Role of B Cells beyond Antibodies in HBV-Induced Oncogenesis: Fulminant Cancer in Common Variable Immunodeficiency-Clinical and Immunotransplant Implications with a Review of the Literature

Although lymphoma is the most frequent malignancy in common variable immunodeficiency (CVID), solid tumors, especially affected by oncogenic viruses, are not considered. Furthermore, in vitro genetic studies and cell cultures are not adequate for immune system and HBV interaction. We adopted a previously introduced clinical model of host-virus interaction (i.e., infectious process in immunodeficiency) for analysis of B cells and the specific IgG role (an observational study of a CVID patient who received intravenous immunoglobulin (IVIG). Suddenly, the patient deteriorated and a positive results of for HBs and HBV-DNA (369 × 106 copies) were detected. Despite lamivudine therapy and IVIG escalation (from 0.3 to 0.4 g/kg), CT showed an 11 cm intrahepatic tumor (hepatocellular carcinoma). Anti-HBs were positive in time-lapse analysis (range 111-220 IU/mL). Replacement therapy intensification was complicated by an immune complex disease with renal failure. Fulminant HCC in CVID and the development of a tumor as the first sign is of interest. Unfortunately, treatment with hepatitis B immune globulins (HBIG) plays a major role in posttransplant maintenance therapy. Anti-HB substitution has not been proven to be effective, oncoprotective, nor safe. Therefore, immunosuppression in HBV-infected recipients should be carefully minimized, and patient selection more precise with the exclusion of HBV-positive donors. Our clinical model showed an HCC pathway with important humoral host factors, contrary to epidemiological/cohort studies highlighting risk factors only (e.g., chronic hepatitis). The lack of cell cooperation as well as B cell deficiency observed in CVID play a crucial role in high HBV replication, especially in carcinogenesis.

High Monocyte Count Associated with Human Cytomegalovirus Replication In Vivo and Glucocorticoid Therapy May Be a Hallmark of Disease

Cytomegalovirus (CMV) syndrome and infectious disease are defined as pathogen detection with appropriate clinical symptoms, but there are not pathognomonic signs of CMV disease. Although the prodrome of acute minor viral infections leukopenia (lymphopenia and neutropenia) is noted with onset of fever, followed by monocytosis, the role of monocytosis in CMV disease has not been described. Furthermore, under influence of corticosteroid therapy, CMV reactivation and monocytosis are described, but without a strict relationship with steroids dose. In the study, the monocyte level was investigated during the CMV infectious process. Regrettably, a non-selected group of 160 patients with high CMV viremia showed high dispersion of monocyte level and comparable with the median value for healthy subjects. Therefore, we investigated monocyte level in CMV-infected patients in relation to the logarithmic phase of the infectious process. Samples from patients with active CMV replication (exponential growth of CMV viremia) were tested. Significant monocytosis (above 1200/µL) during the logarithmic phase of CMV infection (with exponent between 3.23 and 5.77) was observed. Increased count and percentage of monocytes correlated with viral replication in several clinical situations except when there was a rapid recovery without relapse. Furthermore, glucocorticoids equivalent to 10 and 20 mg of dexamethasone during a 2–3-week period caused monocytosis—significant increase (to 1604 and 2214/µL, respectively). Conclusion: In light of the logarithmic increase of viral load, high monocytosis is a hallmark of CMV replication. In the COVID-19 era, presence of high virus level, especially part of virome (CMV) in the molecular technique, is not sufficient for the definition of either proven or probable CMV replication at any site. These preliminary observations merit additional studies to establish whether this clinical response is mediated by monocyte production or by decrease of differentiation to macrophages.

Lymphoid Interstitial Pneumonia in Common Variable Immune Deficiency - Case Report With Disease Monitoring in Various Therapeutic Options: Pleiotropic Effects of Rituximab Regimens

Lymphoid interstitial pneumonia (LIP) is a rare lymphoproliferative disease. LIP in common variable immunodeficiency (CVID) was observed in a patient during immunomodulatory therapy after progression of the disease (i.e., glucocorticoids, immunoglobulin dose escalation, and finally rituximab). Due to humoral immunodeficiency and serious serum sickness rituximab was used initially at a low dose (150 mg/m² weekly). It resulted in temporary remission with the decrease of serum paraproteinemia, β₂-microglobulin (β2M) and SUV decrease as well as increase of FVC. Owing to the relapse after 6-month remission in the second cycle a standard dose of rituximab was used (375 mg/m²). Therapeutic regimen with 375 mg/m² of Rtx in optimal schedule (i.e., every 3 weeks) resulted in no longer remission but higher incidence of opportunistic infections. Finally, after another cycle of immunotherapy FVC, paraproteinemia and β2M level normalization were observed as well as the decrease of severe splenomegaly. In laboratory and immunological progress the increase of NK and NKT cells was observed after the initial dose but the standard one caused NK cell increase only. Unfortunately, the decrease of CD19+Bcells was comparable between both doses, as was the decline of FoxP3+ regulatory T cell. On the contrary, after the low dose absolute T cell (both CD4 and CD8) number decreased but after the standard one - it normalized. Rtx (especially in low dose) brought further increase of persistent T cell activation (CD38+ T cells made up 79%). Innate immune response and the decrease of Treg are a compensatory pathways for the decrease of B and T cells. Immunodeficiency requires a different investigative approach to a immunotherapy. Clinical Trial Registration: ClinicalTrials.gov, NCT02789397.

Correction to: Passive blood anaphylaxis: subcutaneous immunoglobulins are a cause of ongoing passive anaphylactic reaction

[This corrects the article DOI: 10.1186/s13223-017-0213-x.].

Detection of Polish clinical Aspergillus fumigatus isolates resistant to triazoles

We studied the presence of triazole resistance of 121 Aspergillus fumigatus clinical isolates collected in two Polish cities, Warsaw and Wrocław, to determine if resistance is emerging in our country. We identified five itraconazole resistant isolates (4.13%) carrying the TR34/L98H alteration in Cyp51A gene, four of which were cross-resistant to posaconazole and one to voriconazole. One isolate was intermediate susceptible to itraconazole and harbored no Cyp51A alterations. The study confirms the presence of azole resistant A. fumigatus strains in Poland at a level that is comparative to other European countries.

Passive blood anaphylaxis: subcutaneous immunoglobulins are a cause of ongoing passive anaphylactic reaction

Background

Allergic, especially anaphylactic, reactions during immunoglobulin replacement therapy are rare, but their pathophysiology and classification remain ambiguous. Recent findings show positive results of skin tests with commercially available immunoglobulins, but target antigens and responsible compounds of the tested immunoglobulins have not been strictly identified.

Case description and findings

Four adult patients with recently diagnosed common variable immunodeficiency qualified for standard subcutaneous immunoglobulin replacement therapy regimen. They had no history of receiving immunoglobulins, blood or blood product transfusions. Edema, confluent wheals and erythema were observed at the site of subcutaneous immunoglobulin infusion: typical early and late phase reaction. A transient increase in various passively transferred IgG and IgE antibodies was responsible for misleading positive outcome of the serological testing for active humoral response such as type I allergy, anti-Rh, isohemagglutinins and rheumatoid factor (RF). Although the clinical presentation was very unusual and severe, the retrospective analysis showed no isohemagglutinins, RF and IgE in the patients’ serum before but it was positive after the infusion (median IgE = 18 IU/ml, RF = 8 IU/ml). Type I allergic reaction (laryngeal edema, rhinoconjuctivitis) came out at +14 days of replacement therapy when the patient visited countryside. In the second patient anaphylactic reaction was observed 5 days after ScIg administration, and only when the patient consumed peanuts. Therefore, IgE concentration was measured retrospectively in a series of commercial preparations used in the initial subcutaneous immunoglobulin replacement therapy that caused the adverse event (AE) and it was determined between 138 and 232 IU/ml (kU/l), i.e. 690–2100 IU per g of protein. Specific IgE was within a wide range from 198 (mix of food) to 2809 kUA/l (mix of grass) but many of the tested allergen-specific IgE were class 2 or 3 (i.e. 0.71–17.5 kUA/l).

Conclusions

The case resembles passive cutaneous anaphylaxis and Prausnitz–Küstner reaction but clinical significance of the classical phenomena has not yet been described. This observation indicates that anaphylactic reactions during immunoglobulin replacement therapy may result from IgE or pathological IgG content. Such IgE presence was sporadically reported (34.5–105 IU/ml, i.e. 862.5–1450 IU/g of protein) in intravenous immunoglobulins that are used and monitored by healthcare professionals. In clinical practice the definition of adverse events is inadequate since individual batches of immunoglobulins come with different specificity therefore, they should be classified as transfusion products (not bioequivalents). Such new approach implies establishing (1) new control methods and strategies to ensure introduction of the safety regulations for subcutaneous home self-administration of immunoglobulins as well as (2) guidelines for the prevention of anaphylaxis in patients receiving immunoglobulins (for example peanut).

A case report of lymphoid intestitial pneumonia in common variable immunodeficiency: Oligoclonal expansion of effector lymphocytes with preferential cytomegalovirus-specific immune response and lymphoproliferative disease promotion

RATIONALE

Lymphoid interstitial pneumonia (LIP) is a rare disease with lymphocytic infiltration of the alveolar interstitial and air spaces, sometimes classified as a clonal lymphoproliferative disease (LPD) with high prevalence in patients with immunodysregulation. Although association of mucosa-associated lymphoid tissue (MALT) lymphoma development with infectious agents has been well described, it is not so in the case of LIP. Attempts to demonstrate an infective cause by direct microbe detection have failed, but association with atypical specific immune response to opportunistic infectious agent has not been studied.

PATIENT CONCERNS AND DIAGNOSES

We performed clinical, biochemical, and immunologic analysis of patients LIP that arises primarily from the common variable immune deficiency (CVID) with normal immunoglobulin class M (IgM) level and mild infectious course as a result of immunodysregulation. At the age of 13 multiple nodules, areas of consolidation were observed and LIP was confirmed by histological examination. The progression of the disease with massive splenomegaly (17→27 cm), lymphadenopathy soft tissue infiltration coincides with high standardized uptake value (SUV was 3.1-5.2), regulatory T cells decrease (CD4+25FoxP3+ level -0.02%, i.e., 8 cells per 100 μL), oligoclonal gammapathy: very high IgM (3340 mg/dL) and β2-microglobulin (18.8 mg/L) level observed 10 years later.Immune response polarization was observed in humoral and cellular compartment -Th and Tc-dependent: 10.8% of lymphocytes are CD8high+CMV pp65-pentamer positive cells (Epstein-Barr virus-specific not observed). Specific immune response polarization correlates with negative immunofixation, light chains κ/λ = 2.84 and narrow, but non-monoclonal T cell receptor (TCR)/ B cell receptor (BCR) repertoire.

LESSONS

Taking everything into account, this case report shows that LIP is a consequence of immune-dysregulation in CVID, that is, Treg deficiency, narrow lymphocyte repertoire, and abnormal ability to respond to cytomegalovirus (CMV) antigens. It may be visualized by positron emission tomography (PET) and monitored by CMV-specific immune response, β2-microglobulin level, and IgM paraproteinaemia, but not by immunofixation and κ/λ ratio.

A Case of Stiff Person Syndrome: Immunomodulatory Effect of Benzodiazepines: Successful Rituximab and Tizanidine Therapy

Stiff person syndrome (SPS) is a rare autoimmune disease. Most patients have high-titer antibodies against glutamate decarboxylase (GADAb), which is without practical value in disease monitoring. Benzodiazepines are the first line drugs, but long-term use is not well characterized. This report demonstrates ineffective benzodiazepine therapy of SPS that prompts tachyphylaxis, loss of responsiveness, and finally benzodiazepine withdrawal syndrome. Convulsion and anxiety correlate with high level of creatine phosphokinase (CK). Although tonus and spasm attacks were successfully controlled by tizanidine, glutamate release inhibitor, the immune response, and autoimmune diabetes development require the plasmapheresis, mycophenolat mofetil, and rituximab therapy that results in a significant decrease of GADAb, impaired glucose tolerance (IGT), lactate dehydrogenase (LDH), and CK normalization. Unfortunately, reintroduction of benzodiazepine was a source of rapid and high increase of CK, LDH, GADAb titer (up to 1:15,000), IGT, and SPS relapse. Contrary to previous publications, we observed IGT that correlated with high anti-GAD level, but without high immunogenetic susceptibility to haplotype human leukocyte antigens-DR3, DQw2. This preliminary observation and the last finding of immunomodulatory properties of peripheral benzodiazepine receptor suggest that increased antigenic stimulation during benzodiazepine therapy and glutamatergic hyperactivity could account for convulsions observed in SPS. Benzodiazepine withdrawal prompted alternative muscle relaxant therapy (tizanidine). Muscular and brain abnormalities observed in SPS indicate that noncardiac CK level may be a useful tool in SPS therapy monitoring.

Multicenter experience in hematopoietic stem cell transplantation for serious complications of common variable immunodeficiency

BACKGROUND

Common variable immunodeficiency (CVID) is usually well controlled with immunoglobulin substitution and immunomodulatory drugs. A subgroup of patients has a complicated disease course with high mortality. For these patients, investigation of more invasive, potentially curative treatments, such as allogeneic hematopoietic stem cell transplantation (HSCT), is warranted.

OBJECTIVE

We sought to define the outcomes of HSCT for patients with CVID.

METHODS

Retrospective data were collected from 14 centers worldwide on patients with CVID receiving HSCT between 1993 and 2012.

RESULTS

Twenty-five patients with CVID, which was defined according to international criteria, aged 8 to 50 years at the time of transplantation were included in the study. The indication for HSCT was immunologic dysregulation in the majority of patients. The overall survival rate was 48%, and the survival rate for patients undergoing transplantation for lymphoma was 83%. The major causes of death were treatment-refractory graft-versus-host disease accompanied by poor immune reconstitution and infectious complications. Immunoglobulin substitution was stopped in 50% of surviving patients. In 92% of surviving patients, the condition constituting the indication for HSCT resolved.

CONCLUSION

This multicenter study demonstrated that HSCT in patients with CVID was beneficial in most surviving patients; however, there was a high mortality associated with the procedure. Therefore this therapeutic approach should only be considered in carefully selected patients in whom there has been extensive characterization of the immunologic and/or genetic defect underlying the CVID diagnosis. Criteria for patient selection, refinement of the transplantation protocol, and timing are needed for an improved outcome.

[Sepsis--continual pathogenetic, diagnostic and therapeutic problem]

Sepsis is defined as systemic inflammatory response syndrome (SIRS) caused by infection. Massive activation of humoral and cellular mechanisms of host defense is present and can lead to a multiple organ dysfunction syndrome. Sepsis is good example, that inflammation binds with considerable energetic and metabolic effort of organism i.e. demand for oxygen, protein and microelements. The effort during SIRS exceeds compensatory abilities of organism, cause shock and death. The high mortality (40-70% in the case of septic shock) is a good illustration of the therapeutic problem. In the paper pathogenesis, diagnosis and therapy of sepsis was described. Pathogenetic importance of intoxication was explained--massive intoxication (for example by Staphylococcal enterotoxin) without infection cans lead to SIRS too. Precious advice in selection of antibiotic were given. Advantage penicillins and karbapenems over cephalosporins result from binding to PBP 2 or 1, considerably smaller release of free endotoxin and smaller induction Jarish-Heixhaimer's reaction. The side effect stimulates inflammation and deepens SIRS by release toxins and increase of TNF-alpha.

[Allergy to penicillin: facts and controversies]

Correct diagnosis in patients with side effect during benzylpenicillin (penicillin G) treatment is highly problematic. It is accepted, that hypersensitivity to penicillin is overdiagnosed. Very little qualitative information is available on the diagnostic and differentiation of penicillin allergy. On present stage it is not techniques permitting to exclude anaphylaxis. This paper describe topical knowledge about risks administration of benzylpenicillin to patients suspected of penicillin hypersensitivity. Precious advice in diagnostic procedures and therapeutic management was given.

[Hoigne syndrome as an acute non-allergic reaction to different drugs: case reports]

In 1959 Hoigne described the first cases of pseudo-anaphylactic reactions induced by intramuscular administration of procaine penicillin G. This complication, characterized by acute psychological and neurological manifestations, is still of current interest. We report cases of patient, whose Hoigne syndrome was not due to procaine penicillin G (i.e. lidocaine, edan, azlocillin, gentamycin, klaritromycin and cefuroxime). It is accepted that Hoigne syndrome can be caused by lidocaine. Further Stell i.m. and Ojo OA published similar case report of Amoxycillin-induced hallucinations. These clinical observations indicate also that using term "acute non-allergic reaction to procaine penicillin G" as synonym of Hoigne syndrome is not precise. Further classification of the reaction among psychic disturbances or adverse drug reactions is very difficult. Much of literature is devoted to the differentiation from anaphylaxis rather than other symptoms of main disease or side effects. Harmful effect of main disease is very likely. Lidocaine was taken intravenously by patient with diabetes and heart attack or locally with chronic hepatitis during topical anesthesia. Benzylpenicillin, azlocycillin, gentamycin, klaritromycin and cefuroxime was used during serious bacterial infections. These observations indicate that pathogenesis of Hoigne syndrome may be associated with main disease and organic brain disease. Then procaine kindling mechanism partly explain Hoigne syndrome. Therefore pathogenesis, definition, differentiation and classification of this complication is still unclear.

Electrophoretic properties of beta-lactam and serum protein conjugates

Beta-lactam antibiotics can easy bind to protein. Available information on the nature of the conjugates is rather poor. In this study, agarose electrophoresis was used to determine and comparison physicochemical properties of the complexes. Benzylpenicillin, ampicillin, cefoperazone, cefotaxime, ceftazidime, cefuroxime, ceftriaxone, imipenem and serum protein were used for free generation drug-protein conjugates. Agarose electrophoresis shows heterogeneous migration of the conjugates. Interestingly-binding of benzylpenicillin and ampicillin exerts an effect on electrophoretic migration of albumin and globulin, but others--only serum albumin. Binding of ampicillin shows down migration of all anionic fractions of plasma protein, benzylpenicillin--anionic and cationic. Otherwise--migration of albumin was accelerate by others. This finding can explain higher frequency of penicillins hypersensitivity than cephalosporins, carbapenems or monobaktams. The commercially available and cheap procedure allows to execute the screening of physicochemical properties, which exert an effect on electrophoretic mobility of protein i.e. electric charge and molecule length (Stockes's diameter). Therefore, the electrophoretic mobility modification probably reflects the transformation of molecular weight, charge and space structure serum proteins by binding of beta-lactam antibiotics.

[Hypersensitivity to penicillin therapy in the course of treatment: a case report]

Adverse reactions to benzylpenicillin are well known. Full allergy testing is time-consuming, expensive and doesn't exclude anaphylaxis to penicillin. It is accepted that penicillin allergy is overdiagnosed. Therefore clinical observations are not useful for pathogenesis research without follow up examination. 100 patients with negative skin test before and with symptoms of penicillin hypersensitivity during treatment was diagnosed. We report only 4 cases of patients, whose allergy to penicillin was confirmed by the same skin test. They had received penicillin during serious bacterial infections and had experienced allergic symptoms. Skin rush, asthma or hypotension have been observed during treatment with penicillin. Immediate hypersensitivity was confirmed by positive skin test after treatment. This study reinforce findings of our experimental study, when intraperitoneal injections of penicillin and Freunds adjuvant or bacterial lysate lead to anaphylactic shock and death of guinea pigs. Eastaway et all published similar case report of gas gangrene complicated by penicillin allergy. These observations indicate that pathogenesis of penicillin allergy may be associated with bacterial infection and nonspecific inflammation.