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Parrack PH, Zucker SD, Zhao L. Liver Pathology Related to Onco-Therapeutic Agents. Surg Pathol Clin 2023; 16:499-518. [PMID: 37536885 DOI: 10.1016/j.path.2023.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/05/2023]
Abstract
Oncotherapeutic agents can cause a wide range of liver injuries from elevated liver functions tests to fulminant liver failure. In this review, we emphasize a newer generation of drugs including immune checkpoint inhibitors, protein kinase inhibitors, monoclonal antibodies, and hormonal therapy. A few conventional chemotherapy agents are also discussed.
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Affiliation(s)
- Paige H Parrack
- Department of Pathology, Brigham and Women's Hospital, 75 Francis street, Boston, MA, 02115, USA; Harvard Medical School
| | - Stephen D Zucker
- Harvard Medical School; Department of Medicine, Brigham and Women's Hospital, 75 Francis street, Boston, MA, 02115, USA
| | - Lei Zhao
- Department of Pathology, Brigham and Women's Hospital, 75 Francis street, Boston, MA, 02115, USA; Harvard Medical School.
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Yu B, Saravanan L, Tran DH, Davies AJ, Kaur H, Naraynanan S, Verceles AC, Kim HJ. A case of fatal disseminated adenovirus and drug-resistant Pneumocystis pneumonia in a patient who received chemotherapy for mantle cell lymphoma. Clin Case Rep 2023; 11:e7220. [PMID: 37155427 PMCID: PMC10122681 DOI: 10.1002/ccr3.7220] [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: 01/08/2023] [Revised: 03/29/2023] [Accepted: 04/04/2023] [Indexed: 05/10/2023] Open
Abstract
Adenovirus (ADV) may cause severe complications in hematopoietic stem cell transplant recipients, but disseminated ADV infections in patients who received chemotherapy alone for hematological malignancies are poorly understood due to the rarity of cases. Concomitant infection with Pneumocystis (PCP) is extremely rare. Despite being diagnostically challenging, a more specific workup needs to be initiated with a low threshold in patients who are exposed to agents with the potential to suppress T cells. We report a fatal case of disseminated ADV and drug-resistant PCP pneumonia in a patient with mantle cell lymphoma who had only received combination chemotherapy. A 75-year-old man who was diagnosed with mantle cell lymphoma 10 months prior was admitted for mild hypoxic respiratory failure. Bendamustine, Rituximab, Cytarabine regimen had resulted in complete remission of his lymphoma, with the last cycle of chemotherapy administered 3 months prior to admission. CT of the chest revealed ground-glass opacities concerning pneumonia. Initial laboratory tests were remarkable for mild leukopenia. The respiratory viral panel was only positive for ADV. He did not respond to empiric antibiotics for community-acquired pneumonia and Trimethoprim / Sulfamethoxazole given later for positive Beta D Glucan (BDG) suggestive of Pneumocystis pneumonia. Then, he developed hemorrhagic cystitis, followed by liver and renal function derangement that prompted checking serum ADV viral load by polymerase chain reaction (PCR). This test took 1 week to return, with a viral load of 50, 000 copies/mL suggesting disseminated ADV infection. Despite initiation of Cidofovir, multi-organ failure continued to progress, and the follow-up viral load had doubled on Day 2. The patient passed away the same day shortly after transition to comfort care. T cell suppression seems to be a risk factor for disseminated ADV disease. Clinicians may need to maintain a low threshold to send serum quantitative ADV PCR when symptoms are not improved by antimicrobial treatment for more conventional infections in patients who received agents that are known to suppress T cells, such as Bendamustine.
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Affiliation(s)
- Bo Yu
- Department of MedicineUniversity of Maryland Medical Center Midtown CampusBaltimoreMarylandUSA
| | - Lakshmi Saravanan
- American University of Antigua College of MedicineOsbournAntigua and Barbuda
| | - Dena H. Tran
- Department of MedicineUniversity of Maryland Medical Center Midtown CampusBaltimoreMarylandUSA
| | - Alexander J. Davies
- Division of Pulmonary and Critical Care MedicineUniversity of Maryland Medical School of MedicineMarylandBaltimoreUSA
| | - Harpreet Kaur
- Department of Infectious DiseasesUniversity of Maryland Medical Center Midtown CampusBaltimoreMarylandUSA
| | - Shivakumar Naraynanan
- Department of Infectious DiseasesUniversity of Maryland Medical Center Midtown CampusBaltimoreMarylandUSA
| | - Avelino C. Verceles
- Division of Pulmonary and Critical Care MedicineUniversity of Maryland Medical School of MedicineMarylandBaltimoreUSA
| | - Hyeong J. Kim
- Division of Pulmonary and Critical Care MedicineUniversity of Maryland Medical School of MedicineMarylandBaltimoreUSA
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3
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Kager J, Schneider J, Rasch S, Herhaus P, Verbeek M, Mogler C, Heim A, Frösner G, Hoffmann D, Schmid RM, Lahmer T. Fulminant Adenoviral-Induced Hepatitis in Immunosuppressed Patients. Viruses 2022; 14:v14071459. [PMID: 35891439 PMCID: PMC9323657 DOI: 10.3390/v14071459] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Revised: 06/22/2022] [Accepted: 06/27/2022] [Indexed: 01/16/2023] Open
Abstract
Human adenovirus (HAdV) can often lead to fulminant hepatitis in immunocompromised patients, mostly after reactivation of HAdV. Different risk factors, e.g., transplantation and chemotherapy, increase the risk of developing a HAdV hepatitis. We retrospectively analyzed three patients who showed the characteristics of a HAdV hepatitis observed in disseminated disease. In addition to PCR, diagnosis could be proven by pathology, CT scan, and markedly elevated transaminases. All patients had a hemato-oncologic underlying disease. Two had received a stem-cell transplant, and one was under chemotherapy including rituximab. Despite therapy with cidofovir, all patients died. As the incidence of HAdV hepatitis is low, diagnosis may be easily overlooked. No treatment approaches have yet been established. HAdV hepatitis should be considered as a differential diagnosis, especially when risk factors are present. To avoid dissemination, treatment should be initiated as soon as possible.
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Affiliation(s)
- Juliane Kager
- Department of Internal Medicine II, School of Medicine, University Hospital Rechts der Isar, Technical University of Munich (TUM), 81675 Munich, Germany; (J.K.); (J.S.); (S.R.); (R.M.S.)
| | - Jochen Schneider
- Department of Internal Medicine II, School of Medicine, University Hospital Rechts der Isar, Technical University of Munich (TUM), 81675 Munich, Germany; (J.K.); (J.S.); (S.R.); (R.M.S.)
| | - Sebastian Rasch
- Department of Internal Medicine II, School of Medicine, University Hospital Rechts der Isar, Technical University of Munich (TUM), 81675 Munich, Germany; (J.K.); (J.S.); (S.R.); (R.M.S.)
| | - Peter Herhaus
- Department of Internal Medicine III, School of Medicine, University Hospital Rechts der Isar, Technical University of Munich (TUM), 81675 Munich, Germany; (P.H.); (M.V.)
| | - Mareike Verbeek
- Department of Internal Medicine III, School of Medicine, University Hospital Rechts der Isar, Technical University of Munich (TUM), 81675 Munich, Germany; (P.H.); (M.V.)
| | - Carolin Mogler
- Institute of Pathology, School of Medicine, Technical University of Munich (TUM), 80333 Munich, Germany;
| | - Albert Heim
- German National Reference Laboratory for Adenoviruses, Institute for Virology, Hannover Medical School, 30625 Hannover, Germany;
| | - Gert Frösner
- Institute of Virology, School of Medicine, Technical University of Munich (TUM), 80333 Munich, Germany; (G.F.); (D.H.)
| | - Dieter Hoffmann
- Institute of Virology, School of Medicine, Technical University of Munich (TUM), 80333 Munich, Germany; (G.F.); (D.H.)
| | - Roland M. Schmid
- Department of Internal Medicine II, School of Medicine, University Hospital Rechts der Isar, Technical University of Munich (TUM), 81675 Munich, Germany; (J.K.); (J.S.); (S.R.); (R.M.S.)
| | - Tobias Lahmer
- Department of Internal Medicine II, School of Medicine, University Hospital Rechts der Isar, Technical University of Munich (TUM), 81675 Munich, Germany; (J.K.); (J.S.); (S.R.); (R.M.S.)
- Correspondence:
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4
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Grammatikos A, Donati M, Johnston SL, Gompels MM. Peripheral B Cell Deficiency and Predisposition to Viral Infections: The Paradigm of Immune Deficiencies. Front Immunol 2021; 12:731643. [PMID: 34527001 PMCID: PMC8435594 DOI: 10.3389/fimmu.2021.731643] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2021] [Accepted: 08/09/2021] [Indexed: 12/11/2022] Open
Abstract
In the era of COVID-19, understanding how our immune system responds to viral infections is more pertinent than ever. Immunodeficiencies with very low or absent B cells offer a valuable model to study the role of humoral immunity against these types of infection. This review looks at the available evidence on viral infections in patients with B cell alymphocytosis, in particular those with X-linked agammaglobulinemia (XLA), Good’s syndrome, post monoclonal-antibody therapy and certain patients with Common Variable Immune Deficiency (CVID). Viral infections are not as infrequent as previously thought in these conditions and individuals with very low circulating B cells seem to be predisposed to an adverse outcome. Particularly in the case of SARS-CoV2 infection, mounting evidence suggests that peripheral B cell alymphocytosis is linked to a poor prognosis.
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Affiliation(s)
- Alexandros Grammatikos
- Department of Immunology, Southmead Hospital, North Bristol National Health Service (NHS) Trust, Bristol, United Kingdom
| | - Matthew Donati
- Severn Infection Sciences and Public Health England National Infection Service South West, Department of Virology, Southmead Hospital, North Bristol NHS Trust, Bristol, United Kingdom
| | - Sarah L Johnston
- Department of Immunology, Southmead Hospital, North Bristol National Health Service (NHS) Trust, Bristol, United Kingdom
| | - Mark M Gompels
- Department of Immunology, Southmead Hospital, North Bristol National Health Service (NHS) Trust, Bristol, United Kingdom
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5
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Rogers DL, Ruiz JC, Baze WB, McClure GB, Smith C, Urbanowski R, Boston T, Simmons JH, Williams L, Abee CR, Vanchiere JA. Epidemiological and molecular characterization of a novel adenovirus of squirrel monkeys after fatal infection during immunosuppression. Microb Genom 2020; 6:mgen000395. [PMID: 32614763 PMCID: PMC7643968 DOI: 10.1099/mgen.0.000395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 05/29/2020] [Indexed: 11/18/2022] Open
Abstract
Adenoviruses are a frequent cause of acute upper respiratory tract infections that can also cause disseminated disease in immunosuppressed patients. We identified a novel adenovirus, squirrel monkey adenovirus 1 (SqMAdV-1), as the cause of fatal infection in an immunocompromised squirrel monkey (Saimiri boliviensis) at the Keeling Center for Comparative Medicine and Research (KCCMR). Sequencing of SqMAdV-1 revealed that it is most closely related (80.4 % pairwise nucleotide identity) to the titi monkey (Plecturocebus cupreus) adenovirus (TMAdV). Although identified in the titi monkey, TMAdV is highly lethal in these monkeys, and they are not thought to be the natural host. While SqMAdV-1 is similar to other primate adenoviruses in size and genomic characteristics, a nucleotide polymorphism at the expected stop codon of the DNA polymerase gene results in a 126 amino acid extension at the carboxy terminus, a feature not previously observed among other primate adenoviruses. PCR testing and partial sequencing of 95 archived faecal samples from other squirrel monkeys (Saimiri boliviensis and Saimiri sciureus) housed at the KCCMR revealed the presence of three distinct, and apparently endemic species of adenoviruses. A grouping of ten squirrel monkey adenovirus variants has high similarity to SqMAdV-1. A single adenovirus variant (designated SqMAdV-3), detected in five monkeys, has similarity to tufted capuchin (Sapajus apella) adenoviruses. The largest group of adenovirus variants detected (designated SqMAdV-2.0-2.16) has very high similarity (93-99 %) to the TMAdV, suggesting that squirrel monkeys may be the natural host of the TMAdV.
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Affiliation(s)
- Donna L. Rogers
- Department of Pediatrics, Louisiana State University Health Sciences Center, Shreveport, LA, USA
| | - Julio C. Ruiz
- Keeling Center for Comparative Medicine Research, Department of Comparative Medicine, The University of Texas MD Anderson Cancer Center, Bastrop, TX, USA
| | - Wallace B. Baze
- Keeling Center for Comparative Medicine Research, Department of Comparative Medicine, The University of Texas MD Anderson Cancer Center, Bastrop, TX, USA
| | - Gloria B. McClure
- Department of Pediatrics, Louisiana State University Health Sciences Center, Shreveport, LA, USA
| | - Carolyn Smith
- Department of Pediatrics, Louisiana State University Health Sciences Center, Shreveport, LA, USA
| | - Ricky Urbanowski
- Department of Pediatrics, Louisiana State University Health Sciences Center, Shreveport, LA, USA
| | - Theresa Boston
- Department of Pediatrics, Louisiana State University Health Sciences Center, Shreveport, LA, USA
| | - Joe H. Simmons
- Keeling Center for Comparative Medicine Research, Department of Comparative Medicine, The University of Texas MD Anderson Cancer Center, Bastrop, TX, USA
| | - Lawrence Williams
- Keeling Center for Comparative Medicine Research, Department of Comparative Medicine, The University of Texas MD Anderson Cancer Center, Bastrop, TX, USA
| | - Christian R. Abee
- Keeling Center for Comparative Medicine Research, Department of Comparative Medicine, The University of Texas MD Anderson Cancer Center, Bastrop, TX, USA
| | - John A. Vanchiere
- Department of Pediatrics, Louisiana State University Health Sciences Center, Shreveport, LA, USA
- Keeling Center for Comparative Medicine Research, Department of Comparative Medicine, The University of Texas MD Anderson Cancer Center, Bastrop, TX, USA
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6
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Gu J, Su QQ, Zuo TT, Chen YB. Adenovirus diseases: a systematic review and meta-analysis of 228 case reports. Infection 2020; 49:1-13. [PMID: 32720128 DOI: 10.1007/s15010-020-01484-7] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Accepted: 07/19/2020] [Indexed: 12/15/2022]
Abstract
OBJECTIVE The clinical characteristics of various adenovirus (ADV) infection are underexplored up till now. To investigate the risk factors, manifestation, current status of ADV species, treatment and prognosis of this disease. METHODS We performed a Pubmed and Embase systematic review for case report reporting the ADV infection to analyze the clinical characteristics of disease. RESULTS Initial database searched identified articles of which 168 (228 cases) were included in the final analysis. Previous solid organ transplantation [odds ratio (OR) = 3.45, 95% CI 1.31-9.08, P = 0.01], hematopoietic stem cell transplant (OR = 4.24, 95% CI 1.33-13.51, P = 0.01) and hematological malignancy (OR = 4.78, 95% CI 1.70-13.46, P = 0.01) were associated with increased risk of disseminated ADV infection. Use of corticosteroids (OR = 3.86, 95% CI 1.21-12.24, P = 0.02) was a significant risk factor for acquiring urinary tract infections. A total of six species (21 types) of ADV infection have been identified in 100/228 (43.9%) cases. ADV B was the most common species. ADV B species (26/60, 52.0% or 5/41, 12.2% P = 0.001) were more isolated in patients with ADV pneumonia. ADV C (13/15, 86.7% versus 35/86, 40.7% P = 0.001) species were more identified in patients with disseminated disease. The species associated with keratoconjunctivitis is only ADV D in our analysis. Urinary tract ADV infections were observed in ADV A/B/D species. Cidofovir (CDV) (82/228, 36.0%) remained the most commonly antiviral therapy in our cases, followed by ribavirin (15/228, 6.6%), ganciclovir (18/228, 7.9%), and brincidofovir (12/228, 5.3%). Brincidofovir was administered as salvage therapy in 10 cases. Death was reported in 81/228 (35.5%) patients. Mortality rate was higher among patients with gastrointestinal (GI) ADV infection (5/10, 50.0%), ADV pneumonia (20/45, 44.4%) and disseminated ADV infection (53/122, 43.4%). CONCLUSION Previous solid organ transplantation, hematopoietic stem cell transplant and hematological malignancy were risk factors for disseminated ADV infection. Use of corticosteroids was significant for urinary tract ADV infection. Different species correlated with different clinical manifestations of infection. Mortality rate was higher among patients with GI disease, pneumonia and disseminated disease. Our review clarified the current treatment of ADV infections, and more treatment required further investigation.
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Affiliation(s)
- Jie Gu
- Department of Pulmonary and Critical Care Medicine, The First Affiliated Hospital of Soochow University, 899# Pinghai Road, Suzhou, 215000, China
| | - Qing-Qing Su
- Department of Pulmonary and Critical Care Medicine, The First Affiliated Hospital of Soochow University, 899# Pinghai Road, Suzhou, 215000, China
| | - Ting-Ting Zuo
- Department of Pulmonary and Critical Care Medicine, The First Affiliated Hospital of Soochow University, 899# Pinghai Road, Suzhou, 215000, China
| | - Yan-Bin Chen
- Department of Pulmonary and Critical Care Medicine, The First Affiliated Hospital of Soochow University, 899# Pinghai Road, Suzhou, 215000, China.
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7
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Adenovirus Hepatitis: Clinicopathologic Analysis of 12 Consecutive Cases From a Single Institution. Am J Surg Pathol 2017; 41:810-819. [PMID: 28296681 DOI: 10.1097/pas.0000000000000834] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Adenoviruses are common pathogens that usually cause self-limited infections. However, in the immunocompromised host they can cause severe infections involving multiple organs including the liver. A search of the pathology database at Stanford University Medical Center (1995 to 2016) identified 12 cases of adenovirus hepatitis including biopsy and autopsy specimens. There were 8 pediatric patients, 7 of which had received orthotropic liver transplants and 1 of which was receiving chemotherapy for lymphoblastic leukemia. There were 4 adult patients, of which 1 was actively receiving chemotherapy for chronic lymphocytic leukemia and 2 had undergone hematopoietic stem cell transplantation for hematologic malignancies. One patient had lymphoplasmacytic lymphoma and had received chemotherapy over a year prior but was not receiving therapy at the time he contracted adenovirus hepatitis. In all cases, histologic sections showed nonzonal coagulative hepatocyte necrosis and characteristic intranuclear inclusions. Hepatocyte necrosis ranged from spotty to massive. The majority of cases (7/12; 58%) had no associated inflammation. If present, inflammation was focal and lymphohistiocytic. In 1 case, findings were focal within the liver, requiring an image-guided biopsy. This patient underwent a simultaneous nontargeted liver biopsy that lacked histologic evidence of adenovirus. Among the pediatric patients, 63% (5/8) died secondary to organ failure, while there was 100% (4/4) mortality in the adult population.
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8
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McKillop SJ, Belletrutti MJ, Lee BE, Yap JY, Noga ML, Desai SJ, Sergi C. Adenovirus necrotizing hepatitis complicating atypical teratoid rhabdoid tumor. Pediatr Int 2015; 57:974-7. [PMID: 26508178 DOI: 10.1111/ped.12674] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2014] [Revised: 01/09/2015] [Accepted: 01/19/2015] [Indexed: 11/28/2022]
Abstract
Adenovirus-induced fulminant hepatitis is rare. It has been reported in children with primary immunodeficiency, following transplantation or while receiving chemotherapy for hematological malignancy. We present the case of an infant recovering from chemotherapy for atypical teratoid rhabdoid tumor (ATRT) in whom a diagnosis of hepatic necrosis due to adenovirus was made.
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Affiliation(s)
- Sarah J McKillop
- Divisions of Immunology, Hematology, Oncology, Palliative Care and Environmental Health, University of Alberta, Edmonton, Alberta, Canada.,Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Mark J Belletrutti
- Divisions of Immunology, Hematology, Oncology, Palliative Care and Environmental Health, University of Alberta, Edmonton, Alberta, Canada.,Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Bonita E Lee
- Infectious Disease, University of Alberta, Edmonton, Alberta, Canada.,Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Jason Y Yap
- Gastroenterology and Nutrition, University of Alberta, Edmonton, Alberta, Canada.,Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Michelle L Noga
- Departments of Radiology, University of Alberta, Edmonton, Alberta, Canada
| | - Sunil J Desai
- Divisions of Immunology, Hematology, Oncology, Palliative Care and Environmental Health, University of Alberta, Edmonton, Alberta, Canada.,Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Consolato Sergi
- Laboratory Medicine and Pathology, University of Alberta, Edmonton, Alberta, Canada
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10
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Abstract
PURPOSE To describe the demographics, clinical manifestations, treatment and outcomes of patients with human adenovirus (HAdV) hepatitis. METHODS A case of fulminant HAdV hepatitis in a patient with chronic lymphocytic leukemia receiving rituximab and fludarabine is described. We conducted a comprehensive review of the English-language literature through May, 2012 in search of definite cases of HAdV hepatitis. RESULTS Eighty-nine cases were reviewed. Forty-three (48 %) were liver transplant recipients, 19 (21 %) were bone marrow transplant recipients, 11 (12 %) had received chemotherapy, five (6 %) had severe combined immunodeficiency, four (4 %) were HIV infected, two had heart transplantation, and two were kidney transplant recipients. Ninety percent (46/51) of patients presented within 6 months following transplantation. Fever was the most common initial symptom. Abdominal CT scan revealed hypodense lesions in eight of nine patients. Diagnosis was made by liver biopsy in 43 (48 %), and on autopsy in 46 (52 %). The HAdV was isolated at other sites in 54 cases. Only 24 of 89 patients (27 %) survived: 16 whose immunosuppression was reduced, six with liver re-transplantation, and two who received cidofovir and intravenous immunoglobulin. CONCLUSION HAdV hepatitis can manifest as a fulminant illness in immunocompromised hosts. Definitive diagnosis requires liver biopsy. Early consideration of a viral etiology, reduction in immunosuppression, and liver transplantation can be potentially life-saving.
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José RJP, Chrysochou C, Shurrab AE, New D, Wood GNI. Rituximab for rescue and maintenance therapy in rapidly progressive life-threatening antineutrophil cytoplasmic autoantibody-associated systemic vasculitis. ACTA ACUST UNITED AC 2010; 44:459-62. [PMID: 20645677 DOI: 10.3109/00365599.2010.504193] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Antineutrophil cytoplasmic autoantibody (ANCA)-associated systemic vasculitides (AASV) consists of small-vessel systemic inflammatory disorders which commonly affect the kidneys and without treatment have a poor prognosis. Rituximab is a novel biological agent which is being used experimentally in the management of AASV. This report presents the case of a young woman with rapidly progressive life-threatening AASV. Despite prompt diagnosis and initial treatment with steroids and alkylating agents her condition became life threatening. With addition of rituximab therapy she showed an excellent sustained response. Rituximab appears an effective and safe treatment choice for the induction of remission in severe AASV that is not responding to standard agents, at the initial presentation and for maintenance therapy, without the development of common serious side-effects associated with immunosuppression.
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Affiliation(s)
- Ricardo J P José
- Department of Renal Medicine, Salford Royal NHS Foundation Trust, Salford, Manchester, UK.
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12
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Ram R, Ben-Bassat I, Shpilberg O, Polliack A, Raanani P. The late adverse events of rituximab therapy--rare but there! Leuk Lymphoma 2009; 50:1083-95. [PMID: 19399690 DOI: 10.1080/10428190902934944] [Citation(s) in RCA: 97] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Rituximab, an anti CD20 monoclonal antibody, has now become a cornerstone in the treatment of many CD20 positive hematological malignancies and a variety of autoimmune disorders. In contrast to the acute allergic and cytokine associated reactions, late adverse events of rituximab are indeed uncommon but at the same time probably under-reported. In this review, we detail late adverse events reported since its use in hemato-oncological neoplasias and other disorders. These adverse events include the development of late-onset neutropenia, defects of immune reconstitution with associated immune compromise, infections, progressive multifocal leukoencephalopathy, reactivation of hepatitis, intestinal perforation and interstitial pneumonitis. Possible mechanisms involved in rituximab-associated complications and the pathogenesis of these adverse effects are reviewed and discussed. Evidence based graded recommendations for the management of these adverse effects are proposed.
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Affiliation(s)
- Ron Ram
- Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel
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Hensley JL, Sifri CD, Cathro HP, Lobo P, Sawyer RG, Brayman KL, Hackman RC, Pruett TL, Bonatti HJR. Adenoviral graft-nephritis: case report and review of the literature. Transpl Int 2009; 22:672-7. [PMID: 19210749 DOI: 10.1111/j.1432-2277.2009.00838.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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14
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Lovric S, Erdbruegger U, Kümpers P, Woywodt A, Koenecke C, Wedemeyer H, Haller H, Haubitz M. Rituximab as rescue therapy in anti-neutrophil cytoplasmic antibody-associated vasculitis: a single-centre experience with 15 patients. Nephrol Dial Transplant 2008; 24:179-85. [PMID: 18685144 DOI: 10.1093/ndt/gfn430] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND B-cell depletion with rituximab, a chimeric anti-CD20 antibody, is a novel treatment for refractory and relapsing ANCA-associated small-vessel vasculitis. Data are limited and most reports describe single patients or small numbers of patients followed prospectively. METHODS We report a single-centre experience with 15 patients who received rituximab for refractory or relapsing ANCA-associated vasculitis. All patients had been treated with corticosteroids and cyclophosphamide and a variety of other second-line immunosuppressive agents. None of the patients had evidence of infection and received four infusions of 375 mg/m(2) of rituximab. Disease activity was assessed in accordance with the Birmingham Vasculitis Activity Score (BVAS). BVAS, C-reactive protein and ANCA titres were recorded at baseline and during follow-up. RESULTS B-cell depletion was achieved in all patients. Partial or complete remission was seen in 14 of 15 patients with a significant decline in BVAS compared to baseline (P < 0.007). One patient with granulomatous ANCA-associated vasculitis did not respond to rituximab. There were no side effects during rituximab infusion. Transient leucopenia was observed in two patients. One patient with bronchial stenosis died of pneumonia 5.5 months after the initiation of rituximab treatment. One initially anti-HBc-positive/HBsAg-negative patient experienced a reactivation of hepatitis B, developed end-stage renal failure and died after refusal of dialysis. CONCLUSIONS We report the largest case series of rituximab use for ANCA-associated vasculitis so far. Our data support that the drug is capable of inducing partial or complete remission in refractory or relapsing patients. Leucopenia and infectious complications remain a matter of concern.
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Affiliation(s)
- Svjetlana Lovric
- Department of Nephrology, Hannover Medical School, Hannover, Germany
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15
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Vijay A, Gertz MA. Current Treatment Options for Waldenström Macroglobulinemia. ACTA ACUST UNITED AC 2008; 8:219-29. [DOI: 10.3816/clm.2008.n.029] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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16
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SV40 Infection Associated With Rituximab Treatment After Kidney Transplantation in Nonhuman Primates. Transplantation 2008; 85:893-902. [DOI: 10.1097/tp.0b013e3181668ecc] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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Krause PJ, Gewurz BE, Hill D, Marty FM, Vannier E, Foppa IM, Furman RR, Neuhaus E, Skowron G, Gupta S, McCalla C, Pesanti EL, Young M, Heiman D, Hsue G, Gelfand JA, Wormser GP, Dickason J, Bia FJ, Hartman B, Telford SR, Christianson D, Dardick K, Coleman M, Girotto JE, Spielman A. Persistent and relapsing babesiosis in immunocompromised patients. Clin Infect Dis 2008; 46:370-6. [PMID: 18181735 DOI: 10.1086/525852] [Citation(s) in RCA: 232] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Human babesiosis is a tickborne malaria-like illness that generally resolves without complication after administration of atovaquone and azithromycin or clindamycin and quinine. Although patients experiencing babesiosis that is unresponsive to standard antimicrobial therapy have been described, the pathogenesis, clinical course, and optimal treatment regimen of such cases remain uncertain. METHODS We compared the immunologic status, clinical course, and treatment of 14 case patients who experienced morbidity or death after persistence of Babesia microti infection, despite repeated courses of antibabesial treatment, with those of 46 control subjects whose infection resolved after a single course of standard therapy. This retrospective case-control study was performed in southern New England, New York, and Wisconsin. RESULTS All case patients were immunosuppressed at the time of acute babesiosis, compared with <10% of the control subjects. Most case patients experienced B cell lymphoma and were asplenic or had received rituximab before babesial illness. The case patients were more likely than control subjects to experience complications, and 3 died. Resolution of persistent infection occurred in 11 patients after 2-10 courses of therapy, including administration of a final antimicrobial regimen for at least 2 weeks after babesia were no longer seen on blood smear. CONCLUSIONS Immunocompromised people who are infected by B. microti are at risk of persistent relapsing illness. Such patients generally require antibabesial treatment for >or=6 weeks to achieve cure, including 2 weeks after parasites are no longer detected on blood smear.
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Affiliation(s)
- Peter J Krause
- Division of Infectious Diseases, Connecticut Children's Medical Center, and Department of Pediatrics, University of Connecticut School of Medicine, Farmington, Connecticut 06106, USA.
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Recovery of humoral immunity is critical for successful antiviral therapy in disseminated mouse adenovirus type 1 infection. Antimicrob Agents Chemother 2008; 52:1462-71. [PMID: 18268085 DOI: 10.1128/aac.01311-07] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Severe adenovirus infections in transplant recipients undergoing immunosuppressive therapy are of increasing concern. Controversy exists on the contribution of antiviral therapy and the host immune response to recovery from these infections. Here, we established a systemic mouse adenovirus type 1 (MAV-1) infection in cyclophosphamide (CyP)-treated BALB/c mice. CyP was administered at 100 mg per kg of body weight every other day for 2, 3, or 4 weeks, thereby inducing general but reversible leukopenia, with a major suppression of the B-cell numbers and functionality that was more pronounced than that seen with T cells. The outcome of MAV-1 infection was dependent on the duration of CyP therapy, as the mice with the most severe immunosuppression were the most vulnerable to MAV-1-induced hemorrhagic enteritis and mortality. The protective effect of concomitant antiviral therapy with cidofovir depended on the level of immunosuppression. The combination of cidofovir treatment with the withdrawal of immunosuppression was the most successful regimen for increasing survival rates. Survival was clearly correlated with the clearance of virus and increased titers of MAV-1-specific antibodies in sera. In addition, the passive transfer of MAV-1-specific immunoglobulin G into MAV-1-infected SCID BALB/c mice caused a marked delay in mortality, the extent of the delay being dependent on the titer of MAV-1-specific antibodies. Based on the critical role of the humoral immune response in the early defense against disseminated adenovirus infection, the concomitant use of adenovirus-specific immunoglobulins and antiviral therapy should be considered for transplant patients at risk for severe adenovirus infections.
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Abstract
Over time, Waldenström macroglobulinaemia (WM) has evolved conceptually from a clinical syndrome to a distinct clinicopathological entity. Progress is being made in standardization of the disease definition and treatment response criteria, although nosologic controversies persist. According to the Second International Workshop on WM, the disease is defined as a B-cell neoplasm characterized by a lymphoplasmacytic infiltrate in the bone marrow, with an associated immunoglobulin (Ig) M paraprotein. Disease symptoms are often divided into those related to tumour infiltration and those related to the rheological effects of the monoclonal IgM. As with other low-grade lymphomas, asymptomatic patients are observed only, with treatment reserved for symptomatic patients. There is no standard treatment for WM and choices include rituximab, alkylating agents, purine nucleoside analogues, alone or in combination, as well as autologous peripheral blood stem cell transplant in eligible patients. Novel treatments, such as bortezomib, oblimersen sodium, perifosine and others are being evaluated.
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Affiliation(s)
- Rafael Fonseca
- Division of Hematology-Oncology, Mayo Clinic Scottsdale, Scottsdale, AZ, USA.
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