immunoglobulin therapy and helps to define the infusion nurse's major role in coordinating, assessing, and ensuring patient safety during IGIV administration.

Clinical and investigational considerations for the use of IGIV therapy

PURPOSE

Clinical uses of immunoglobulin intravenous (IGIV) therapy for a number of autoimmune and inflammatory diseases are discussed, as well as the probable mechanisms by which IGIV exerts its immunoregulatory and antiinflammatory actions. Case studies are also presented to examine practical considerations in the selection of IGIV products for patients at risk for adverse events.

SUMMARY

At present, the Food and Drug Administration has approved IGIV for use in six conditions, including replacement therapy for patients with antibody-deficiency disease, adjunct therapy in patients with poor antibody-producing capabilities, prophylaxis against certain types of infections, and several autoimmune disorders, including idiopathic thrombocytopenic purpura and Kawasaki disease. Numerous mechanisms have been proposed to explain the beneficial effects of IGIV, including the interaction of infused IgG with fragment crystallizable (Fc) receptors and complement proteins, the modulation of synthesis and release of cytokines and cytokine antagonists, and neutralization of circulating autoantibodies.IGIV products differ significantly in methods of production, virus elimination, formulation, and composition. These differences can potentially have an impact on safety, tolerability, and efficacy. The major features affecting tolerability include volume load, sugar and salt content, and osmolality. Case studies highlight how these product characteristics could affect patient outcomes.

CONCLUSION

While numerous mechanisms have been proposed to explain the beneficial effects of IGIV, the specific mechanisms remain elusive. Patient outcomes can be affected by IGIV product characteristics. The choice of an IGIV product should be matched to the patient's risk-factor profile.

Immunologic monitoring in chronic lymphocytic leukemia

Chronic lymphocytic leukemia (CLL) is characterized by progressive defects in humoral- and cell-mediated immunity. These defects are manifested as a propensity to develop infections with encapsulated bacteria, and less frequently, with gram-negative enterics. In addition, reactivation of viruses such as herpesvirus is not uncommon. Treatment of the disease further exacerbates immunosuppression by depleting immune effectors and broadening the spectrum of potentially offending pathogens. Risk of infection can potentially be reduced by administration of intravenous immunoglobulin and use of prophylactic antibiotics for individuals who are at high risk. Current work focuses on development of cellular and cytokine therapy to facilitate immune reconstitution in patients with CLL, thereby reducing morbidity and mortality and potentially improving survival.

Intravenous immunoglobulins: clinical experience and viral safety

OBJECTIVES

To discuss the current procedures and processes by which viral safety is ensured for intravenous immunoglobulins (IVIGs), to place in context the current increase in clinical indications for IVIGs, and to describe the safety issues that have led to product shortages.

DATA SOURCES

Articles on viral safety retrieved from MEDLINE using the search terms gamma globulin, intravenous, adverse reaction, and infection and information from the manufacturers' literature and Food and Drug Administration package inserts.

STUDY SELECTION AND DATA EXTRACTION

Studies that specifically addressed the areas of major concern or advancement in viral safety of IVIGs, including donor selection, plasma screening, and other quality control procedures to ensure safety of source plasma; detection of viruses that may have escaped antibody screening tests through the use of polymerase chain reaction-based assays, which are capable of detecting small amounts of viral genomic material (e.g., hepatitis C virus, hepatitis B virus, and human immunodeficiency virus [HIV]) in small plasma pools; and industrial-scale, validated viral inactivation methods, such as pasteurization and solvent/detergent treatment, that have been incorporated into the manufacturing processes of immunoglobulins to further minimize the risk of viral transmission.

DATA SYNTHESIS

In addition to the treatment of primary immunodeficiency disorders, the clinical uses of IVIGs have expanded to include treatment of Kawasaki's syndrome, idiopathic thrombocytopenic purpura, infection following bone marrow transplantation, secondary immunologic disorders (e.g., pediatric HIV infection), hematologic disorders (e.g., chronic lymphocytic leukemia), and neurologic indications (e.g., Guillain-Barré syndrome). Although IVIG preparations are derived from human plasma, they have a long safety record and a low risk for transmitting viral infections.

CONCLUSION

Viral validation studies demonstrated that the processes discussed herein differ in their capabilities to inactivate lipid-enveloped and nonlipid-enveloped viruses.