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Little JS, Kampouri E, Friedman DZ, McCarty T, Thompson GR, Kontoyiannis DP, Vazquez J, Baddley JW, Hammond SP. The Burden of Invasive Fungal Disease Following Chimeric Antigen Receptor T-Cell Therapy and Strategies for Prevention. Open Forum Infect Dis 2024; 11:ofae133. [PMID: 38887472 PMCID: PMC11181190 DOI: 10.1093/ofid/ofae133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Accepted: 03/05/2024] [Indexed: 06/20/2024] Open
Abstract
Chimeric antigen receptor (CAR) T-cell therapy is a novel immunotherapy approved for the treatment of hematologic malignancies. This therapy leads to a variety of immunologic deficits that could place patients at risk for invasive fungal disease (IFD). Studies assessing IFD in this setting are limited by inconsistent definitions and heterogeneity in prophylaxis use, although the incidence of IFD after CAR T-cell therapy, particularly for lymphoma and myeloma, appears to be low. This review evaluates the incidence of IFD after CAR T-cell therapy, and discusses optimal approaches to prevention, highlighting areas that require further study as well as future applications of cellular therapy that may impact IFD risk. As the use of CAR T-cell therapy continues to expand for hematologic malignancies, solid tumors, and most recently to include non-oncologic diseases, understanding the risk for IFD in this uniquely immunosuppressed population is imperative to prevent morbidity and mortality.
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Affiliation(s)
- Jessica S Little
- Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts, USA
- Division of Infectious Diseases, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Eleftheria Kampouri
- Infectious Diseases Service, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Daniel Z Friedman
- Section of Infectious Diseases and Global Health, The University of Chicago, Chicago, Illinois, USA
| | - Todd McCarty
- Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - George R Thompson
- Division of Infectious Diseases, University of California-Davis, Sacramento, California, USA
| | - Dimitrios P Kontoyiannis
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas, M.D. Anderson Cancer Center, Houston, Texas, USA
| | - Jose Vazquez
- Division of Infectious Diseases, Medical College of Georgia/Augusta University, Augusta, Georgia, USA
| | - John W Baddley
- Division of Infectious Diseases, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Sarah P Hammond
- Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts, USA
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Medical Oncology, Massachusetts General Hospital Cancer Center, Boston, Massachusetts, USA
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Mikulska M, Oltolini C, Zappulo E, Bartoletti M, Frustaci AM, Visentin A, Vitale C, Mauro FR. Prevention and management of infectious complications in patients with chronic lymphocytic leukemia (CLL) treated with BTK and BCL-2 inhibitors, focus on current guidelines. Blood Rev 2024; 65:101180. [PMID: 38331696 DOI: 10.1016/j.blre.2024.101180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Revised: 01/27/2024] [Accepted: 01/31/2024] [Indexed: 02/10/2024]
Abstract
CLL is associated with an increased risk of infectious complications. Treatment with BTK or BCL-2 inhibitors does not seem to increase significantly the risk of opportunistic infections, but the role of combination therapies including BTK and/or BCL-2 inhibitors remains to be established. Various infectious complications can be successfully prevented with appropriate risk management strategies. In this paper we reviewed the international guidelines on prevention and management of infectious complications in patients with CLL treated with BTK or BCL-2 inhibitors. Universal pharmacological anti-herpes, antibacterial or antifungal prophylaxis is not warranted. Reactivation of HBV should be prevented in HBsAg-positive subjects. For HBsAg-negative/HBcAb-positive patients recommendations differ, but in case of combination treatment should follow those for other, particularly anti-CD20, agent. Immunization should be provided preferably before the onset of treatment. Immunoglobulin therapy has favourable impact on morbidity but not mortality in patients with hypogammaglobulinemia and severe or recurrent infections. Lack of high-quality data and heterogeneity of patients or protocols included in the studies might explain differences among the main guidelines. Better data collection is warranted.
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Affiliation(s)
- Malgorzata Mikulska
- Infectious Diseases Unit, Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy; IRCCS Ospedale Policlinico San Martino, Genoa, Italy.
| | | | - Emanuela Zappulo
- Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - Michele Bartoletti
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20090 Pieve Emanuele Milan, Italy; Infectious Disease Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy
| | | | - Andrea Visentin
- Hematology and Clinical Immunology Unit, Department of Medicine, University of Padua, Italy
| | - Candida Vitale
- Division of Hematology, A.O.U. Città della Salute e della Scienza di Torino, Italy; Department of Molecular Biotechnology and Health Sciences, University of Turin, Italy
| | - Francesca R Mauro
- Hematology, Department of Translational and Precision Medicine, Sapienza University, Rome, Italy
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Biyun L, Yahui H, Yuanfang L, Xifeng G, Dao W. Risk factors for invasive fungal infections after haematopoietic stem cell transplantation: a systematic review and meta-analysis. Clin Microbiol Infect 2024; 30:601-610. [PMID: 38280518 DOI: 10.1016/j.cmi.2024.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 12/04/2023] [Accepted: 01/04/2024] [Indexed: 01/29/2024]
Abstract
BACKGROUND Invasive fungal infections (IFIs) are common infectious complications after haematopoietic stem cell transplantation (HSCT), seriously threatening the survival of patients. OBJECTIVES This systematic review aimed to investigate risk factors associated with IFIs following HSCT. METHODS Two authors independently conducted the selection of studies and extraction of data. Risk factors for IFIs, invasive aspergillosis or invasive mould infections and invasive candida infection after HSCT were compiled separately by meta-analysis using RevMan 5.4 and R language 4.1.2. DATA SOURCES Pubmed, EMBASE, Web of Science, and the Cochrane Library until April 2023. STUDY ELIGIBILITY CRITERIA Case-control or cohort studies that assessed risk factors for IFIs among HSCT recipients were included. PARTICIPANTS Patients experiencing HSCT. TEST/S None. REFERENCE STANDARD The IFIs were defined according to the European Organisation for Research and Treatment of Cancer/Mycosis Study Group (EORTC/MSG) criteria, or a similar definition. ASSESSMENT OF RISK OF BIAS A modified version of the Newcastle-Ottawa Scale was used. METHODS OF DATA SYNTHESIS A random-effects model with the Mantel-Haenszel method was used to pool results from primary studies. RESULTS Out of 1637 studies screened, 51 studies involving 109 155 patients were included, with 45 studies providing adequate data for meta-analysis. Identified risk factors for IFIs included prolonged neutropenia, intensified therapy for graft-versus-host disease (GVHD), previous transplantation, previous proven or probable IFI, acute GVHD ≥ grade II, extensive or severe chronic GVHD, use of anti-thymocyte globulin during transplantation, haploidentical transplantation, high-dose glucocorticoids, Epstein-Barr virus infection, cytomegalovirus infection or reactivation, and lower albumin. Conversely, antifungal prophylaxis emerged as the sole preventive factor. For invasive aspergillosis or invasive mould infections, the top risk factors were extensive or severe chronic GVHD, respiratory viral infection, high-dose glucocorticoids, acute GVHD ≥ grade II, and human leukocyte antigen mismatch. Cord blood transplantation was the sole significant risk factor for invasive candidiasis. However, there was likely a high degree of interdependence among various risk factors. DISCUSSION This meta-analysis provides a thorough review of risk factors for IFIs infection after HSCT. The achieved insights can aid in stratifying patients who are at an elevated risk of IFIs and promoting antifungal preventive strategies.
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Affiliation(s)
- Li Biyun
- Department of Pediatric Hematology and Oncology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Han Yahui
- Department of Pediatric Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Li Yuanfang
- Department of Pediatric Hematology and Oncology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Guo Xifeng
- Department of Pediatric Hematology and Oncology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Wang Dao
- Department of Pediatric Hematology and Oncology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.
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Fallin T, Thacker E, Sahra S, Siegrist EA, White BP, Summers K, Shibib D, Sassine J. CNS Aspergillosis and Cryptococcosis with Cytomegalovirus Pneumonia in a Patient with Chronic Lymphocytic Leukemia Treated with Acalabrutinib. J Pharm Pract 2024:8971900241247660. [PMID: 38621678 DOI: 10.1177/08971900241247660] [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: 04/17/2024]
Abstract
Bruton's tyrosine kinase inhibitors (BTKis) are the preferred treatment for chronic lymphocytic leukemia (CLL). Despite their therapeutic benefits, these targeted agents have been associated with an increased risk of invasive infections. We describe a 68-year-old male who developed multiple bacterial, fungal and viral infections while on treatment with acalabrutinib. To our knowledge, this is the first reported case of concomitant CNS infections with Cryptococcus neoformans and Aspergillus fumigatus, along with cytomegalovirus (CMV) and herpes simplex virus type 1 (HSV-1) pneumonia while on acalabrutinib. This case adds to the scarce literature of fungal and bacterial infections associated with acalabrutinib, raising the suspicion that infection risk is a medication class effect for BTKis.
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Affiliation(s)
- Taylor Fallin
- Department of Pharmacy, Clinical and Administrative Sciences, OU Health, University of Oklahoma College of Pharmacy, Oklahoma City, OK, USA
| | - Erica Thacker
- Department of Pharmacy, Clinical and Administrative Sciences, OU Health, University of Oklahoma College of Pharmacy, Oklahoma City, OK, USA
| | - Syeda Sahra
- Infectious Diseases Section, Department of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Emily A Siegrist
- Department of Pharmacy, Clinical Infectious Diseases, OU Health, Oklahoma City, OK, USA
| | - Bryan P White
- Department of Pharmacy, Clinical Infectious Diseases, OU Health, Oklahoma City, OK, USA
| | - Katherine Summers
- Department of Pharmacy, Critical Care, OU Health, Oklahoma City, OK, USA
| | - Dena Shibib
- Department of Pathology, Microbiology and Virology Laboratories, OU Health, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Joseph Sassine
- Infectious Diseases Section, Department of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
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Chiu CY, John TM, Matsuo T, Wurster S, Hicklen RS, Khattak RR, Ariza-Heredia EJ, Bose P, Kontoyiannis DP. Disseminated Histoplasmosis in a Patient with Myelofibrosis on Ruxolitinib: A Case Report and Review of the Literature on Ruxolitinib-Associated Invasive Fungal Infections. J Fungi (Basel) 2024; 10:264. [PMID: 38667935 PMCID: PMC11051496 DOI: 10.3390/jof10040264] [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: 02/24/2024] [Revised: 03/24/2024] [Accepted: 03/29/2024] [Indexed: 04/28/2024] Open
Abstract
Ruxolitinib, a selective inhibitor of Janus kinases, is a standard treatment for intermediate/high-risk myelofibrosis (MF) but is associated with a predisposition to opportunistic infections, especially herpes zoster. However, the incidence and characteristics of invasive fungal infections (IFIs) in these patients remain uncertain. In this report, we present the case of a 59-year-old woman with MF who developed disseminated histoplasmosis after seven months of ruxolitinib use. The patient clinically improved after ten weeks of combined amphotericin B and azole therapy, and ruxolitinib was discontinued. Later, the patient received fedratinib, a relatively JAK2-selective inhibitor, without relapse of histoplasmosis. We also reviewed the literature on published cases of proven IFIs in patients with MF who received ruxolitinib. Including ours, we identified 28 such cases, most commonly due to Cryptococcus species (46%). IFIs were most commonly disseminated (39%), followed by localized lung (21%) infections. Although uncommon, a high index of suspicion for opportunistic IFIs is needed in patients receiving JAK inhibitors. Furthermore, the paucity of data regarding the optimal management of IFIs in patients treated with JAK inhibitors underscore the need for well-designed studies to evaluate the epidemiology, pathobiology, early diagnosis, and multimodal therapy of IFIs in patients with hematological malignancies receiving targeted therapies.
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Affiliation(s)
- Chia-Yu Chiu
- Department of Infectious Diseases, Infection Control, and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (C.-Y.C.); (T.M.J.); (T.M.); (S.W.); (R.R.K.); (E.J.A.-H.)
| | - Teny M. John
- Department of Infectious Diseases, Infection Control, and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (C.-Y.C.); (T.M.J.); (T.M.); (S.W.); (R.R.K.); (E.J.A.-H.)
| | - Takahiro Matsuo
- Department of Infectious Diseases, Infection Control, and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (C.-Y.C.); (T.M.J.); (T.M.); (S.W.); (R.R.K.); (E.J.A.-H.)
| | - Sebastian Wurster
- Department of Infectious Diseases, Infection Control, and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (C.-Y.C.); (T.M.J.); (T.M.); (S.W.); (R.R.K.); (E.J.A.-H.)
| | - Rachel S. Hicklen
- Research Medical Library, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA;
| | - Raihaan Riaz Khattak
- Department of Infectious Diseases, Infection Control, and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (C.-Y.C.); (T.M.J.); (T.M.); (S.W.); (R.R.K.); (E.J.A.-H.)
| | - Ella J. Ariza-Heredia
- Department of Infectious Diseases, Infection Control, and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (C.-Y.C.); (T.M.J.); (T.M.); (S.W.); (R.R.K.); (E.J.A.-H.)
| | - Prithviraj Bose
- Department of Leukemia, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA;
| | - Dimitrios P. Kontoyiannis
- Department of Infectious Diseases, Infection Control, and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (C.-Y.C.); (T.M.J.); (T.M.); (S.W.); (R.R.K.); (E.J.A.-H.)
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6
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Romiti R, Hirayama ALDS, Porro AM, Gonçalves HDS, Miot LDB, Durães SMB, Marques SA. Infections in the era of immunobiologicals. An Bras Dermatol 2024; 99:167-180. [PMID: 38238209 PMCID: PMC10943328 DOI: 10.1016/j.abd.2023.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 08/15/2023] [Accepted: 08/27/2023] [Indexed: 03/11/2024] Open
Abstract
Immunobiologicals represent an innovative therapeutic option in dermatology. They are indicated in severe and refractory cases of different diseases when there is contraindication, intolerance, or failure of conventional systemic therapy and in cases with significant impairment of patient quality of life. The main immunobiologicals used in dermatology basically include inhibitors of tumor necrosis factor-alpha (anti-TNF), inhibitors of interleukin-12 and -23 (anti-IL12/23), inhibitors of interleukin-17 and its receptor (anti-IL17), inhibitors of interleukin-23 (anti-IL23), rituximab (anti-CD20 antibody), dupilumab (anti-IL4/IL13) and intravenous immunoglobulin. Their immunomodulatory action may be associated with an increase in the risk of infections in the short and long term, and each case must be assessed individually, according to the risk inherent to the drug, the patient general condition, and the need for precautions. This article will discuss the main risks of infection associated with the use of immunobiologicals, addressing the risk in immunocompetent and immunosuppressed patients, vaccination, fungal infections, tuberculosis, leprosy, and viral hepatitis, and how to manage the patient in the most diverse scenarios.
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Affiliation(s)
- Ricardo Romiti
- Department of Dermatology, Hospital das Clínicas, Universidade de São Paulo, São Paulo, SP, Brazil
| | | | - Adriana Maria Porro
- Department of Dermatology, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brazil
| | - Heitor de Sá Gonçalves
- State Health Secretariat of Ceará, Centro de Dermatologia Dona Libânia, Fortaleza, CE, Brazil
| | - Luciane Donida Bartoli Miot
- Department of Infectology, Dermatology, Imaging Diagnosis and Radiotherapy, Faculty of Medicine, Universidade Estadual Paulista, Botucatu, SP, Brazil
| | - Sandra Maria Barbosa Durães
- Department of Internal Medicine, Dermatology Unit, Faculty of Medicine, Universidade Federal Fluminense, Niterói, RJ, Brazil
| | - Silvio Alencar Marques
- Department of Infectology, Dermatology, Imaging Diagnosis and Radiotherapy, Faculty of Medicine, Universidade Estadual Paulista, Botucatu, SP, Brazil
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7
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Borman AM, Johnson EM. Changes in fungal taxonomy: mycological rationale and clinical implications. Clin Microbiol Rev 2023; 36:e0009922. [PMID: 37930182 PMCID: PMC10732072 DOI: 10.1128/cmr.00099-22] [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: 05/22/2023] [Accepted: 07/13/2023] [Indexed: 11/07/2023] Open
Abstract
Numerous fungal species of medical importance have been recently subjected to and will likely continue to undergo nomenclatural changes as a result of the application of molecular approaches to fungal classification together with abandonment of dual nomenclature. Here, we summarize those changes affecting key groups of fungi of medical importance, explaining the mycological (taxonomic) rationale that underpinned the changes and the clinical relevance/importance (where such exists) of the key nomenclatural revisions. Potential mechanisms to mitigate unnecessary taxonomic instability are suggested, together with approaches to raise awareness of important changes to minimize potential clinical confusion.
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Affiliation(s)
- Andrew M. Borman
- UK HSA National Mycology Reference Laboratory, Science Quarter, Southmead Hospital, Bristol, United Kingdom
- Medical Research Council Centre for Medical Mycology (MRC CMM), University of Exeter, Exeter, United Kingdom
| | - Elizabeth M. Johnson
- UK HSA National Mycology Reference Laboratory, Science Quarter, Southmead Hospital, Bristol, United Kingdom
- Medical Research Council Centre for Medical Mycology (MRC CMM), University of Exeter, Exeter, United Kingdom
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8
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Palmucci JR, Messina JA, Tenor JL, Perfect JR. New anticancer therapeutics impact fungal pathobiology, infection dynamics, and outcome. PLoS Pathog 2023; 19:e1011845. [PMID: 38127685 PMCID: PMC10735005 DOI: 10.1371/journal.ppat.1011845] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2023] Open
Affiliation(s)
- Julia R. Palmucci
- Division of Infectious Diseases, Department of Medicine, Duke University, Durham, North Carolina, United States of America
| | - Julia A. Messina
- Division of Infectious Diseases, Department of Medicine, Duke University, Durham, North Carolina, United States of America
| | - Jennifer L. Tenor
- Division of Infectious Diseases, Department of Medicine, Duke University, Durham, North Carolina, United States of America
| | - John R. Perfect
- Division of Infectious Diseases, Department of Medicine, Duke University, Durham, North Carolina, United States of America
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9
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Davis MJ, Rypka KJ, Perron AK, Keilty J, Wils B, Levine J, Rezcallah AT, Solomon R, Goldfarb N, Kaka A. Angioinvasive Trichophyton rubrum associated necrotizing fasciitis in an immunocompromised patient. Clin Case Rep 2023; 11:e7718. [PMID: 37786455 PMCID: PMC10541569 DOI: 10.1002/ccr3.7718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 06/28/2023] [Accepted: 07/07/2023] [Indexed: 10/04/2023] Open
Abstract
Angioinvasive dermatophytosis with necrotizing fasciitis can be a rare complication in immunocompromised patients with early surgical debridement, 12 weeks of oral terbinafine, and reduction in immunosuppression being a viable management strategy.
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Affiliation(s)
- Michael J. Davis
- Minneapolis VA Health Care System – Department of Infectious Diseases and University of Minnesota – Department of Infectious DiseasesMinneapolisMinnesotaUSA
| | - Katelyn J. Rypka
- Minneapolis VA Health Care System – Department of Dermatology and University of Minnesota – Department of DermatologyMinneapolisMinnesotaUSA
| | | | - John Keilty
- University of Minnesota Medical SchoolMinneapolisMinnesotaUSA
| | - Benjamin Wils
- University of Minnesota Medical SchoolMinneapolisMinnesotaUSA
| | - Joshua Levine
- University of Minnesota Medical SchoolMinneapolisMinnesotaUSA
| | - Anthony T. Rezcallah
- Minneapolis VA Health Care System – Department of Surgery and University of Minnesota – Department of SurgeryMinneapolisMinnesotaUSA
| | - Robin Solomon
- Department of PathologyMinneapolis VA Health Care SystemMinneapolisMinnesotaUSA
| | - Noah Goldfarb
- Minneapolis VA Health Care System – Department of Dermatology and University of Minnesota – Department of DermatologyMinneapolisMinnesotaUSA
| | - Anjum Kaka
- Department of Infectious DiseasesMinneapolis VA Health Care SystemMinneapolisMinnesotaUSA
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10
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Maggioni G, Fedrigo M, Visentin A, Carturan E, Ruocco V, Trentin L, Alaibac M, Angelini A. Severe Fatal Mucormycosis in a Patient with Chronic Lymphocytic Leukaemia Treated with Zanubrutinib: A Case Report and Review of the Literature. Curr Oncol 2023; 30:8255-8265. [PMID: 37754514 PMCID: PMC10529318 DOI: 10.3390/curroncol30090599] [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: 07/26/2023] [Revised: 09/04/2023] [Accepted: 09/05/2023] [Indexed: 09/28/2023] Open
Abstract
Severe mucormycosis is a fatal disease rarely complicating chronic lymphoproliferative disorders. We present a fulminant and fatal case of a 74-year-old Caucasian woman suffering from CLL treated with second-generation BTK inhibitor zanubrutinib. After a first septic episode a month prior, originating from the lung with later systemic involvement by an unidentified agent and treated with large-spectrum antibiotics and fluconazonle, a slow-onset enlarging tender warm and erythematous nodular swollen cutaneous lesion appeared in her lower limbs and spread subsequently to her upper limbs, progressing towards central ulceration with a necrotic core. Suspecting a mycotic dissemination from an unknown agent, a skin punch biopsy was performed, and intraconazole was started. Due to spread of the skin lesions, the patient was hospitalized and intravenous liposomal ampthotericin B was started. Histopathology showed an atypical sporangium-rich mycotic angioinvasion of the small vessels. Only the increase of BDG and GM could corroborate the hypothesis of mycotic infection. However, long-term CLL, immunosuppressive therapies, neutropenia, and prior use of azoles and other antimycotic agents were risk factors for mucormycosis; BTK inhibitor could also be added as another novel risk factor. Despite all therapeutic efforts, the patient died. Post-mortem molecular exams confirmed the diagnosis of disseminated mucormycosis.
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Affiliation(s)
- Giuseppe Maggioni
- Pathology Unit, Department of Medicine, University of Padova, Via A. Gabelli 61, 35121 Padova, Italy
| | - Marny Fedrigo
- Cardiovascular Pathology Unit, Department of Cardio-Thoracic-Vascular Sciences and Public Health, University of Padova, 35128 Padova, Italy
| | - Andrea Visentin
- Hematology Unit, Department of Medicine, University of Padova, Via N. Giustiniani 2, 35128 Padova, Italy
| | - Elisa Carturan
- Cardiovascular Pathology Unit, Department of Cardio-Thoracic-Vascular Sciences and Public Health, University of Padova, 35128 Padova, Italy
| | - Valeria Ruocco
- Hematology Unit, Department of Medicine, University of Padova, Via N. Giustiniani 2, 35128 Padova, Italy
| | - Livio Trentin
- Hematology Unit, Department of Medicine, University of Padova, Via N. Giustiniani 2, 35128 Padova, Italy
| | - Mauro Alaibac
- Dermatology Unit, Department of Medicine, University of Padova, 35128 Padova, Italy
| | - Annalisa Angelini
- Cardiovascular Pathology Unit, Department of Cardio-Thoracic-Vascular Sciences and Public Health, University of Padova, 35128 Padova, Italy
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11
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Apostolidi EA, Gamaletsou MN, Arapaki M, Asimakopoulos JV, Diamantopoulos P, Zafeiratou S, Kofteridis D, Pagoni M, Kotsopoulou M, Voulgarelis M, Sipsas NV. Bone Marrow Iron Stores Are Not Associated with Increased Risk for Invasive Fungal Infections in Patients with Newly Diagnosed Acute Leukemia or Myelodysplastic Syndrome in Transformation: Is There a Relationship? J Fungi (Basel) 2023; 9:748. [PMID: 37504736 PMCID: PMC10381291 DOI: 10.3390/jof9070748] [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: 06/07/2023] [Revised: 07/02/2023] [Accepted: 07/12/2023] [Indexed: 07/29/2023] Open
Abstract
Iron plays an important role in the pathogenesis of infections, including invasive fungal infections (IFIs). Studies suggested that iron overload might represent an additional risk factor for IFIs among patients with hematological malignancies. We conducted a prospective, multi-center study amongst adult patients with newly diagnosed acute myeloid leukemia (AML) or myelodysplastic syndrome (MDS) in transformation to determine whether baseline iron overload as measured using the bone marrow iron store (BMIS) score is an independent risk factor for the development of IFIs. We also measured baseline serum iron and ferritin levels. A total of 98 patients were enrolled (76 with AML) and were followed for 12 months. Twenty-two patients developed IFI during the follow-up period (invasive aspergillosis n = 16, candidemia n = 5, mucormycosis n = 1). A baseline BMIS score ≥ 3 indicated that iron overload was relatively common (38/98 patients, 38%), and its frequency was comparable between patients with no IFIs (31/76, 40.7%) and in those with IFIs (8/22, 36.4%). Univariate analysis showed that only the presence of AML was associated with increased risk for IFIs [OR (95% CI) 7.40 (1.05-325.42)]. Both univariate and multivariate analyses showed that an increased BMIS score (≥3) at baseline was not an independent risk factor for IFIs. Similarly, there was no difference in serum iron and ferritin between the two groups that had similar demographic characteristics. Indices of iron overload were not independent risk factors for IFIs in our cohort of Greek patients with newly diagnosed AML/MDS in transformation.
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Affiliation(s)
- Eirini A Apostolidi
- Pathophysiology Department, General Hospital of Athens Laiko, Medical School, National and Kapodistrian University of Athens, 11527 Athens, Greece
| | - Maria N Gamaletsou
- Pathophysiology Department, General Hospital of Athens Laiko, Medical School, National and Kapodistrian University of Athens, 11527 Athens, Greece
| | - Maria Arapaki
- Hematology Department, General Hospital of Athens Laiko, 11527 Athens, Greece
| | | | - Panagiotis Diamantopoulos
- First Department of Internal Medicine, General Hospital of Athens Laiko, Medical School, National and Kapodistrian University of Athens, 11527 Athens, Greece
| | - Sofia Zafeiratou
- Department of Hygiene, Epidemiology and Medical Statistics, Medical School, National and Kapodistrian University of Athens, 11527 Athens, Greece
| | - Diamantis Kofteridis
- Medicine Department, Medical School, University of Crete, 71003 Heraklion, Greece
| | - Maria Pagoni
- Hematology Department, General Hospital of Athens Evangelismos, 10676 Athens, Greece
| | | | - Michael Voulgarelis
- Pathophysiology Department, General Hospital of Athens Laiko, Medical School, National and Kapodistrian University of Athens, 11527 Athens, Greece
| | - Nikolaos V Sipsas
- Pathophysiology Department, General Hospital of Athens Laiko, Medical School, National and Kapodistrian University of Athens, 11527 Athens, Greece
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Liu N, Tu J, Huang Y, Yang W, Wang Q, Li Z, Sheng C. Target- and prodrug-based design for fungal diseases and cancer-associated fungal infections. Adv Drug Deliv Rev 2023; 197:114819. [PMID: 37024014 DOI: 10.1016/j.addr.2023.114819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 03/28/2023] [Accepted: 03/31/2023] [Indexed: 04/07/2023]
Abstract
Invasive fungal infections (IFIs) are emerging as a serious threat to public health and are associated with high incidence and mortality. IFIs also represent a frequent complication in patients with cancer who are undergoing chemotherapy. However, effective and safe antifungal agents remain limited, and the development of severe drug resistance further undermines the efficacy of antifungal therapy. Therefore, there is an urgent need for novel antifungal agents to treat life-threatening fungal diseases, especially those with new mode of action, favorable pharmacokinetic profiles, and anti-resistance activity. In this review, we summarize new antifungal targets and target-based inhibitor design, with a focus on their antifungal activity, selectivity, and mechanism. We also illustrate the prodrug design strategy used to improve the physicochemical and pharmacokinetic profiles of antifungal agents. Dual-targeting antifungal agents offer a new strategy for the treatment of resistant infections and cancer-associated fungal infections.
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Ledoux MP, Herbrecht R. Invasive Pulmonary Aspergillosis. J Fungi (Basel) 2023; 9:jof9020131. [PMID: 36836246 PMCID: PMC9962768 DOI: 10.3390/jof9020131] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 01/12/2023] [Accepted: 01/15/2023] [Indexed: 01/19/2023] Open
Abstract
Invasive pulmonary aspergillosis is growing in incidence, as patients at risk are growing in diversity. Outside the classical context of neutropenia, new risk factors are emerging or newly identified, such as new anticancer drugs, viral pneumonias and hepatic dysfunctions. Clinical signs remain unspecific in these populations and the diagnostic work-up has considerably expanded. Computed tomography is key to assess the pulmonary lesions of aspergillosis, whose various features must be acknowledged. Positron-emission tomography can bring additional information for diagnosis and follow-up. The mycological argument for diagnosis is rarely fully conclusive, as biopsy from a sterile site is challenging in most clinical contexts. In patients with a risk and suggestive radiological findings, probable invasive aspergillosis is diagnosed through blood and bronchoalveolar lavage fluid samples by detecting galactomannan or DNA, or by direct microscopy and culture for the latter. Diagnosis is considered possible with mold infection in lack of mycological criterion. Nevertheless, the therapeutic decision should not be hindered by these research-oriented categories, that have been completed by better adapted ones in specific settings. Survival has been improved over the past decades with the development of relevant antifungals, including lipid formulations of amphotericin B and new azoles. New antifungals, including first-in-class molecules, are awaited.
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A real-world pharmacovigilance study of FDA Adverse Event Reporting System (FAERS) events for venetoclax. PLoS One 2022; 17:e0278725. [PMID: 36477747 PMCID: PMC9728853 DOI: 10.1371/journal.pone.0278725] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Accepted: 11/21/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Venetoclax (VEN) is the first selective small molecule Bcl-2 inhibitor approved by FDA and used in adult chronic lymphocytic leukemia (CLL), small lymphocytic lymphoma (SLL) and some acute myeloid leukemia (AML). However, the long-term safety of VEN in large sample population was unknown. This study evaluated the adverse events (AEs) of VEN from FDA Adverse Event Reporting System (FAERS) since its approval in 2016 by data mining. METHODS The disproportionality analyses, including four algorithms of reporting odd ratio (ROR), proportional reporting ratio (PRR), bayesian configuration promotion neural network (BCPNN), and multi item gamma poisson shrinker (MGPS), were employed to quantify the signals of VEN-associated AEs. RESULTS From the FAERS database, a total of 8,379,682 reports were collected during the study period. After removing the duplication, the number of reports with VEN as the primary suspect (PS) was 19,107. The 19,107 cases of AEs involved 27 organ systems, 256 significant PTs which conforming to the four algorithms. Unexpected serious AEs, such as pleural effusion, splenic infarction, atrial fibrillation, skin squamous cell carcinoma, etc., have signals. The median time of occurrence of AEs related to VEN was 31 days (inter quartile range [IQR] 7-131 days), and half of the reported AEs occurred within 1 month after administration. CONCLUSION Our research has found new significant AEs signals of VEN, which improved its safety information in real-world after marketing approval, and contributed to its risk control of use in clinic.
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Wurster S, Watowich SS, Kontoyiannis DP. Checkpoint inhibitors as immunotherapy for fungal infections: Promises, challenges, and unanswered questions. Front Immunol 2022; 13:1018202. [PMID: 36389687 PMCID: PMC9640966 DOI: 10.3389/fimmu.2022.1018202] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Accepted: 10/11/2022] [Indexed: 09/22/2023] Open
Abstract
Opportunistic fungal infections have high mortality in patients with severe immune dysfunction. Growing evidence suggests that the immune environment of invasive fungal infections and cancers share common features of immune cell exhaustion through activation of immune checkpoint pathways. This observation gave rise to several preclinical studies and clinical case reports describing blockade of the Programmed Cell Death Protein 1 and Cytotoxic T-Lymphocyte Antigen 4 immune checkpoint pathways as an adjunct immune enhancement strategy to treat opportunistic fungal infections. The first part of this review summarizes the emerging evidence for contributions of checkpoint pathways to the immunopathology of fungal sepsis, opportunistic mold infections, and dimorphic fungal infections. We then review the potential merits of immune checkpoint inhibitors (ICIs) as an antifungal immunotherapy, including the incomplete knowledge of the mechanisms involved in both immuno-protective effects and toxicities. In the second part of this review, we discuss the limitations of the current evidence and the many unknowns about ICIs as an antifungal immune enhancement strategy. Based on these gaps of knowledge and lessons learned from cancer immunology studies, we outline a research agenda to determine a "sweet spot" for ICIs in medical mycology. We specifically discuss the importance of more nuanced animal models, the need to study ICI-based combination therapy, potential ICI resistance, the role of the immune microenvironment, and the impact of ICIs given as part of oncological therapies on the natural immunity to various pathogenic fungi.
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Affiliation(s)
- Sebastian Wurster
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Stephanie S. Watowich
- Department of Immunology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Dimitrios P. Kontoyiannis
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
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Novel Insights into Fungal Infections Prophylaxis and Treatment in Pediatric Patients with Cancer. Antibiotics (Basel) 2022; 11:antibiotics11101316. [PMID: 36289974 PMCID: PMC9598217 DOI: 10.3390/antibiotics11101316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Revised: 09/20/2022] [Accepted: 09/22/2022] [Indexed: 11/23/2022] Open
Abstract
Invasive fungal diseases (IFDs) are a relevant cause of morbidity and mortality in children with cancer. Their correct prevention and management impact patients’ outcomes. The aim of this review is to highlight the rationale and novel insights into antifungal prophylaxis and treatment in pediatric patients with oncological and hematological diseases. The literature analysis showed that IFDs represent a minority of cases in comparison to bacterial and viral infections, but their impact might be far more serious, especially when prolonged antifungal therapy or invasive surgical treatments are required to eradicate colonization. A personalized approach is recommended since pediatric patients with cancer often present with different complications and require tailored therapy. Moreover, while the Aspergillus infection rate does not seem to increase, in the near future, new therapeutic recommendations should be required in light of new epidemiological data on Candidemia due to resistant species. Finally, further studies on CAR-T treatment and other immunotherapies are needed in patients with unique needs and the risk of complications. Definitive guidelines on IFD treatment considering the evolving epidemiology of antifungal resistance, new therapeutic approaches in pediatric cancer, novel antifungal drugs and the importance of an appropriate antifungal stewardship are urgently needed.
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Role of Iron and Iron Overload in the Pathogenesis of Invasive Fungal Infections in Patients with Hematological Malignancies. J Clin Med 2022; 11:jcm11154457. [PMID: 35956074 PMCID: PMC9369168 DOI: 10.3390/jcm11154457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 07/28/2022] [Accepted: 07/28/2022] [Indexed: 02/04/2023] Open
Abstract
Iron is an essential trace metal necessary for the reproduction and survival of fungal pathogens. The latter have developed various mechanisms to acquire iron from their mammalian hosts, with whom they participate in a continuous struggle for dominance over iron. Invasive fungal infections are an important problem in the treatment of patients with hematological malignancies, and they are associated with significant morbidity and mortality. The diagnosis of invasive clinical infections in these patients is complex, and the treatment, which must occur as early as possible, is difficult. There are several studies that have shown a possible link between iron overload and an increased susceptibility to infections. This link is also relevant for patients with hematological malignancies and for those treated with allogeneic hematopoietic stem cell transplantation. The role of iron and its metabolism in the virulence and pathogenesis of various invasive fungal infections is intriguing, and so far, there is some evidence linking invasive fungal infections to iron or iron overload. Clarifying the possible association of iron and iron overload with susceptibility to invasive fungal infections could be important for a better prevention and treatment of these infections in patients with hematological malignancies.
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Low Incidence of Invasive Fungal Disease Following CD19 Chimeric Antigen Receptor T-Cell (CAR-T) Therapy for Non-Hodgkin Lymphoma. Blood Adv 2022; 6:4821-4830. [PMID: 35802461 DOI: 10.1182/bloodadvances.2022007474] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 06/18/2022] [Indexed: 11/20/2022] Open
Abstract
CAR T-cell (CAR-T) therapy has revolutionized the treatment of hematologic malignancies, though its use may be complicated by toxicities including cytokine release syndrome (CRS), immune effector cell-associated neurotoxicity syndrome (ICANS), and infections. Invasive fungal disease (IFD) has been reported following CAR-T therapy, but the incidence in the absence of antifungal prophylaxis is unknown. Optimal screening, prophylaxis, and preemptive treatment strategies are widely debated. We performed a single-center retrospective study of 280 adults receiving CD19 CAR-T therapy for Non-Hodgkin's lymphoma (NHL) between December 2017 and September 2021 (n=280). Patients did not receive routine anti-yeast or mold prophylaxis. Proven and probable IFD was identified between day of cell infusion and last follow up. Cumulative Incidence Functions were calculated at 100 days and 18 months based on time to IFD using dates of IFD-free death, initiation of salvage treatment following relapse, and hematopoietic cell transplantation as competing risks. Eight patients (2.9%) developed IFD, including 3 Pneumocystis jirovecii pneumonia (PJP), 3 invasive mold infections (IMIs), and 2 invasive yeast infections (IYIs). Five infections (3 IMI; 2 IYI) occurred prior to day 100 and the 100-day cumulative incidence of IFD accounting for competing risks was 1.8% (95% CI 0.8 - 4.4%). Amongst the 280 patients, many developed early toxicity including CRS (85%) and ICANS (55%). Late toxicities after day 30 including grade 3/4 neutropenia (41%), hypogammaglobulinemia (35%), and low CD4 T-cell count (20%) were common. IFD was rare amongst patients who received CD19 CAR-T therapy for NHL in the absence of routine antifungal prophylaxis despite frequent toxicities including CRS, ICANS, and late neutropenia. This study suggests that in settings with low institutional rates of IFD, routine antifungal prophylaxis may not be indicated.
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BTK Inhibitors Impair Platelet-Mediated Antifungal Activity. Cells 2022; 11:cells11061003. [PMID: 35326454 PMCID: PMC8947638 DOI: 10.3390/cells11061003] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Revised: 03/09/2022] [Accepted: 03/11/2022] [Indexed: 01/27/2023] Open
Abstract
In recent years, the introduction of new drugs targeting Bruton’s tyrosine kinase (BTK) has allowed dramatic improvement in the prognosis of patients with chronic lymphocytic leukemia (CLL) and other B-cell neoplasms. Although these small molecules were initially considered less immunosuppressive than chemoimmunotherapy, an increasing number of reports have described the occurrence of unexpected opportunistic fungal infections, in particular invasive aspergillosis (IA). BTK represents a crucial molecule in several signaling pathways depending on different immune receptors. Based on a variety of specific off-target effects on innate immunity, namely on neutrophils, monocytes, pulmonary macrophages, and nurse-like cells, ibrutinib has been proposed as a new host factor for the definition of probable invasive pulmonary mold disease. The role of platelets in the control of fungal growth, through granule-dependent mechanisms, was described in vitro almost two decades ago and is, so far, neglected by experts in the field of clinical management of IA. In the present study, we confirm the antifungal role of platelets, and we show, for the first time, that the exposure to BTK inhibitors impairs several immune functions of platelets in response to Aspergillus fumigatus, i.e., the ability to adhere to conidia, activation (as indicated by reduced expression of P-selectin), and direct killing activity. In conclusion, our experimental data suggest that antiplatelet effects of BTK inhibitors may contribute to an increased risk for IA in CLL patients.
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