Infections in the Era of Targeted Therapies: Mapping the Road Ahead

Fly Me to the Immune: Immunonutrition in Rheumatic Diseases

Immunonutrition is the maintenance and induction of immune homeostasis with the use of nutritional factors, the so called, immunonutrients. Immunonutrition focuses on four "Is" representing an equal number of systemic responses with regards to: a) Immunity, b) Infection, c) Inflammation and d) Injury. Although at the early stages of the development of immunonutrition, its application was focused on malnourished patients, with a latter extension in the intensive care unit setting, today we acknowledge the great importance of immunonutrients in rheumatology. In rheumatic diseases (RDs), all the "Is" representing the four aims and targets of immunonutrition are fulfilled. Impaired Immunity is the hallmark of RDs, with both innate and adaptive immunity contributing to the development and course of each disease entity, representing distinct immunoregulation abnormalities, often paired with micronutrient deficiencies. Infections are both drivers and a frequent epiphenomenon of systemic RDs. Subclinical inflammation is propagated long before the first signs or symptoms of RDs and musculoskeletal conditions (injury) are apparent in all patients with RDs, accompanied by pain, underlying connective tissue disease and the consequent reduction in the function of musculoskeletal. Herein, the role of probiotics, curcumin, vitamins, Selenium, Zinc and n-3 fatty acids as immunonutrients is discussed.

Viral infections in pediatric brain tumor patients treated with targeted therapies

BACKGROUND

Brain tumors are the most common solid malignancies and the leading cause of cancer-related mortality in children. While numerous studies report on viral infections in children with hematologic malignancies and solid organ transplantation, epidemiologic data on the incidence and outcome of viral infections in pediatric patients with brain tumors treated with targeted therapies are still lacking.

OBJECTIVES/STUDY DESIGN

We retrospectively reviewed all children with brain tumors receiving targeted therapies in a primary or recurrent setting at the Medical University of Vienna from 2006 to 2021. Demographic variables, quantitative and qualitative parameters of possible infections, and treatment outcomes were recorded.

RESULTS

In our cohort (n = 117), 36% of the patients developed at least one PCR-proven viral infection. Respiratory and gastrointestinal tract infections were most common, with 31% and 25%, respectively. Central nervous system (CNS) infections occurred in approximately 10%, with an almost equal distribution of varicella-zoster virus, John Cunningham virus (JCV), and enterovirus. Two patients tested PCR-positive for SARS-CoV-2 infection, with one virus-related death caused by a SARS-CoV-2-related acute respiratory distress syndrome. Patients receiving bevacizumab or mTOR inhibitors seem to have a greater susceptibility to viral infections.

CONCLUSION

Pediatric patients with brain tumors receiving targeted therapies have a higher risk of viral infections when compared to children receiving conventional chemotherapy or the general population, and life-threatening infections can occur. Fast detection and upfront treatment are paramount to prevent life-threatening infections in immunocompromised children suffering from brain tumors receiving targeted therapies.

Progressive multifocal leukoencephalopathy in the context of newer therapies in hematology and review of new treatment strategies

Progressive multifocal leukoencephalopathy (PML) is a rare, often fatal demyelinating disease of the central nervous system (CNS) caused by the reactivation of JC polyomavirus in the CNS. We present a case of a 54-year-old man with follicular lymphoma diagnosed with PML after being treated with anti-CD20 monoclonal antibody-based regimens for several years. Due to the lack of effective treatment choices for PML, the patient was treated with nivolumab, based on recent reports, but succumbed to his disease a few months after diagnosis. In this paper, we focus on reviewing the literature of PML cases correlated with newer agents used in hematology, possible factors affecting disease prognosis, as well as the available data on upcoming therapeutic options for patients with PML. Though newer promising treatments such as anti-PD1 monoclonal antibodies arise, a definitive treatment option is yet to be found. Vigilance, early detection, and prompt intervention play a crucial role in the prognosis of PML in patients with hematological malignancies.

[Latest findings from the RABBIT register]

Seit 2001 rekrutieren Rheumatolog:innen deutschlandweit Patient:innen mit rheumatoider Arthritis in das Biologikaregister RABBIT, um die Langzeitsicherheit und -wirksamkeit moderner antirheumatischer Therapien zu untersuchen. In den vergangenen 20 Jahren wurden mehr als 20.000 Patient:innen in die prospektive Kohortenstudie eingeschlossen. In diesem Beitrag fassen wir aktuelle Forschungsergebnisse der Jahre 2020 und 2021 zusammen; dabei stehen Sicherheitsaspekte, Einflussfaktoren auf die Therapiewirksamkeit und patientenberichtete Outcomes im Fokus. Mit Herpes zoster, Fazialisparese und Psoriasis wurden verschiedene unerwünschte Ereignisse untersucht, die entweder als Sicherheitssignal aus klinischen Studien oder durch die EudraVigilance-Datenbank gemeldet wurden oder als paradoxe Reaktion unter medikamentöser Behandlung aufgetreten sind. Für diese Ereignisse wurde der Einfluss der biologischen DMARD(„disease-modifying antirheumatic drug“)-Therapie analysiert. In der Publikation zu Herpes zoster berücksichtigten wir auch die medikamentöse Behandlung mit Januskinaseinhibitoren. Starkes Übergewicht kann den Erfolg einer Therapie beeinflussen. Hier gibt es geschlechtsspezifische Unterschiede, und auch das Wirkprinzip einer Therapie entscheidet, ob eine Adipositas das Therapieansprechen reduziert. Die Mehrheit der in RABBIT beobachteten Patient:innen ist nach 1 Jahr Behandlung mit der erhaltenen Therapie zufrieden. Wir konnten zeigen, welche Faktoren die Zufriedenheit mit der Wirksamkeit und der Sicherheit der Behandlung begünstigen oder aber negativ beeinflussen. Diese Übersichtsarbeit zeigt, dass Langzeitbeobachtungsstudien wie das RABBIT-Register auch nach 2 Dekaden der Datenerhebung zum Verständnis von Therapierisiken beiträgt sowie Faktoren identifiziert, die die Wirkung der Therapien beeinflussen können.

COVID-19 Outcomes in Patients Undergoing B Cell Depletion Therapy and Those with Humoral Immunodeficiency States: A Scoping Review

BACKGROUND

The role of humoral immunity has been well established in reducing infection risk and facilitating viral clearance in patients with COVID-19. However, the relationship between specific antibody responses and severity of COVID-19 is less well understood.

METHODS

To address this question and identify gaps in knowledge, we utilized the methodology of a scoping review to interrogate risk of infection and clinical outcomes of COVID-19 in patients with iatrogenic and inborn humoral immunodeficiency states based on existing literature.

RESULTS

Among patients with iatrogenic B-cell depletion, particularly with agents targeting CD20, our analysis found increased risk of severe COVID-19 and death across a range of underlying disease states. Among patients with humoral inborn errors of immunity with COVID-19, our synthesis found that patients with dysregulated humoral immunity, predominantly common variable immunodeficiency (CVID), may be more susceptible to severe COVID-19 than patients with humoral immunodeficiency states due to X-linked agammaglobulinemia and other miscellaneous forms of humoral immunodeficiency. There were insufficient data to appraise the risk of COVID-19 infection in both populations of patients.

CONCLUSIONS

Our work identifies potentially significant predictors of COVID-19 severity in patients with humoral immunodeficiency states and highlights the need for larger studies to control for clinical and biologic confounders of disease severity.