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Kolev M, Sarbu AC, Möller B, Maurer B, Kollert F, Semmo N. Belimumab treatment in autoimmune hepatitis and primary biliary cholangitis - a case series. J Transl Autoimmun 2023; 6:100189. [PMID: 36718275 PMCID: PMC9883290 DOI: 10.1016/j.jtauto.2023.100189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Accepted: 01/12/2023] [Indexed: 01/15/2023] Open
Abstract
Background The majority of patients with autoimmune hepatitis (AIH) achieve complete remission with established treatment regiments. In patients with intolerance or insufficient response to these drugs, the remaining options are limited and novel treatment approaches necessary. In primary biliary cholangitis (PBC), ursodeoxycholic acid (UDCA) and fibrates have improved prognosis dramatically, but there remains a proportion of patients with refractory disease.In patients with refractory AIH and/or PBC, we used a novel treatment strategy with the anti-B cell activating factor, belimumab. The first three patients had concomitant Sjögren's disease. The connecting element between all three diseases is B cell activation, including elevated levels of the B cell activating factor (BAFF). Furthermore, belimumab has been shown to be beneficial in Sjögren's disease. Aims and methods To retrospectively investigate treatment response in six patients with AIH or PBC with or without concomitant Sjögren's disease treated with the anti-BAFF therapy belimumab at the University Hospital in Bern, Switzerland. Results In all three patients with AIH, belimumab improved disease control and helped by-pass or reduce problematic side effects from corticosteroids and calcineurin inhibitors. In PBC patients (n = 3), there was no clear improvement of liver function tests, despite reduction or normalization of IgM. All patients with concomitant Sjögren's disease (n = 3) had an improvement of sicca symptoms and two out of three patients experienced an initially marked reduction in fatigue, which lessened over time. Conclusions Belimumab may be a promising treatment option for patients with AIH and further investigations are needed. In PBC however, response was not convincing. The effects on sicca symptoms and fatigue were encouraging.
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Key Words
- AIH, autoimmune hepatitis
- ALT, alanine aminotransferase
- AMA, anti-mitochondrial antibodies
- ANA, anti-nuclear antibodies
- AP, alkaline phosphatase
- APS, anti-phospholipid-antibody syndrome
- AZA, azathioprine
- Autoimmune hepatitis
- Autoimmune liver disease
- BDN, budesonide
- Belimumab
- CI, calcineurin inhibitor
- CyA, cyclosporine A
- INR, international normalized ratio
- IgG, immunoglobulin G
- IgM, immunoglobulin M
- LC 1, liver cytosol 1 antibodies
- LKM-1, liver-kidney-microsomal antibodies
- MMF, mycophenolate mofetil
- MRCP, magnetic resonance cholangiopancreatography
- NA, not applicable
- NRH, nodular regenerative hyperplasia
- PBC, primary biliary cholangitis
- PDN, prednisolone
- PLA2R, anti-phospholipase 2 receptor antibody
- PSC, primary sclerosing cholangitis
- Primary biliary cholangitis
- RF, rheumatoid factor
- SLA, soluble liver antigen antibodies
- SLE, systemic lupus erythematosus
- SMA, smooth-muscle cell antibodies
- SS-A, SS-A (Ro) antibodies
- SS-B, SS-B (La) antibodies
- Sjögren's disease
- TNFi, tumor necrosis factor inhibitor
- UDCA, ursodeoxycholic acid
- ULN, upper limit of normal
- disease-modifying anti-rheumatic drugs, DMARDs
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Affiliation(s)
- Mirjam Kolev
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland,Graduate School for Health Sciences, University of Bern, 3012, Bern, Switzerland
| | - Adela-Cristina Sarbu
- Department of Rheumatology and Immunology, Bern University Hospital, University of Bern, Switzerland
| | - Burkhard Möller
- Department of Rheumatology and Immunology, Bern University Hospital, University of Bern, Switzerland
| | - Britta Maurer
- Department of Rheumatology and Immunology, Bern University Hospital, University of Bern, Switzerland
| | - Florian Kollert
- Department of Rheumatology and Immunology, Bern University Hospital, University of Bern, Switzerland
| | - Nasser Semmo
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland,Corresponding author. University Clinic for Visceral Surgery and Medicine, Inselspital Bern, Murtenstrasse 35, 3010, Bern, Switzerland.
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De Martin E, Michot JM, Rosmorduc O, Guettier C, Samuel D. Liver toxicity as a limiting factor to the increasing use of immune checkpoint inhibitors. JHEP Rep 2020; 2:100170. [PMID: 33205034 PMCID: PMC7648167 DOI: 10.1016/j.jhepr.2020.100170] [Citation(s) in RCA: 65] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Revised: 07/23/2020] [Accepted: 07/30/2020] [Indexed: 02/07/2023] Open
Abstract
Immune checkpoint inhibitors (ICIs) improve clinical outcomes in patients suffering from different types of cancer. Liver toxicity is one of the immune-related adverse events associated with immunotherapy; although not common, its management is challenging as it is extremely heterogeneous in terms of presentation and severity. Differences in the development and evolution of ICI-related toxicity in healthy or cirrhotic livers have not yet been elucidated. Assessing causality is key to diagnosing ICI-induced liver toxicity; liver biopsies can assist not only in the differential diagnosis but also in assessing the severity of histological liver damage. The current classification of severity overestimates the grade of liver injury and needs to be revised to reflect the views of hepatologists. Spontaneous improvements in ICI-related liver toxicity have been reported, so corticosteroid therapy should probably be individualised not systematic. The reintroduction of ICIs in a patient with previous immune-mediated hepatitis may be possible, but the risk/benefit ratio should be considered, as the risk factors for hepatitis recurrence are currently unclear. The management of these patients, requiring a balance between efficacy, toxicity and specific treatments, necessitates multidisciplinary collaboration. The incidence of immune-related liver toxicity will continue to rise based on the increasing use of ICIs for most cancers, mandating improved understanding and management of this complication.
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Key Words
- AIH, autoimmune hepatitis
- ALP, alkaline phosphatase
- ALT, alanine aminotransferase
- AMA, anti-mitochondrial antibodies
- ANA, anti-nuclear antibodies
- ASMA, anti-smooth muscles antibodies
- AST, aspartate aminotransferase
- CTLA-4, cytotoxic T lymphocyte-associated protein 4
- Corticosteroid therapy
- DCR, disease control rate
- DILI, drug-induced liver injury
- GGT, gamma-glutamyltransferase
- HCC, hepatocellular carcinoma
- ICI, immune checkpoint inhibitor
- INR, international normalised ratio
- Immune-mediated hepatitis
- Immunotherapy
- Liver biopsy
- MMF, mycophenolate mofetil
- ORR, objective response rate
- OS, overall survival
- PD-1, programmed cell death 1
- PD-L1-2, programmed cell death ligands 1-2
- PFS, progression-free survival
- TKI, tyrosine kinase inhibitor
- UDCA, ursodeoxycholic acid
- ULN, upper limit of normal
- anti-LC1, anti-liver cytosol type-1 antibodies
- anti-LKM, anti-liver-kidney microsomal antibodies
- anti-SLA, anti-soluble liver antigen antibodies
- irAE, immune-related adverse event
- trAE, treatment-related adverse event
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Affiliation(s)
- Eleonora De Martin
- AP-HP Hôpital Paul-Brousse, Centre Hépato-Biliaire, INSERM Unit 1193, Univ Paris-Sud, Université Paris-Saclay, FHU Hépatinov, Villejuif, F-94800, France
| | - Jean-Marie Michot
- Département d'innovation thérapeutique et d'Essais Précoces (DITEP), Institut Gustave-Roussy, Université Paris Saclay, Villejuif, France
| | - Olivier Rosmorduc
- AP-HP Hôpital Paul-Brousse, Centre Hépato-Biliaire, INSERM Unit 1193, Univ Paris-Sud, Université Paris-Saclay, FHU Hépatinov, Villejuif, F-94800, France.,Sorbonne-Université
| | - Catherine Guettier
- AP-HP Hôpital Bicêtre, Laboratoire Anatomie Pathologique, Le Kremlin-Bicêtre, France, Univ Paris-Sud, UMR-S 1193, Université Paris-Saclay, France
| | - Didier Samuel
- AP-HP Hôpital Paul-Brousse, Centre Hépato-Biliaire, INSERM Unit 1193, Univ Paris-Sud, Université Paris-Saclay, FHU Hépatinov, Villejuif, F-94800, France
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Maoz-Segal R, Levy T, Haj-Yahia S, Offengenden I, Iancovich-Kidon M, Agmon-Levin N. Combination therapy with omalizumab and an immune-suppressive agent for resistant chronic spontaneous rrticaria - A real-life experience. World Allergy Organ J 2020; 13:100448. [PMID: 32774663 DOI: 10.1016/j.waojou.2020.100448] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Revised: 07/13/2020] [Accepted: 07/15/2020] [Indexed: 11/20/2022] Open
Abstract
Background Chronic Spontaneous Urticaria (CSU) is a relatively common immune mediated disease that can be effectively treated nowadays. Nevertheless, for some patients remission cannot be achieved following current treatment recommendations, defined as resistant CSU (r-CSU). Treating r-CSU is challenging, and, currently, there are no recommended interventions. In this real-life study we describe successful therapy of 18 r-CSU patients using an "intensified protocol" of anti-IgE-antibody (omalizumab) concomitantly with an immunosuppressant. We defined the r-CSU phenotype and compared it to omalizumab-responsive CSU (Or-CSU) phenotype. Methods Clinical and serological data of 72 CSU patients (ie, 18 r-CSU and 54 age and sex matched Or-CSU) were retrospectively collected and analyzed. All patients were diagnosed with CSU for ≥6 months and treated at the Sheba Medical Center during 2013–2018. Results Of 289 CSU patients, 18 (6%) were diagnosed with r-CSU and treated with the "intensified protocol" including omalizumab and cyclosporine-A (16p), methotrexate (1p), and azathioprine (1p). Of which, 14/18 (78%) achieved complete remission, 2/18 (11%) partial remission, and 2/18 (11%) no remission. During follow-up no serious adverse events were documented. r-CSU patients received higher doses of antihistamine (p < 0.0001) and omalizumab (425 ± 58 mg/month vs. 283 ± 86 mg/month; p < 0.0001) compared to Or-CSU. The r-CSU phenotype was linked with concomitant autoimmunity (p = 0.0005) and a lower level of IgE prior to initiation of therapy (p = 0.027). Conclusion r-CSU may be a distinct CSU phenotype characterized by severe disease, concomitant autoimmunity, and lower baseline-IgE levels (low "autoallergy"). An "intensified protocol" with omalizumab and an immunosuppressive agent was found to be efficacious and safe for r-CSU. Further larger studies are required to verify these results.
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Sacco KA, Burton MC. Persistent immune thrombocytopenia heralds the diagnosis of Mycobacterium chimaera prosthetic valve endocarditis. IDCases 2016; 7:1-3. [PMID: 27909685 PMCID: PMC5126133 DOI: 10.1016/j.idcr.2016.10.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2016] [Revised: 10/26/2016] [Accepted: 10/26/2016] [Indexed: 11/28/2022] Open
Abstract
A 63 year old female was admitted for investigation of worsening renal insufficiency. During hospitalization she developed persistent immune thrombocytopenia refractory to supportive or immunosuppressive treatment. She was diagnosed with Mycobacterium chimaera prosthetic valve endocarditis and thrombocytopenia resolved with anti-mycobacterial therapy.
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Key Words
- ANA, anti-nuclear antibodies
- ANCA, anti-neutrophil cytoplasmic antibodies
- AVR, aortic valve repair
- Aortic root abscess
- CT, computerized tomography
- ENA, extractable nuclear antigen
- Granulomas
- HIV, human immunodeficiency virus
- ITP, immune thrombocytopenia purpura
- IVIG, intravenous immunoglobulin
- MRI, magnetic resonance imaging
- Mycobacterium chimaera
- PVE, prosthetic valve endocarditis
- Prosthetic-valve endocarditis
- TEE, transesophageal echocardiogram
- Thrombocytopenia
- eGFR, estimated glomerular filtration rate
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Affiliation(s)
- Keith A Sacco
- Department of Internal Medicine, Mayo Clinic, Jacksonville, FL, USA
| | - M Caroline Burton
- Department of Internal Medicine, Mayo Clinic, Jacksonville, FL, USA; Associate Professor, Mayo College of Medicine, Rochester, MN, USA
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Prajapati R, Kumar A, Sharma P, Singla V, Bansal N, Dhawan S, Arora A. A Rare Presentation of Leishmaniasis. J Clin Exp Hepatol 2016; 6:146-8. [PMID: 27493461 PMCID: PMC4963322 DOI: 10.1016/j.jceh.2016.01.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2014] [Accepted: 01/06/2016] [Indexed: 12/12/2022] Open
Abstract
Leishmaniasis or kala-azar is a protozoan disease that can present as cutaneous, mucocutaneous, visceral, and disseminated disease. In India, it is usually localized in distinct areas of Bihar, Jharkhand, West Bengal, and parts of Eastern Uttar Pradesh. Visceral leishmaniasis (VL) involves the visceral organs, mainly the liver, the spleen and bone marrow. VL is characterized by prolonged fever, massive splenomegaly, weight loss, progressive anemia, pancytopenia, and hypergammaglobulinemia, and can be complicated by serious infections. In most of the patient the diagnosis is made on bone marrow biopsy or splenic aspirate. We hereby present an unusual case of kala-azar in a 52-year-old patient non-resident of endemic area presenting with pyrexia of unknown origin, in whom bone marrow biopsy was negative for Leishmanin Donovan (LD) bodies, and diagnosis was made by liver biopsy in which LD bodies were seen.
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Key Words
- ALP, alkaline phosphatase
- ALT, alanine aminotransferase
- ANA, anti-nuclear antibodies
- AST, aspartate aminotransferase
- CT, computerized tomography
- E, eosinophils
- ESR, erythrocyte sedimentation rate
- GGT, gamma glutamyl transferase
- HBsAg, hepatitis B surface antigen
- HCV, hepatitis C virus
- HIV, human immunodeficiency virus
- L, lymphocytes
- LD, Leishmanin Donovan
- Leishmanin Donovan bodies
- P, polymorphs
- PET, positron emission tomography
- PUO, pyrexia of unknown origin
- VL, visceral leishmaniasis
- WBC, white blood count
- kala-azar
- protozoan disease
- pyrexia of unknown origin
- visceral leishmaniasis
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Affiliation(s)
- Ritesh Prajapati
- Department of Gastroenterology & Hepatology, Sir Ganga Ram Hospital, New Delhi, India
| | - Ashish Kumar
- Department of Gastroenterology & Hepatology, Sir Ganga Ram Hospital, New Delhi, India,Address for correspondence: Dr. Ashish Kumar, Associate Professor, Department of Gastroenterology & Hepatology, Ganga Ram Institute of Postgraduate Medical Education & Research (GRIPMER), Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi 110 060, India. Tel.: +91 9312792573; fax: +91 11 25861002.
| | - Praveen Sharma
- Department of Gastroenterology & Hepatology, Sir Ganga Ram Hospital, New Delhi, India
| | - Vikas Singla
- Department of Gastroenterology & Hepatology, Sir Ganga Ram Hospital, New Delhi, India
| | - Naresh Bansal
- Department of Gastroenterology & Hepatology, Sir Ganga Ram Hospital, New Delhi, India
| | - Shashi Dhawan
- Department of Pathology, Sir Ganga Ram Hospital, New Delhi, India
| | - Anil Arora
- Department of Gastroenterology & Hepatology, Sir Ganga Ram Hospital, New Delhi, India
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Santos Silva AF, Figueiredo Dias JPBC, Nuak JMNGS, Rocha Aguiar F, Araújo Pinto JA, Sarmento ACEM. Visceral leishmaniasis in a patient with systemic lupus erythematosus. IDCases 2015; 2:102-5. [PMID: 26793472 PMCID: PMC4712211 DOI: 10.1016/j.idcr.2015.09.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2015] [Revised: 09/22/2015] [Accepted: 09/22/2015] [Indexed: 02/07/2023] Open
Abstract
Visceral leishmaniasis is an infection with an insidious and disabling course caused by parasites of the genus Leishmania. In Europe, it is mostly associated with HIV infection. Systemic lupus erythematosus and its treatment are associated with increased risk of infection, neoplastic and concomitant autoimmune disorders. The association of these diseases may go unnoticed. A 60 year-old Caucasian woman with lupus presented with a one-year history of fever, malaise, weakness and weight loss. The highlights on physical examination were pallor, palpable hepatosplenomegaly and low-grade fever. Blood tests showed pancytopenia, hyperproteinemia with hypoalbuminemia and hypergammaglobulinemia; electrophoresis showed a polyclonal gamma curve. Full-body CT scan revealed massive hepatosplenomegaly. Microbiology investigation was negative for the most common pathogens, including tuberculosis. There were no signs of hematologic malignancy in the bone marrow smear. PCR for Leishmania infantum was positive both in blood and bone marrow. The patient was treated with liposomal amphotericin B, and immunosuppression was adjusted. She showed rapid clinical improvement and 6 months later had no signs of disease. The differential diagnosis in a patient with lupus presenting with fever and multisystemic manifestations includes infectious or neoplastic disorders. The patient lived in an endemic area of Leishmania, and typical clinical and analytical changes were all present, making this case highly educational. The case highlights the importance of a patient's epidemiological background and how it can lead to the diagnosis and timely treatment of a rare disease.
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Key Words
- ANA, anti-nuclear antibodies
- AmB, amphotericin B
- CMV, cytomegalovirus
- CT, computerized tomography
- EBV, Epstein–Barr virus
- ENA, anti-extractable nuclear antigens
- ESR, erythrocyte sedimentation rate
- Fever
- HIV, human immunodeficiency virus
- ID, infectious diseases
- LAB, liposomal amphotericin B
- LDH, lactic dehydrogenase
- PCP, primary care physician
- PCR, polymerase chain reaction
- RNA, ribonucleic acid
- SLE, systemic lupus erythematosus
- Systemic lupus erythematosus
- VL, visceral leishmaniasis
- Visceral leishmaniasis
- WBC, white blood cell count
- dsDNA, double-stranded deoxyribonucleic acid
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Affiliation(s)
- André Filipe Santos Silva
- Infectious Diseases Department, São João Hospital Center, Alameda Hernâni Monteiro, Estrada da Circunvalação, 4200-019 Oporto, Portugal; Faculty of Medicine of the University of Oporto, Alameda Hernâni Monteiro, Estrada da Circunvalação, 4200-019 Oporto, Portugal
| | - João Paulo Branco Calheiros Figueiredo Dias
- Infectious Diseases Department, São João Hospital Center, Alameda Hernâni Monteiro, Estrada da Circunvalação, 4200-019 Oporto, Portugal; Faculty of Medicine of the University of Oporto, Alameda Hernâni Monteiro, Estrada da Circunvalação, 4200-019 Oporto, Portugal
| | - João Miguel Neves Gonçalves Santos Nuak
- Infectious Diseases Department, São João Hospital Center, Alameda Hernâni Monteiro, Estrada da Circunvalação, 4200-019 Oporto, Portugal; Faculty of Medicine of the University of Oporto, Alameda Hernâni Monteiro, Estrada da Circunvalação, 4200-019 Oporto, Portugal
| | - Francisca Rocha Aguiar
- Rheumatology Department, São João Hospital Center, Alameda Hernâni Monteiro, Estrada da Circunvalação, 4200-019 Oporto, Portugal
| | - José António Araújo Pinto
- Rheumatology Department, São João Hospital Center, Alameda Hernâni Monteiro, Estrada da Circunvalação, 4200-019 Oporto, Portugal
| | - António Carlos Eugénio Megre Sarmento
- Infectious Diseases Department, São João Hospital Center, Alameda Hernâni Monteiro, Estrada da Circunvalação, 4200-019 Oporto, Portugal; Faculty of Medicine of the University of Oporto, Alameda Hernâni Monteiro, Estrada da Circunvalação, 4200-019 Oporto, Portugal
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