1
|
Mendes ICM, Mamani RF, Coelho DRA, Pimentel C. Myelotoxicity and kidney dysfunction related to the use of trimethoprim-sulfamethoxazole for the treatment of Pneumocystis jirovecii pneumonia: a case report of severe adverse events with a common drug. Rev Inst Med Trop Sao Paulo 2024; 66:e18. [PMID: 38511807 PMCID: PMC10946418 DOI: 10.1590/s1678-9946202466018] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Accepted: 02/19/2024] [Indexed: 03/22/2024] Open
Abstract
Trimethoprim-sulfamethoxazole (TMP-SMX) is the primary therapeutic option for Pneumocystis jirovecii pneumonia (PCP). Gastrointestinal symptoms and cutaneous rash are common side effects, with hyperkalemia being uncommon in patients without kidney dysfunction, and myelotoxicity being even rarer. We present the case of a male patient with hypertension and a recent diagnosis of non-Hodgkin lymphoma, undergoing rituximab treatment for two months. He was admitted to the intensive care unit due to dyspnea, tachypnea, and pleuritic pain, requiring mechanical ventilation. Chest computed tomography showed bilateral and multilobed ground-glass opacities, compromising more than 80% of the lung parenchyma. Pulmonary tuberculosis and COVID-19 were ruled out. An angiotomography and Doppler ultrasound revealed an extensive pulmonary thrombus and deep venous thrombosis. Empiric treatment with TMP-SMX for PCP was initiated, but within four days, the patient experienced metabolic acidosis and severe hyperkalemia, necessitating hemodialysis. He also presented with progressive pancytopenia and critical levels of leukopenia and thrombocytopenia. The hypothesis of TMP-SMX-induced myelotoxicity was suspected. Considering the unavailability of an alternative treatment, it was opted to continue TMP-SMX and initiate a granulocyte-colony-stimulating factor. However, the patient maintained medullary deterioration, becoming refractory to the transfusion of blood derivates. On the 17th day of treatment, a clinical decision was made to suspend TMP-SMX, leading to improvements within 48 hours in marrow and kidney functions, metabolic acidosis, and hyperkalemia. Despite all efforts, the patient died after 35 days of hospitalization due to hospital-acquired infections. This case highlights the importance of clinicians recognizing potential myelotoxicity with TMP-SMX and promptly discontinuing the drug if necessary.
Collapse
Affiliation(s)
- Isabel Cristina Melo Mendes
- Instituto Estadual de Infectologia São Sebastião, Rio de Janeiro, Rio de Janeiro, Brazil
- Universidade Federal do Rio de Janeiro, Programa de Pós-Graduação em Doenças Infecciosas e Parasitárias, Rio de Janeiro, Rio de Janeiro, Brazil
| | - Roxana Flores Mamani
- Instituto Nacional de Infectologia Evandro Chagas, Manguinhos, Rio de Janeiro, Brazil
| | | | - Clarisse Pimentel
- Instituto Estadual de Infectologia São Sebastião, Rio de Janeiro, Rio de Janeiro, Brazil
| |
Collapse
|
2
|
Nettleton E, Sattui SE, Wallace Z, Putman M. Incidence of Pneumocystis Jiroveci Pneumonia in Patients With ANCA-Associated Vasculitis Initiating Therapy With Rituximab or Cyclophosphamide. Arthritis Care Res (Hoboken) 2024; 76:288-294. [PMID: 37643919 PMCID: PMC10841679 DOI: 10.1002/acr.25222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2023] [Revised: 07/28/2023] [Accepted: 08/24/2023] [Indexed: 08/31/2023]
Abstract
OBJECTIVE This manuscript assesses the incidence of Pneumocystis jiroveci pneumonia (PJP) among patients receiving contemporary treatment regimens for antineutrophil cytoplasmic antibody-associated vasculitis (AAV) and adverse events associated with PJP prophylaxis. METHODS Incident users of rituximab or cyclophosphamide for AAV were identified in the TriNetX electronic health records database from 2011 to 2022. The incidence rates (IRs) of PJP in the first 6 months of induction therapy with rituximab and/or cyclophosphamide and during postinduction maintenance therapy with rituximab were calculated. Cox proportional hazard models were used to estimate hazard ratios (HRs) and confidence intervals (CIs) for the risk of adverse events commonly associated with PJP prophylaxis. RESULTS We identified 1,461 AAV cases who received induction therapy with rituximab (69.7%), cyclophosphamide (18.9%), or both (11.4%). Prophylaxis prescribed within 30 days of induction included trimethoprim-sulfamethoxazole (30.7%), atovaquone (5.4%), dapsone (3.8%), and pentamidine (0.8%). During induction therapy, 10 cases of PJP were identified (IR 15.0 cases per 1,000 patient-years); no deaths occurred. In adjusted analyses, those who received prophylaxis had a higher risk of leukopenia (HR 3.1; 95% CI 1.1-8.6), rash (HR 1.9; 95% CI 1.0-3.6), and nephropathy (HR 2.6; 95% CI 1.3-5.1) than those who did not. During rituximab maintenance therapy (n = 709), five cases of PJP were identified (IR 2.1 cases per 1,000 person-years), one of whom died during the hospitalization associated with a PJP diagnosis. CONCLUSION Rates of PJP in patients with AAV were lower than previously observed, and few cases occurred during rituximab maintenance therapy. PJP prophylaxis was associated with adverse events.
Collapse
Affiliation(s)
| | - Sebastian E Sattui
- University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | | | | |
Collapse
|
3
|
Ishikawa Y, Tokutsu K, Nakayamada S, Kuchiba A, Fushimi K, Matsuda S, Tanaka Y. Short-term effectiveness and safety of rituximab versus cyclophosphamide for life-threatening ANCA-associated vasculitis: a propensity score analysis of the real-world nationwide database. Ann Rheum Dis 2024; 83:103-111. [PMID: 37726117 DOI: 10.1136/ard-2023-224472] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 09/05/2023] [Indexed: 09/21/2023]
Abstract
OBJECTIVES Life-threatening antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) with rapidly progressive glomerulonephritis (RPGN) and/or alveolar haemorrhage (AH) has a poor prognosis. Rituximab (RTX) is as effective as cyclophosphamide (CY) in remission induction therapy; however, the effectiveness and safety of RTX have not been established in life-threatening AAV. This study aimed to investigate the short-term effectiveness and safety of RTX in life-threatening AAV with RPGN and/or AH. METHODS Between April 2018 and March 2020, cases treated with systemic glucocorticoids and RTX or intravenous CY (IVCY) was extracted from a Japanese nationwide inpatient database. Effectiveness was evaluated by in-hospital mortality and severe renal dysfunction requiring haemodialysis (HD) at discharge. Safety was evaluated by the in-hospital incidence of infections. The propensity score (PS) for RTX was estimated. Multivariable Cox and logistic regression with adjustment for PS were conducted to estimate the association of RTX with outcomes. RESULTS From 16 001 612 hospitalised records, 687 life-threatening AAV cases were extracted. No significant difference in in-hospital mortality (adjusted HR 1.06; 95% CI 0.62 to 1.80) was found between the groups. Although the RTX group had a lower risk of fungal infections (adjusted OR (aOR) 0.45; 95% CI 0.23 to 0.84) and pneumocystis pneumonia (aOR 0.58; 95% CI 0.32 to 1.00), they might have an increased risk of severe renal dysfunction requiring HD at discharge (aOR 2.58; 95% CI 1.02 to 6.91). CONCLUSIONS In life-threatening AAV, RTX has similar short-term effectiveness on mortality to IVCY. Although RTX might have a lower risk of fungal infections and pneumocystis pneumonia, the short-term renal prognosis might be inferior to IVCY.
Collapse
Affiliation(s)
- Yuichi Ishikawa
- The First Department of Internal Medicine, University of Occupational and Environmental Health Japan, Kitakyushu, Japan
- Graduate School of Health Innovation, Kanagawa University of Human Services, Kawasaki, Japan
- Sato Clinic, Shibuya-ku, Japan
| | - Kei Tokutsu
- Preventive Medicine and Community Health, University of Occupational and Environmental Health Japan, Kitakyushu, Japan
| | - Shingo Nakayamada
- The First Department of Internal Medicine, University of Occupational and Environmental Health Japan, Kitakyushu, Japan
| | - Aya Kuchiba
- Graduate School of Health Innovation, Kanagawa University of Human Services, Kawasaki, Japan
| | - Kiyohide Fushimi
- Health Policy and Informatics, Tokyo Medical and Dental University Graduate School of Medical and Dental Sciences, Bunkyo-ku, Japan
| | - Shinya Matsuda
- Preventive Medicine and Community Health, University of Occupational and Environmental Health Japan, Kitakyushu, Japan
| | - Yoshiya Tanaka
- The First Department of Internal Medicine, University of Occupational and Environmental Health Japan, Kitakyushu, Japan
| |
Collapse
|
4
|
Sumi T, Takeda K, Michimata H, Nagayama D, Koshino Y, Watanabe H, Yamada Y, Kodama K, Nishikiori H, Chiba H. Pneumocystis Pneumonia Infection Following the Initiation of Pembrolizumab Therapy for Lung Adenocarcinoma. Intern Med 2023; 62:3381-3385. [PMID: 37005268 DOI: 10.2169/internalmedicine.1163-22] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/03/2023] Open
Abstract
Pneumocystis pneumonia (PCP) is an opportunistic infection that presents a ground-glass appearance in the lungs on chest radiography. Interstitial lung disease is a commonly reported adverse effect of immune checkpoint inhibitor (ICI) treatment; however, there are few reports of ICI treatment-associated PCP infection. A 77-year-old man with lung adenocarcinoma was administered pembrolizumab and hospitalized for dyspnea 2 weeks after treatment. Chest computed tomography showed bilateral ground-glass opacities in all lung lobes. PCP was therefore diagnosed, and steroids and sulfamethoxazole-trimethoprim were initiated. Following treatment, the patient's condition improved promptly. This report suggests that ICI treatment can cause PCP infection.
Collapse
Affiliation(s)
- Toshiyuki Sumi
- Department of Respiratory Medicine and Allergology, Sapporo Medical University School of Medicine, Japan
- Department of Pulmonary Medicine, Hakodate Goryoukaku Hospital, Japan
| | - Kazuya Takeda
- Department of Respiratory Medicine and Allergology, Sapporo Medical University School of Medicine, Japan
| | - Haruhiko Michimata
- Department of Respiratory Medicine and Allergology, Sapporo Medical University School of Medicine, Japan
- Department of Pulmonary Medicine, Hakodate Goryoukaku Hospital, Japan
| | - Daiki Nagayama
- Department of Respiratory Medicine and Allergology, Sapporo Medical University School of Medicine, Japan
- Department of Pulmonary Medicine, Hakodate Goryoukaku Hospital, Japan
| | - Yuta Koshino
- Department of Respiratory Medicine and Allergology, Sapporo Medical University School of Medicine, Japan
- Department of Pulmonary Medicine, Hakodate Goryoukaku Hospital, Japan
| | - Hiroki Watanabe
- Department of Pulmonary Medicine, Hakodate Goryoukaku Hospital, Japan
| | - Yuichi Yamada
- Department of Pulmonary Medicine, Hakodate Goryoukaku Hospital, Japan
| | - Kentaro Kodama
- Department of Respiratory Medicine and Allergology, Sapporo Medical University School of Medicine, Japan
| | - Hirotaka Nishikiori
- Department of Respiratory Medicine and Allergology, Sapporo Medical University School of Medicine, Japan
| | - Hirofumi Chiba
- Department of Respiratory Medicine and Allergology, Sapporo Medical University School of Medicine, Japan
| |
Collapse
|
5
|
Lam L, Jiang M, Bacchi S, Kovoor J, Inglis JM, Shakib S, Yuson C, Smith W. Prevalence of Trimethoprim-Sulfamethoxazole Adverse Reaction Mislabelling in Australia. Int Arch Allergy Immunol 2023; 184:1225-1229. [PMID: 37673046 DOI: 10.1159/000531975] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 07/02/2023] [Indexed: 09/08/2023] Open
Abstract
INTRODUCTION Trimethoprim-sulfamethoxazole (TMP-SMX) is an important antibiotic, with the most compelling indications for Pneumocystis jirovecii pneumonia prophylaxis and methicillin-resistant Staphylococcus aureus treatment. Previous adverse reactions (AR) to TMP-SMX may limit the usability of TMP-SMX. Electronic medical record (EMR) of AR for other antibiotics has previously been shown to be inaccurate; however, the extent to which this occurs for TMP-SMX is unknown. METHODS A multi-centre retrospective observational study was conducted for consecutive inpatient admissions over a 2.5-year period commencing 2020. Adverse reactions to TMP-SMX recorded in the EMR were collected and reviewed by two independent medical officers using pre-defined expert criteria for the classification of allergies and intolerances. RESULTS TMP-SMX AR were present in the EMR of 759 individuals (prevalence 0.6%). The majority were labelled as allergy (725, 95.5%) rather than intolerance (34, 4.5%). Most common AR were rash, vomiting, and swelling. When classified against the gold-standard expert criteria, there were 437 allergies (57.6%) and 159 intolerances (21.0%). Overall, the number of incorrect EMR AR labels was 133/759 (17.5%). Both medical and surgical specialties had significant numbers of patients with TMP-SMX AR labels and incorrectly classified EMR AR labels. CONCLUSION TMP-SMX AR labels affect inpatients admitted under multiple specialty units. The user-entered categorization as allergy or intolerance labels in EMRs are frequently used incorrectly. These incorrect labels may inappropriately contraindicate the use of TMP-SMX, and formal evaluation of TMP-SMX ARs with immunological assessment and relabelling where appropriate may increase the use of this agent.
Collapse
Affiliation(s)
- Lydia Lam
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
- Department of Neurology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Melinda Jiang
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
- Immunology and Allergy Department, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Stephen Bacchi
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
- Department of Neurology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
- Flinders Medical Centre and Flinders University, Bedford Park, South Australia, Australia
| | - Joshua Kovoor
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
- Discipline of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Joshua M Inglis
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
- Flinders Medical Centre and Flinders University, Bedford Park, South Australia, Australia
- Department of Clinical Pharmacology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Sepehr Shakib
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
| | - Carlo Yuson
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
| | - William Smith
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
- Immunology and Allergy Department, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| |
Collapse
|
6
|
Sohani ZN, Butler-Laporte G, Aw A, Belga S, Benedetti A, Carignan A, Cheng MP, Coburn B, Costiniuk CT, Ezer N, Gregson D, Johnson A, Khwaja K, Lawandi A, Leung V, Lother S, MacFadden D, McGuinty M, Parkes L, Qureshi S, Roy V, Rush B, Schwartz I, So M, Somayaji R, Tan D, Trinh E, Lee TC, McDonald EG. Low-dose trimethoprim-sulfamethoxazole for the treatment of Pneumocystis jirovecii pneumonia (LOW-TMP): protocol for a phase III randomised, placebo-controlled, dose-comparison trial. BMJ Open 2022; 12:e053039. [PMID: 35863836 PMCID: PMC9310160 DOI: 10.1136/bmjopen-2021-053039] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Pneumocystis jirovecii pneumonia (PJP) is an opportunistic infection of immunocompromised hosts with significant morbidity and mortality. The current standard of care, trimethoprim-sulfamethoxazole (TMP-SMX) at a dose of 15-20 mg/kg/day, is associated with serious adverse drug events (ADE) in 20%-60% of patients. ADEs include hypersensitivity reactions, drug-induced liver injury, cytopenias and renal failure, all of which can be treatment limiting. In a recent meta-analysis of observational studies, reduced dose TMP-SMX for the treatment of PJP was associated with fewer ADEs, without increased mortality. METHODS AND ANALYSIS A phase III randomised, placebo-controlled, trial to directly compare the efficacy and safety of low-dose TMP-SMX (10 mg/kg/day of TMP) with the standard of care (15 mg/kg/day of TMP) among patients with PJP, for a composite primary outcome of change of treatment, new mechanical ventilation, or death. The trial will be undertaken at 16 Canadian hospitals. Data will be analysed as intention to treat. Primary and secondary outcomes will be compared using logistic regression adjusting for stratification and presented with 95% CI. ETHICS AND DISSEMINATION This study has been conditionally approved by the McGill University Health Centre; Ethics approval will be obtained from all participating centres. Results will be submitted for publication in a peer-reviewed journal. TRIAL REGISTRATION NUMBER NCT04851015.
Collapse
Affiliation(s)
- Zahra N Sohani
- Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
| | - Guillaume Butler-Laporte
- Department of Epidemiology, Occupational Health, and Biostatistics, McGill University, Montreal, Quebec, Canada
- Division of Infectious Diseases, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
| | - Andrew Aw
- Division of Hematology, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Sara Belga
- Division of Infectious Diseases, Department of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Andrea Benedetti
- Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
- Department of Epidemiology, Occupational Health, and Biostatistics, McGill University, Montreal, Quebec, Canada
- Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Alex Carignan
- Division of Microbiology and Infectious Diseases, Centre hospitalier universitaire de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Matthew P Cheng
- Division of Infectious Diseases, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
- Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Bryan Coburn
- Division of Infectious Diseases, Department of Medicine, University Health Network, Toronto, Ontario, Canada
| | - Cecilia T Costiniuk
- Division of Infectious Diseases, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
- Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
- Chronic Viral Illness Service, McGill University, Montreal, Quebec, Canada
| | - Nicole Ezer
- Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
- Division of Respirology, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
| | - Dan Gregson
- Departments of Pathology and Laboratory Medicine and Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Andrew Johnson
- Division of Infectious Diseases, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Kosar Khwaja
- Department of Epidemiology, Occupational Health, and Biostatistics, McGill University, Montreal, Quebec, Canada
- Department of Critical Care Medicine, McGill University Health Centre, Montreal, Quebec, Canada
| | - Alexander Lawandi
- Critical Care Medicine Department, National Institutes of Health Clinical Center, Bethesda, Maryland, USA
| | - Victor Leung
- Department of Laboratory Medicine & Pathology, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Sylvain Lother
- Department of Critical Care Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Derek MacFadden
- Division of Infectious Diseases, Department of Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Michaeline McGuinty
- Division of Infectious Diseases, Department of Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Leighanne Parkes
- Division of Medical Microbiology and Infectious Diseases, Lady Davis Institute for Medical Research, Montreal, Quebec, Canada
| | - Salman Qureshi
- Department of Epidemiology, Occupational Health, and Biostatistics, McGill University, Montreal, Quebec, Canada
- Division of Respirology, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
- Department of Critical Care Medicine, McGill University Health Centre, Montreal, Quebec, Canada
| | - Valerie Roy
- Division of Microbiology and Infectious Diseases, Centre Hospitalier Universitaire de Sherbrooke Hôtel-Dieu, Sherbrooke, Quebec, Canada
| | - Barret Rush
- Department of Critical Care Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Ilan Schwartz
- Division of Infectious Diseases, University of Alberta, Edmonton, Alberta, Canada
| | - Miranda So
- Sinai Health System-University Health Network Antimicrobial Stewardship Program, University Health Network, Toronto, Ontario, Canada
| | - Ranjani Somayaji
- Division of Infectious Diseases, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Darrell Tan
- Division of Infectious Diseases, St Michael's Hospital, Toronto, Ontario, Canada
| | - Emilie Trinh
- Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
- Division of Nephrology, Department of Medicine, McGill University, Montreal, Quebec, Canada
| | - Todd C Lee
- Division of Infectious Diseases, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
- Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
- Clinical Practice Assessment Unit, Montreal, Quebec, Canada
| | - Emily G McDonald
- Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
- Clinical Practice Assessment Unit, Montreal, Quebec, Canada
- Division of General Internal Medicine, McGill University Health Centre, Montreal, Quebec, Canada
| |
Collapse
|
7
|
Ohmura SI, Homma Y, Masui T, Miyamoto T. Factors Associated with Pneumocystis jirovecii Pneumonia in Patients with Rheumatoid Arthritis Receiving Methotrexate: A Single-center Retrospective Study. Intern Med 2022; 61:997-1006. [PMID: 34511571 PMCID: PMC9038457 DOI: 10.2169/internalmedicine.8205-21] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objective To investigate the risk factors for the development of Pneumocystis jirovecii pneumonia (PCP) in patients with rheumatoid arthritis (RA) undergoing methotrexate (MTX) therapy. Methods This single-center retrospective cohort study included consecutive patients with RA who received MTX for at least one year. The study population was divided into PCP and non-PCP groups, depending on the development of PCP, and their characteristics were compared. We excluded patients who received biologic disease-modifying anti-rheumatic drugs (DMARDs), Janus kinase inhibitors, and anti-PCP drugs for prophylaxis. Results Thirteen patients developed PCP, and 333 did not develop PCP. At the initiation of MTX therapy, the PCP group had lower serum albumin levels, a higher frequency of pulmonary disease and administration of DMARDs, and received a higher dosage of prednisolone (PSL) than the non-PCP group. A multivariate Cox regression analysis revealed that the concomitant use of PSL [hazard ratio (HR) 5.50, p=0.003], other DMARDs (HR 5.98, p=0.002), and serum albumin <3.5 mg/dL (HR 4.30, p=0.01) were risk factors for the development of PCP during MTX therapy. Patients with these risk factors had a significantly higher cumulative probability of developing PCP than patients who lacked these risk factors. Conclusion Clinicians should pay close attention to patients with RA who possess risk factors for the development of PCP during MTX therapy.
Collapse
Affiliation(s)
| | - Yoichiro Homma
- Department of General Internal Medicine, Seirei Hamamatsu General Hospital, Japan
| | - Takayuki Masui
- Department of Radiology, Seirei Hamamatsu General Hospital, Japan
| | - Toshiaki Miyamoto
- Department of Rheumatology, Seirei Hamamatsu General Hospital, Japan
| |
Collapse
|
8
|
Himeji D, Tanaka GI, Shiiba R, Matsumoto R, Takamura K, Morishita H, Taniguchi S, Moriguchi S, Marutsuka K. Pneumocystis Pneumonia in a Patient with Ovarian Cancer Receiving Olaparib Therapy. Intern Med 2022; 61:217-221. [PMID: 34248119 PMCID: PMC8851181 DOI: 10.2169/internalmedicine.7485-21] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
We herein report a case of pneumocystis pneumonia (PCP) in a 77-year-old woman with ovarian cancer who was receiving olaparib therapy. After the patient's second relapse of ovarian cancer, she was administered olaparib as maintenance therapy following successful completion of docetaxel and carboplatin therapy. On receiving olaparib, she showed symptoms of a fever and malaise. Based on laboratory and imaging findings, she was diagnosed with PCP. After treatment with corticosteroids and trimethoprim/sulfamethoxazole followed by atovaquone, the patient's general condition improved. The lymphocytopenia observed after olaparib administration may have been associated with the development of PCP.
Collapse
Affiliation(s)
- Daisuke Himeji
- Department of Internal Medicine, Miyazaki Prefectural Miyazaki Hospital, Japan
| | - Gen-Ichi Tanaka
- Department of Internal Medicine, Miyazaki Prefectural Miyazaki Hospital, Japan
| | - Ritsuya Shiiba
- Department of Internal Medicine, Miyazaki Prefectural Miyazaki Hospital, Japan
| | - Ryoichi Matsumoto
- Department of Internal Medicine, Miyazaki Prefectural Miyazaki Hospital, Japan
| | - Kazuhiro Takamura
- Department of Obstetrics and Gynecology, Miyazaki Prefectural Miyazaki Hospital, Japan
| | - Hirotaka Morishita
- Department of Obstetrics and Gynecology, Miyazaki Prefectural Miyazaki Hospital, Japan
| | - Shuichi Taniguchi
- Department of Obstetrics and Gynecology, Miyazaki Prefectural Miyazaki Hospital, Japan
| | - Sayaka Moriguchi
- Department of Anatomic Pathology, Miyazaki Prefectural Miyazaki Hospital, Japan
| | - Kousuke Marutsuka
- Department of Anatomic Pathology, Miyazaki Prefectural Miyazaki Hospital, Japan
| |
Collapse
|
9
|
Kikuchi T, Mizuno K, Mori T. [Early recurrence of pneumocystis pneumonia post trimethoprim-sulfamethoxazole therapy that developed after chemotherapy for follicular lymphoma]. Rinsho Ketsueki 2021; 62:42-46. [PMID: 33551424 DOI: 10.11406/rinketsu.62.42] [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] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
A 75-year-old man was treated with bendamustine-containing chemotherapy for follicular lymphoma. Trimethoprim-sulfamethoxazole (TMP-SMX) for pneumocystis pneumonia (PCP) prophylaxis was discontinued at the last course of the chemotherapy. However, the patient developed PCP 6 months after the last course, and treatment with TMP-SMX (480 mg/day) was initiated. The TMP-SMX dose was reduced after 3 weeks of treatment. However, PCP recurred 6 days after dose reduction. Increasing the TMP-SMX dose to the therapeutic dose improved PCP. The dose was reduced to a maintenance dose after 7 weeks of the therapeutic dose of TMP-SMX treatment, and PCP did not recur thereafter. This case demonstrated that the early recurrence of PCP after appropriate treatment duration in immunocompromised conditions after chemotherapy, including bendamustine, may require prolonged treatment.
Collapse
Affiliation(s)
- Taku Kikuchi
- Division of Hematology, Department of Medicine, Keio University School of Medicine
| | - Kota Mizuno
- Division of Hematology, Department of Medicine, Keio University School of Medicine
| | - Takehiko Mori
- Division of Hematology, Department of Medicine, Keio University School of Medicine
| |
Collapse
|
10
|
Malpica L, Moll S. Practical approach to monitoring and prevention of infectious complications associated with systemic corticosteroids, antimetabolites, cyclosporine, and cyclophosphamide in nonmalignant hematologic diseases. Hematology Am Soc Hematol Educ Program 2020; 2020:319-327. [PMID: 33275674 PMCID: PMC7727566 DOI: 10.1182/hematology.2020000116] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/08/2023]
Abstract
Corticosteroids constitute a first-line therapy for adults and children suffering from nonmalignant immune-mediated hematologic diseases. However, high disease relapse rates during the tapering period or upon drug discontinuation result in long-term corticosteroid use that increases the risk of infection. This same concept applies to other immunosuppressive agents, such as antimetabolites, calcineurin inhibitors, and cyclophosphamide. Corticosteroids are associated with a length-of-treatment and dose-dependent risk for infection. Screening and antimicrobial prophylaxis against tuberculosis, hepatitis B, Strongyloides stercoralis, and Pneumocystis jirovecii pneumonia (PJP) might be indicated in patients who are scheduled to be on high-dose corticosteroids for >4 weeks (>30 mg of prednisone-equivalent dose [PEQ]) or in patients chronically treated (≥8 weeks of continuous or intermittent corticosteroid use) with moderate doses (≥15 to <30 mg PEQ). Antimetabolites (azathioprine, mycophenolate) increase the risk of progressive multifocal leukoencephalopathy (PML); however, other opportunistic infections and viral reactivation have also been reported. In case of new onset of neurological symptoms, PML needs to be considered, and an urgent neurology consultation should be obtained. Cyclophosphamide-induced myelosuppression can lead to serious infections related to neutropenia. PJP prophylaxis should be considered with combination therapy of cyclophosphamide and corticosteroids until a PEQ dose ≤ 5 mg/d is reached. Data on infectious risk when cyclosporine is used in patients with nonmalignant hematologic diseases are lacking. Discontinuation of any immunosuppressive agent during an episode of infection is recommended. In all patients, adherence to an age-based immunization schedule is appropriate.
Collapse
Affiliation(s)
- Luis Malpica
- Division of Hematology and Oncology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Stephan Moll
- Division of Hematology and Oncology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC
| |
Collapse
|
11
|
Watanabe H, Kitahara Y, Murakami Y, Nihashi F, Matsushima S, Eifuku T, Uto T, Sato J, Imokawa S, Suda T. Pneumocystis jirovecii Pneumonia in a Patient with Breast Cancer Receiving Neoadjuvant Dose-dense Chemotherapy. Intern Med 2020; 59:987-990. [PMID: 31839658 PMCID: PMC7184075 DOI: 10.2169/internalmedicine.3907-19] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
We herein report a 38-year-old woman with breast cancer who developed Pneumocystis jirovecii pneumonia (PCP) during neoadjuvant dose-dense chemotherapy combined with dexamethasone as antiemetic therapy. Chest computed tomography showed bilateral ground-glass opacities and consolidation. The serum β-D-glucan levels were elevated, and P. jirovecii DNA was detected from the bronchoalveolar lavage fluid by polymerase chain reaction. Her clinical findings improved with trimethoprim/sulfamethoxazole and adjunctive steroid therapy. Clinicians must be mindful of the manifestations of PCP in non-human immunodeficiency virus (HIV)-infected immunocompromised patients and include the possibility of PCP in the differential diagnosis when confronted with breast cancer on dose-dense chemotherapy showing diffuse lung disease.
Collapse
Affiliation(s)
| | | | - Yurina Murakami
- Division of Respiratory Medicine, Iwata City Hospital, Japan
| | - Fumiya Nihashi
- Division of Respiratory Medicine, Iwata City Hospital, Japan
| | | | - Tatsuru Eifuku
- Division of Respiratory Medicine, Iwata City Hospital, Japan
| | - Tomohiro Uto
- Division of Respiratory Medicine, Iwata City Hospital, Japan
| | - Jun Sato
- Division of Respiratory Medicine, Iwata City Hospital, Japan
| | - Shiro Imokawa
- Division of Respiratory Medicine, Iwata City Hospital, Japan
| | - Takafumi Suda
- Second Division, Department of Internal Medicine, Hamamatsu University School of Medicine, Japan
| |
Collapse
|
12
|
Duarte C, Gilbert D, Sheridan AD, PharmaD SDW, Lam ET. Pneumocystis jirovecii Pneumonia in Patients With Metastatic Prostate Cancer on Corticosteroids for Malignant Spinal Cord Compression: Two Case Reports and a Guideline Review. Oncology (Williston Park) 2020; 34:692493. [PMID: 32212136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Pneumocystis jirovecii, formerly known as Pneumocystis carinii, is an atypical fungal pathogen best known for causing Pneumocystis jirovecii pneumonia (PCP). The epidemiology of PCP is changing such that patients without HIV infection now comprise the largest subset of individuals diagnosed with PCP. While those with hematologic malignancies and organ transplants are at greatest risk for non-HIV-related PCP, this review will focus on PCP in patients with solid tumors. They are at risk for PCP due to their chemotherapy regimens and use of steroids in the management of various complications of treatment, and possibly because of the immunosuppressive effect of the cancer itself. In particular, patients with solid tumors being treated for metastatic spinal cord compression are at great risk for PCP. Patients with solid tumors and PCP face greater mortality than those with HIV infection. Multiple reviews have attempted to describe the ideal regimen of corticosteroids for metastatic spinal cord compression, but there is little consensus. We present 2 cases of patients with metastatic spinal cord compression due to prostate cancer undergoing radiation therapy and treatment with corticosteroids. These cases highlight the difficulties in predicting the length of corticosteroid therapy and the dangers that patients face without appropriate prophylaxis. This article will also provide a review of the current guidelines for PCP prophylaxis in patients undergoing treatment for metastatic spinal cord compression. We recommend empiric treatment with trimethoprim-sulfamethoxazole or dapsone in those patients with a sulfa allergy in all patients with solid tumors when any high-dose steroids are started for the treatment of metastatic spinal cord compression. Further research is needed to assess the epidemiology of PCP in patients with solid tumors and additional trials are necessary to refine PCP prophylaxis.
Collapse
|
13
|
Minderhoud TC, van Meer MPA, van Thiel RJ, den Hoed CM, van Daele PLA, Schurink CAM. [Infections during glucocorticoid use]. Ned Tijdschr Geneeskd 2018; 162:D2215. [PMID: 30212002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Glucocorticoid treatment increases the risk of opportunistic infection. Infections that can arise during glucocorticoid use, and for which preventative measures can be taken, include reactivation of latent tuberculosis and hepatitis B, pneumococcal and Pneumocystis jiroveci pneumonia, influenza, herpes zoster and Strongyloides stercoralis hyperinfection syndrome. The risk of such infections depends upon the duration of glucocorticoid use and dosage, as well as comorbidity and comedication. It is important to enquire about vaccinations, travel, exposure and previous infections when taking a case history. Possible infectious complications should be considered in patients who are receiving high-dose glucocorticoids treatment amounting to more than 420 mg PED per 4 weeks. Preventative measures are not usually required in patients who receive a short high-dosed treatment (30 mg PED in 7 days) or prednisolone at a dosage of < 15 mg/day.
Collapse
Affiliation(s)
- T C Minderhoud
- Amsterdam UMC, locatie VUmc, afd. Interne Geneeskunde
- Contact: T.C. Minderhoud
| | | | | | | | | | | |
Collapse
|
14
|
de Mast Q, Thurlings R, Ten Oever J. [Pneumocystis prophylaxis during glucocorticoid use?]. Ned Tijdschr Geneeskd 2018; 162:D2927. [PMID: 30212009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Pneumocystis jiroveci pneumonia (PJP) is a much-feared complication of the use of immunosuppressive drugs. There is no current consensus on the indications for PJP prophylaxis in patients with rheumatological diseases who are receiving higher-dose glucocorticoid treatment over a prolonged period. The decision on whether or not to administer prophylaxis depends primarily on the Number Needed to Treat (NNT) vs the Number Needed to Harm (NNH) of trimethoprim/sulfamethoxazole (TMP/SMX) or other forms of prophylaxis. A recent retrospective study from South Korea supports the efficacy and safety of TMP/SMX for patients using ≥ 30 mg prednisone for > 1 month, especially in those with high-risk disease or other risk factors. Surveillance of regional and national PJP incidence, along with possible predictors, may help in gaining a better understanding of risk groups and in drawing up a regional, or preferably national, protocol.
Collapse
Affiliation(s)
- Quirijn de Mast
- Radboudumc, afd. Interne Geneeskunde en Radboud Center for Infectious Diseases, Nijmegen
- Contact: Q. de Mast
| | | | - Jaap Ten Oever
- Radboudumc, afd. Interne Geneeskunde en Radboud Center for Infectious Diseases, Nijmegen
| |
Collapse
|
15
|
Keefer K, Bender R, Liao J, Sivik J, Van de Louw A. Characteristics of pulmonary complications in non-Hodgkin's lymphoma patients treated with rituximab-containing chemotherapy and impact on survival. Ann Hematol 2018; 97:2373-2380. [PMID: 30030570 PMCID: PMC7102168 DOI: 10.1007/s00277-018-3448-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Accepted: 07/17/2018] [Indexed: 11/29/2022]
Abstract
Patients with non-Hodgkin’s lymphoma (NHL) receiving rituximab-containing chemotherapy are at risk of developing respiratory complications, but comprehensive information on these complications and their impact on survival is lacking. We performed a retrospective cohort analysis on 123 NHL patients who received rituximab-containing chemotherapy between 2009 and 2016 in order to describe the incidence, etiologies and effect on survival of respiratory complications defined by new or worsening respiratory symptoms requiring diagnostic work-up or hospitalization. Thirty patients (24%) developed respiratory complications during a follow-up time of 825 (555–1338) days after chemotherapy. They had a higher prevalence of congestive heart failure and lung or pleural involvement at diagnosis as compared to patients who did not develop complications. Overall, 58 episodes of pulmonary complications were observed after median (interquartile) times from the first and last rituximab doses of 205 (75–580) days and 27 (14–163) days respectively. Infectious etiologies accounted for 75% of the respiratory complications, followed by heart failure exacerbation, lymphomatous involvement, and ARDS. Two Pneumocystis jirovecii pneumonias were observed, and no complication was ascribed to rituximab toxicity. Respiratory complications required ICU admission in 19 cases (33%) and invasive mechanical ventilation in 14 cases (24%). Using a time-dependent Cox regression analysis, we observed that the occurrence of respiratory complications was associated with a 170% increase in death hazard (hazard ratio 2.65, 95% CI 1.60–4.40, p = 0.001). In conclusion, respiratory complications in NHL patients receiving chemotherapy are relatively frequent, severe, and mostly infectious and are associated with increased mortality.
Collapse
Affiliation(s)
- Kimberly Keefer
- Department of Pharmacy, Pennsylvania State University College of Medicine and Milton S Hershey Medical Center, 500 University Drive, Hershey, PA, 17033, USA
| | - Regis Bender
- Department of Pharmacy, Pennsylvania State University College of Medicine and Milton S Hershey Medical Center, 500 University Drive, Hershey, PA, 17033, USA
| | - Jason Liao
- Department of Public Health Sciences, Pennsylvania State University College of Medicine and Milton S Hershey Medical Center, 500 University Drive, Hershey, PA, 17033, USA
| | - Jeffrey Sivik
- Department of Pharmacy, Pennsylvania State University College of Medicine and Milton S Hershey Medical Center, 500 University Drive, Hershey, PA, 17033, USA
| | - Andry Van de Louw
- Division of Pulmonary and Critical Care Medicine, Pennsylvania State University College of Medicine and Milton S Hershey Medical Center, 500 University Drive, Hershey, PA, 17033, USA.
| |
Collapse
|
16
|
Sagawa N, Abe N, Ishimine T, Zaha H. [A Case of Pneumocystis Pneumonia during Adjuvant Dose-Dense Chemotherapy for Breast Cancer]. Gan To Kagaku Ryoho 2017; 44:783-785. [PMID: 28912409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
A 47-year-old woman received adjuvant chemotherapy for breast cancer. On the 13th day of 4 courses of dose-dense AC therapy, she developed a fever. She was orally administered an antibioticfor febrile neutropenia treatment. She showed no improvement of symptoms and gradually presented with new symptoms, including a non-productive cough and dyspnea. After admission, she underwent a further examination, and was provided a diagnosis of pneumocystis pneumonia. It is reported that patients receiving chemotherapy for solid tumors are less likely to develop opportunistic infections. However, patients receiving dose-dense chemotherapy may have a higher risk for developing opportunistic infections than those receiving conventional chemotherapy.
Collapse
|
17
|
Abstract
Corticosteroids are frequently used to treat rheumatic diseases. Their use comes with several well-established risks, including osteoporosis, avascular necrosis, glaucoma, and diabetes. The risk of infection is of utmost concern and is well documented, although randomized controlled trials of short-term and lower-dose steroids have generally shown little or no increased risk. Observational studies from the real world, however, have consistently shown dose-dependent increases in risk for serious infections as well as certain opportunistic infections. In patients who begin chronic steroid therapy, vaccination and screening strategies should be used in an attempt to mitigate this risk.
Collapse
Affiliation(s)
- Jameel Youssef
- Oregon Health & Science University, 3181 Southwest Sam Jackson Park Road, Portland, OR 97239, USA.
| | - Shannon A Novosad
- Oregon Health & Science University, 3181 Southwest Sam Jackson Park Road, Portland, OR 97239, USA
| | - Kevin L Winthrop
- Oregon Health & Science University, 3181 Southwest Sam Jackson Park Road, Portland, OR 97239, USA
| |
Collapse
|
18
|
Abstract
A 59-year-old woman, diagnosed with advanced rectal cancer, presented with a low-grade fever and dyspnea on exertion after the 2nd cycle of TAS-102. TAS-102 has promising efficacy in patients with metastatic colorectal cancer. A CT scan revealed mosaic patterns with bilateral ground-glass opacities. The drug lymphocyte stimulation test for TAS-102 was strongly positive and serum β-D glucan level was elevated. The clinical course was compatible with TAS-102-induced pneumonitis combined with pneumocystis pneumonia (PCP). We herein report a rare case of drug-induced pneumonitis in a patient receiving TAS-102 in combination with PCP.
Collapse
|
19
|
Berger CT, Greiff V, John S, Koenig KF, Bigler MB, Recher M, Hess C, Daikeler T. Risk factors for pneumocystis pneumonia in giant cell arteritis: a single-centre cohort study. Clin Exp Rheumatol 2015; 33:S-122-5. [PMID: 26016762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2014] [Accepted: 04/21/2015] [Indexed: 06/04/2023]
Abstract
OBJECTIVES Pneumocystis jiroveci pneumonia (PCP) is a life-threatening opportunistic infection. Few PCP cases in giant cell arteritis (GCA) have been described, but it remains unknown, which patients need PCP prophylaxis. METHODS Sixty-two patients with GCA from a prospective cohort were studied to identify treatment-related predictors of PCP infection. RESULTS Four PCP infections occurred, all in patients treated with methotrexate in addition to prednisone. Moreover, PCP is associated with higher cumulative PDN doses and severe lymphocytopenia (<400/μl). CONCLUSIONS Our findings support PCP-prophylaxis in GCA patients who are treated with methotrexate and PDN, and need high prednisone doses to achieve remission, or develop severe lymphocytopenia.
Collapse
Affiliation(s)
- C T Berger
- Medical Outpatient Clinic, Department of Internal Medicine, and Translational Immunology, Department of Biomedicine, University Hospital Basel, Switzerland
| | - V Greiff
- Department of Biosystems Science and Engineering, ETH Zürich, Basel, Switzerland
| | - S John
- Medical Outpatient Clinic, Department of Internal Medicine, University Hospital Basel, Switzerland
| | - K F Koenig
- Medical Outpatient Clinic, Department of Internal Medicine, University Hospital Basel, Switzerland
| | - M B Bigler
- Translational Immunology, Department of Biomedicine, University Hospital Basel, Switzerland
| | - M Recher
- Medical Outpatient Clinic, Department of Internal Medicine; and Immunodeficiency Lab, Department of Biomedicine, University Hospital Basel, Switzerland
| | - C Hess
- Medical Outpatient Clinic, Department of Internal Medicine; and Immunobiology Lab, Department of Biomedicine, University Hospital Basel, Switzerland
| | - T Daikeler
- Clinic of Rheumatology, University Hospital Basel, Switzerland
| |
Collapse
|
20
|
Abstract
OBJECTIVE Pneumocystis jiroveci pneumonia (PJP) infection is a rare but lethal complication in immunocompromised hosts. However, risk factors for PJP infection in glomerulonephritis (GN) patients receiving immunosuppressants are unknown. METHODS From August 2009 to July 2010, we encountered a cluster occurrence of PJP infection in our renal biopsy patients. Seven of 73 GN patients under immunosuppressant agents developed PJP infection, which were diagnosed by the Giemsa and Gomori's methenamine silver stains of the bronchoalveolar lavage specimen. RESULTS The average time of PJP onset was 2.4 months after immunosuppressant initiation. We found that the immunosuppressant regimens were equal between patients with and without the development of PJP infection regarding the daily dose per body weight, treatment duration, and accumulative dose per body weight. Logistic regression analysis indicated that high serum creatinine, low hemoglobin, and low absolute lymphocyte count at immunosuppressant initiation, and high chronicity indices of kidney pathology were predictors of PJP infection. In addition, patients with PJP infection had persistently worse renal function, more severe anemia, and more severe lymphocytopenia as compared to those without. CONCLUSION Prophylactic therapy for P. jiroveci and immunosuppressant dose reduction should be considered in GN patients with high chronicity of their kidney diseases and/or persistent lymphocytopenia.
Collapse
Affiliation(s)
- Chih-Yu Yang
- Division of Nephrology, Department of Medicine, Taipei Veterans General Hospital, Taiwan
| | | | | | | |
Collapse
|
21
|
Isidori A, Merli F, Angrilli F, Ferrara F, Alesiani F, Visani G. The incidence of Pneumocystis jirovecii pneumonia is not higher in patients receiving dose-dense therapy with rituximab, cyclophosphamide, non-pegylated liposomal doxorubicin, vincristine, and prednisolone and adequate Pneumocystis jirovecii pneumonia prophylaxis. Leuk Lymphoma 2010; 52:148-9. [PMID: 21067442 DOI: 10.3109/10428194.2010.525726] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
|
22
|
Hugle B, Solomon M, Harvey E, James A, Wadhwa A, Amin R, Bell-Peter A, Benseler S. Pneumocystis jiroveci pneumonia following rituximab treatment in Wegener's granulomatosis. Arthritis Care Res (Hoboken) 2010; 62:1661-4. [PMID: 20583109 DOI: 10.1002/acr.20279] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2010] [Accepted: 06/17/2010] [Indexed: 11/09/2022]
Affiliation(s)
- Boris Hugle
- The Hospital for Sick Children, University of Toronto, Ontario, Canada
| | | | | | | | | | | | | | | |
Collapse
|
23
|
Derungs A, Rätz Bravo AE, Kummer O. [Rash, fever, eosinophilia and elevated liver enzymes. DRESS syndrome (drug reaction or rash with eosinophilia and systemic symptoms)]. Praxis (Bern 1994) 2010; 99:767-776. [PMID: 20571998 DOI: 10.1024/1661-8157/a000199] [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] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
We report on a patient with Pneumocystis jirovecii pneumonia who developed fever, rash, eosinophilia and hepatitis 10 days after initiation of a therapy with sulfamethoxazole and trimethoprim. A DRESS syndrome was diagnosed and the therapy was changed successfully to pyrimethamine and dapsone. We describe the clinical picture, causative drugs, pathogenesis, differential diagnoses and therapy of this life-threatening disease to acquaint the general practitioner with it.
Collapse
MESH Headings
- Antibodies, Monoclonal/administration & dosage
- Antibodies, Monoclonal/adverse effects
- Antibodies, Monoclonal, Murine-Derived
- Antineoplastic Combined Chemotherapy Protocols/administration & dosage
- Antineoplastic Combined Chemotherapy Protocols/adverse effects
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Cyclophosphamide/administration & dosage
- Cyclophosphamide/adverse effects
- Diagnosis, Differential
- Doxorubicin/administration & dosage
- Doxorubicin/adverse effects
- Drug Eruptions/diagnosis
- Drug Hypersensitivity/diagnosis
- Eosinophilia/etiology
- Exanthema/etiology
- Fever of Unknown Origin/etiology
- Humans
- Liver Function Tests
- Lymphoma, T-Cell/drug therapy
- Male
- Middle Aged
- Opportunistic Infections/chemically induced
- Opportunistic Infections/drug therapy
- Pneumocystis carinii
- Pneumonia, Pneumocystis/chemically induced
- Pneumonia, Pneumocystis/drug therapy
- Prednisone/administration & dosage
- Prednisone/adverse effects
- Rituximab
- Trimethoprim, Sulfamethoxazole Drug Combination/adverse effects
- Trimethoprim, Sulfamethoxazole Drug Combination/therapeutic use
- Vincristine/administration & dosage
- Vincristine/adverse effects
Collapse
Affiliation(s)
- Adrian Derungs
- Abteilung für Klinische Pharmakologie und Toxikologie, Departement Innere Medizin, Universitätsspital Basel.
| | | | | |
Collapse
|
24
|
Estrada S, García-Campos F, Calderón R, Delgado E, Bengoa R, Enciso C. Pneumocystis jiroveci (carinii) pneumonia following a second infusion of infliximab in a patient with ulcerative colitis. Inflamm Bowel Dis 2009; 15:315-6. [PMID: 19058233 DOI: 10.1002/ibd.20536] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
|
25
|
Tabarsi P, Mirsaeidi M, Amiri M, Karimi S, Masjedi MR, Mansouri D. Inappropriate use of steroid and pneumocystis jiroveci pneumonia: report of two cases. East Mediterr Health J 2008; 14:1217-1221. [PMID: 19161096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Affiliation(s)
- P Tabarsi
- National Research Institute of TB and Lung Disease, Shahid Beheshti University of Medical Sciences, Tehran, Islamic Republic of Iran.
| | | | | | | | | | | |
Collapse
|
26
|
Teichmann LL, Woenckhaus M, Vogel C, Salzberger B, Schölmerich J, Fleck M. Fatal Pneumocystis pneumonia following rituximab administration for rheumatoid arthritis. Rheumatology (Oxford) 2008; 47:1256-7. [PMID: 18567919 DOI: 10.1093/rheumatology/ken234] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
|
27
|
Venhuizen AC, Hustinx WNM, van Houte AJ, Veth G, van der Griend R. Three cases of Pneumocystis jirovecii pneumonia (PCP) during first-line treatment with rituximab in combination with CHOP-14 for aggressive B-cell non-Hodgkin's lymphoma. Eur J Haematol 2008; 80:275-6. [PMID: 18005387 DOI: 10.1111/j.1600-0609.2007.00994.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
28
|
|
29
|
Laros-van Gorkom BAP, Huisman CAM, Wijermans PW, Schipperus MR. Experience with alemtuzumab in treatment of chronic lymphocytic leukaemia in the Netherlands. Neth J Med 2007; 65:333-338. [PMID: 17954952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
BACKGROUND Alemtuzumab (MabCampath) is a monoclonal antibody against CD52, indicated as third-line treatment of chronic lymphocytic leukaemia (CLL). As most important side effect opportunistic infections are mentioned. It is, however, unknown whether these complications often lead to problems in general patient care in the Netherlands. METHODS To gain insight into the use and complications of alemtuzumab therapy, the alemtuzumab-treated CLL patients in 15 hospitals in the Netherlands were evaluated by means of a questionnaire. RESULTS In the period from 31 October 2001 until 17 November 2005, 27 patients with CLL or prolymphocytic leukaemia (PLL), RAI stage I to IV, Binet stage A to C, received 32 treatments with alemtuzumab. The time from diagnosis until start of alemtuzumab treatment was 6 +/- 4.5 years (mean +/- SD ). The treatment lasted 11 +/- 7 weeks. Of the treatments, 41% could be administered for the full 12 weeks. The most frequent adverse events were fever (72%), shivering (47%), fatigue (22%) and dyspnoea (16%). Haematological side effects consisted of leucopenia (75%), thrombocytopenia (44%), and anaemia (13%). Infectious complications occurred in 12 of 32 (38%) treatments: pneumonia (25%; of which one Pneumocystis carini pneumonia and four Aspergillus infections), sepsis (9%; of which one Listeria), herpes zoster (9%), herpes simplex (6%), CMV reactivation (6%), meningitis (3%) and Guillain Barre (3%). The overall response was 53%, with complete remission in 13%, partial remission in 41%, stable disease in 25% and progressive disease in 13%, and lasted for 8.3 +/- 7.3 months. CONCLUSION Treatment with alemtuzumab is often terminated prematurely, leading to a suboptimal treatment effect. Fear of severe uncontrollable opportunistic infections seems unjustified.
Collapse
MESH Headings
- Alemtuzumab
- Antibodies, Monoclonal/administration & dosage
- Antibodies, Monoclonal/adverse effects
- Antibodies, Monoclonal/therapeutic use
- Antibodies, Monoclonal, Humanized
- Antibodies, Neoplasm/administration & dosage
- Antibodies, Neoplasm/adverse effects
- Antibodies, Neoplasm/therapeutic use
- Antigens, CD/drug effects
- Antigens, Neoplasm/drug effects
- Aspergillosis/chemically induced
- CD52 Antigen
- Drug Evaluation
- Drug Resistance, Neoplasm
- Glycoproteins/drug effects
- Humans
- Leukemia, Lymphocytic, Chronic, B-Cell/drug therapy
- Medical Records
- Netherlands
- Opportunistic Infections/chemically induced
- Pneumonia, Pneumocystis/chemically induced
- Remission Induction
- Retrospective Studies
- Surveys and Questionnaires
- Treatment Outcome
- Vidarabine/analogs & derivatives
- Vidarabine/therapeutic use
Collapse
Affiliation(s)
- B A P Laros-van Gorkom
- Department of Haematology, Haga Hospital, location Leyenburg, The Hague, the Netherlands.
| | | | | | | |
Collapse
|
30
|
Dai XD, Qin YH, Zhou CH, Zheng LL, Shao WJ, Tao L, Cui Y. [Effects of Fructus Psoralea and Brucea javanica on the level of IL-2 and NK cell in rats infected with Pneumocystis carinii]. Zhongguo Ji Sheng Chong Xue Yu Ji Sheng Chong Bing Za Zhi 2007; 25:436-438. [PMID: 18442007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
SD rat model of PCP was established by subcutaneous injection with dexamethasone. The treatment groups received Fructus Psoralea (FP, 10.0 mg/kg), Brucea javanica (BJ, 1.2 mg/kg) and a mixture of the two Chinese herbs(FP 5mg/kg, BJ 0.6 mg/kg) respectively. By means of detecting the level of IL-2 in sera and NK cells in spleens, the effect of FP and BJ on the level of IL-2 and NK cells in rats with Pneumocystis carinii pneumonia (PCP) was observed, with SMZco treatment group (TMP 50 mg/kg, SMZ 250 mg/kg) and groups of infected and normal rats as controls. Compared with the infected group, the level of IL-2(526.1 +/- 5.5) pg/ml and NK cells (27.1% +/- 0.8%) significantly increased in the FP group (P < 0.01), followed by the FP/BJ combination group [(314.7 +/- 6.7) pg/ml, 22.9% +/- 0.9%) (P < 0.05)], and BJ group [(285.4 +/- 6.1) pg/ml, 20.7% +/- l.0%) (P < 0.05)]. Chinese herbs Fructus Psoralea and Brucea javanica show an immune regulatory action on the PCP rats.
Collapse
MESH Headings
- Animals
- Brucea/chemistry
- Cell Line, Tumor
- Dexamethasone
- Drug Combinations
- Drugs, Chinese Herbal/chemistry
- Drugs, Chinese Herbal/pharmacology
- Drugs, Chinese Herbal/therapeutic use
- Fabaceae/chemistry
- Female
- Interleukin-2/blood
- Interleukin-2/metabolism
- Killer Cells, Natural/drug effects
- Killer Cells, Natural/metabolism
- Killer Cells, Natural/microbiology
- Mice
- Phytotherapy
- Pneumocystis Infections/drug therapy
- Pneumocystis Infections/metabolism
- Pneumocystis Infections/microbiology
- Pneumocystis carinii/drug effects
- Pneumocystis carinii/growth & development
- Pneumonia, Pneumocystis/chemically induced
- Pneumonia, Pneumocystis/prevention & control
- Rats
- Rats, Sprague-Dawley
Collapse
Affiliation(s)
- Xiao-dong Dai
- Department of Parasitology, Dalian Medical University, Dalian 116023, China
| | | | | | | | | | | | | |
Collapse
|
31
|
Wang JX, Duan YN, Chen JL, Dong YS. [Construction and expression of prokaryotic expression plasmids of Pneumocystis carinii p55 antigen gene fragment]. Zhongguo Ji Sheng Chong Xue Yu Ji Sheng Chong Bing Za Zhi 2007; 25:328-332. [PMID: 18038806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
OBJECTIVE To construct prokaryotic recombinant expression plasmid carrying Pneumocystis carinii Mr 55 000 antigen (p55) gene fragment and express the recombinant protein. METHODS P. carinii pneumonia (PcP) rat models were established by subcutaneous injection of dexamethasone for 14 weeks. Total RNA was extracted from lung of P. carinii rat and p55 antigen gene fragment was cloned by RT-PCR, which was identified by sequencing. The 690 bp fragment was cloned to pGEX-4T-1, the recombinant plasmid was screened and identified by restriction analysis and PCR. The recombinant plasmid was finally induced with IPTG to express a new fusion protein, and the products were analyzed by SDS-PAGE and Western blot. RESULTS A fragment of 690 bp was obtained by RT-PCR. The recombinant pGEX-4T-1/690 was constructed. SDS-PAGE revealed that the molecular weight of the recombinant protein was approximately Mr 62,000, the maximum amount of the fusion protein produced was 11.6% of the total protein. The recombinant protein can be recognized by GST antibody and by the sera from P. carinii infected rats using Western blotting. CONCLUSION Prokaryotic expression plasmid pGEX-4T-1/690 has been constructed and the recombinant fusion protein shows antigenicity.
Collapse
Affiliation(s)
- Jian-xin Wang
- School of Medicine, Nantong University, Nantong 226001, China
| | | | | | | |
Collapse
|
32
|
Lu ZM, Zhang YC, Zhang JS, Shi BL, Jia TJ, Tang HW, Liu JH. [Enzyme change in bronchoalveolar lavage fluid of pneumocystis pneumonia rats and the effect of garlicin treatment]. Zhongguo Ji Sheng Chong Xue Yu Ji Sheng Chong Bing Za Zhi 2007; 25:300-303. [PMID: 18038800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
OBJECTIVE To study the change of enzymes and effect of garlicin treatment on the change in bronchoalveolar lavage fluid (BALF) of rats with Pneumocystis carinii pneumonia (PCP). METHODS Wistar rats were injected intramuscularly continually with dexamethasone to establish the rat model of PCP. The experimental rats (group A) were injected intramuscularly with garlicin at a dose of 10 mg/(kg x d) for 5 days in the 3rd, 6th and 9th week respectively, and SMZ/TMP therapy group (B), PCP infected group (C) and normal group (D) were established as controls. Three days after the last treatment, the rats of all groups were killed and BALF was collected without contamination and enzymes AST, ALF, CHE, ALP, LDH, CK, CKMB, HBDH, AFU, 5'NT, ADA were examined. RESULTS The ALP level in group C [(573.41 +/- 350.63)U/L] was significantly higher than that in group D [(210.56 +/- 114.41) U/L] (q = 4.682, P < 0.01), group A [(392.07 +/- 217.57) U/L] (q = 3.851, P < 0.05), and group B [(325.21 +/- 180.65) U/L] (q = 4.380, P < 0.01); the level of CK, CKMB and 5'NT in group C [948.94 +/- 403.43, 489.47 +/- 254.46 and (6.76 +/- 3.11) U/L respectively] was higher than those in group D [426.22 +/- 319.00, 213.33 +/- 144.54 and (3.22 +/- 1.20) U/L] (q = 4.696, 3.784, 3.812, P< 0.05); there was no significant difference in the level of AST, ALT, CHE, LDH, HBDH, AFU and ADA among the four groups (F = 1.852, 0.958, 2.470, 1.423, 1.178, 1.342, 0.611, P > 0.05). CONCLUSIONS The level of ALP, CK, CKMB but the ALP level decreases distinctly after the garlicin and 5'NT increases evidently in BALF of PCP infected rats, but the ALP level decreases distinctly after the garlicin treatment.
Collapse
Affiliation(s)
- Zhi-min Lu
- Department of Parasitology, Hebei North University, Zhangjiakou 075000, China
| | | | | | | | | | | | | |
Collapse
|
33
|
Abstract
Anti-tumor necrosis factor-alpha therapy, infliximab, has become an established effective therapy for Crohn's disease and rheumatoid arthritis. However, infliximab has been associated with various opportunistic pathogens such as tuberculosis, histoplasmosis, listeriosis, aspergillosis, and Pneumocystis jiroveci (carinii) pneumonia. We reviewed the FDA Adverse Event Reporting System for cases of Pneumocystis associated with infliximab use from January 1998 through December 2003. The database revealed 84 cases of PCP following infliximab therapy. Concomitant immunosuppressive medications included methotrexate, prednisone, azathioprine, 6-mercaptopurine, and cyclosporine. Mean time between infliximab infusion and onset of symptoms of pneumonia, when reported, was 21 days (+/-18 days; n=40). Twenty-three of the 84 (27%) patients died. The use of infliximab is associated with PCP infection. Further, the mortality rate for Pneumocystis following the use of infliximab is significant. The potential for severe disease, mortality, and often subtle presentation of these infections warrant close follow-up and careful monitoring after therapy.
Collapse
Affiliation(s)
- Nirmal Kaur
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | | |
Collapse
|
34
|
Maldonado F, Limper AH, Lim KG, Aubrey MC. Temozolomide-associated organizing pneumonitis. Mayo Clin Proc 2007; 82:771-3. [PMID: 17550757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/21/2023]
Abstract
Temozolomide is an oral alkylating agent recently approved for the treatment of glioblastoma multiforme. It has a favorable side effect profile and is generally well tolerated. Although mild respiratory symptoms have been described, pulmonary toxicity that requires discontinuation of therapy is rare. To our knowledge, this is the first case of temozolomide-associated organizing pneumonitis.
Collapse
Affiliation(s)
- Fabien Maldonado
- Division of Pulmonary and Critical Care Medicine, College of Medicine, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA.
| | | | | | | |
Collapse
|
35
|
Kasai S, Tokuda H, Otsuka Y, Ookohchi Y, Handa H, Emoto N, Yoshikawa M. [Two cases of respiratory infection complicating treatment with infliximab]. Nihon Kokyuki Gakkai Zasshi 2007; 45:366-71. [PMID: 17491318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
Infliximab, an anti-TNF-alpha agent, is highly effective against rheumatoid arthritis and Crohn's disease. However, respiratory infection can occur as a complication. We report two cases complicated by respiratory infection following administration of infliximab. The first case, a 67-year-old woman with rheumatoid arthritis, developed pneumocystis pneumonia after three courses of infliximab therapy. The second case, a 31-year-old man with Crohn's disease, developed pulmonary tuberculosis after four courses of infliximab therapy. Respiratory complications associated with anti-TNF therapy include infectious diseases such as pneumocystis pneumonia, tuberculosis, and bacterial pneumonia. They often lead a fulminant course, and early diagnosis is essential. The final report of a survey of the initial 5000 cases with rheumatoid arthritis treated with infliximab in Japan was released in April 2006; pulmonary infectious complications included 22 cases of pneumocystis pneumonia, 14 cases of tuberculosis, and 108 cases of bacterial pneumonia. The growing use of anti-TNF therapy might lead to increasing pulmonary complications. Accumulation of similar cases is expected to elucidate the mechanism of the complications and methods for effective prophylaxis.
Collapse
Affiliation(s)
- Shogo Kasai
- Department of Internal Medicine, Social Insurance Central General Hospital
| | | | | | | | | | | | | |
Collapse
|
36
|
Avery JK. Loss prevention case of the month--chronic renal disease. Tenn Med 2006; 99:33-4. [PMID: 17256393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Affiliation(s)
- J Kelley Avery
- State Volunteer Mutual Insurance Company, Brentwood, USA
| |
Collapse
|
37
|
Dungarwalla M, Marsh JCW, Tooze JA, Lucas G, Ouwehand W, Pettengell R, Dearden CE, Gordon Smith EC, Elebute MO. Lack of clinical efficacy of rituximab in the treatment of autoimmune neutropenia and pure red cell aplasia: implications for their pathophysiology. Ann Hematol 2006; 86:191-7. [PMID: 17123083 DOI: 10.1007/s00277-006-0202-5] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2006] [Accepted: 09/11/2006] [Indexed: 11/25/2022]
Abstract
We describe 11 patients with severe refractory autoimmune cytopenias treated with the anti-CD20 monoclonal antibody rituximab. Six patients had autoimmune neutropenia (AIN), two had pure red cell aplasia (PRCA), one had AIN and autoimmune haemolytic anaemia, one had AIN and immune thrombocytopaenia purpura (ITP) and one had PRCA and ITP. Rituximab was administered at a dose of 375 mg/m(2) as an intravenous infusion weekly for 4 weeks. Six of eight patients with AIN and all three patients with PRCA did not respond. Two patients died: one with resistant AIN and autoimmune haemolytic anaemia died of pneumocytis pneumonia infection, and one with PRCA and ITP died of an acute exacerbation of bronchiectasis. Rituximab in AIN and PRCA appears to be less effective than Campath-1H when compared to historical data from our group. This supports the hypothesis that T cells may be important in the pathophysiology of AIN and PRCA.
Collapse
MESH Headings
- Adult
- Aged
- Anemia, Hemolytic, Autoimmune/drug therapy
- Anemia, Hemolytic, Autoimmune/pathology
- Antibodies, Monoclonal/administration & dosage
- Antibodies, Monoclonal/adverse effects
- Antibodies, Monoclonal/therapeutic use
- Antibodies, Monoclonal, Murine-Derived
- Bronchiectasis/chemically induced
- Drug Administration Routes
- Drug Administration Schedule
- Female
- Humans
- Immunologic Factors/administration & dosage
- Immunologic Factors/adverse effects
- Immunologic Factors/therapeutic use
- Male
- Middle Aged
- Neutropenia/drug therapy
- Neutropenia/pathology
- Pilot Projects
- Pneumonia, Pneumocystis/chemically induced
- Purpura, Thrombocytopenic/drug therapy
- Purpura, Thrombocytopenic/pathology
- Red-Cell Aplasia, Pure/drug therapy
- Red-Cell Aplasia, Pure/pathology
- Rituximab
- Time Factors
- Treatment Outcome
Collapse
Affiliation(s)
- M Dungarwalla
- Department of Haematology, St George's Hospital, Tooting, London, UK
| | | | | | | | | | | | | | | | | |
Collapse
|
38
|
Ganière V, Christen G, Bally F, Guillou L, Pica A, de Ribaupierre S, Stupp R. Listeria brain abscess, Pneumocystis pneumonia and Kaposi's sarcoma after temozolomide. ACTA ACUST UNITED AC 2006; 3:339-43; quiz following 343. [PMID: 16757971 DOI: 10.1038/ncponc0514] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2005] [Accepted: 02/15/2006] [Indexed: 11/09/2022]
Abstract
BACKGROUND A 55-year-old man with glioblastoma multiforme was treated with continuous, dose-dense temozolomide. This therapy was curtailed after three cycles because of nausea, asthenia, and neuropsychological deterioration. During a subsequent course of radiotherapy, the patient developed fever, headaches, and cutaneous lesions. INVESTIGATIONS Physical examination, cerebral MRI, brain biopsy, skin biopsy, immunohistochemistry, bronchoscopy with bronchoalveolar lavage, and laboratory tests. DIAGNOSIS Severe temozolomide-induced immunosuppression, exacerbated by corticosteroids, with profound T-cell lymphocytopenia and simultaneous opportunistic infections with Pneumocystis jiroveci pneumonia, brain abscess with Listeria monocytogenes, and cutaneous Kaposi's sarcoma. MANAGEMENT Discontinuation of temozolomide, discontinuation of radiotherapy, antibiotic treatment with amoxicillin and gentamicin, and administration of atovaquone and pentamidine.
Collapse
|
39
|
Mori S, Imamura F, Kiyofuji C, Ito K, Koga Y, Honda I, Sugimoto M. Pneumocystis jiroveci pneumonia in a patient with rheumatoid arthritis as a complication of treatment with infliximab, anti-tumor necrosis factor alpha neutralizing antibody. Mod Rheumatol 2006; 16:58-62. [PMID: 16622728 DOI: 10.1007/s10165-005-0454-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2005] [Accepted: 12/21/2005] [Indexed: 10/25/2022]
Abstract
We report that a-63-year-old woman developed Pneumocystis jiroveci pneumonia (PCP) as a complication from treatment with infliximab for rheumatoid arthritis. Although there was neither symptoms of dyspnea nor typical observations on a chest X-ray examination, low levels of oxygen saturation and findings of high-resolution chest computed tomographic scanning suggested a possibility of interstitial pneumonia. A polymerase chain reaction-based detection of Pneumocystis jiroveci in induced sputum allowed an early diagnosis of PCP and subsequent effective treatment.
Collapse
Affiliation(s)
- Shunsuke Mori
- Division of Rheumatology, Department of Medicine, National Hospital Organization, Kumamoto Saishunso National Hospital, Suya 2659 Nishigohshi-machi, Kikuchi-gun, Kumamoto 860-1196, Japan.
| | | | | | | | | | | | | |
Collapse
|
40
|
Kaneko Y, Suwa A, Ikeda Y, Hirakata M. Pneumocystis jiroveci pneumonia associated with low-dose methotrexate treatment for rheumatoid arthritis: report of two cases and review of the literature. Mod Rheumatol 2006; 16:36-8. [PMID: 16622722 DOI: 10.1007/s10165-005-0443-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2005] [Accepted: 10/19/2005] [Indexed: 10/25/2022]
Abstract
Low-dose methotrexate (MTX) therapy is widely used for rheumatoid arthritis (RA) because of its favorable efficacy and toxicity profile. Although Pneumocystis jiroveci pneumonia (PCP) is most often seen in severely immunosuppressed patients, PCP complicating low-dose MTX therapy for RA has been reported to sometimes occur. We herein report two cases of patients who developed PCP during treatment with low-dose MTX, and discuss the importance of prophylaxis for this opportunistic infection.
Collapse
Affiliation(s)
- Yuko Kaneko
- Department of Internal Medicine, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan.
| | | | | | | |
Collapse
|
41
|
Lemaire CM, Browning JC, Hsu S. Medical Pearl: Pneumocystis pneumonia prophylaxis for patients on chronic systemic corticosteroids. J Am Acad Dermatol 2006; 55:124-5. [PMID: 16781304 DOI: 10.1016/j.jaad.2005.11.1054] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2005] [Revised: 11/03/2005] [Accepted: 11/08/2005] [Indexed: 10/24/2022]
Affiliation(s)
- Chad M Lemaire
- Department of Dermatology, Baylor College of Medicine, Houston, TX 77030, USA
| | | | | |
Collapse
|
42
|
De Castro N, Neuville S, Sarfati C, Ribaud P, Derouin F, Gluckman E, Socié G, Molina JM. Occurrence of Pneumocystis jiroveci pneumonia after allogeneic stem cell transplantation: a 6-year retrospective study. Bone Marrow Transplant 2005; 36:879-83. [PMID: 16151423 DOI: 10.1038/sj.bmt.1705149] [Citation(s) in RCA: 101] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Pneumocystis jiroveci pneumonia (PCP) has become a rare opportunistic infection due to the efficacy of prophylactic regimens. We conducted a 6-year retrospective study at our institution. A total of 13 cases of PCP were diagnosed among 519 patients undergoing allogeneic hematopoietic stem cell transplantation (HSCT) (2.5%). In three patients, PCP occurred within the first 5 months following HSCT. These severely immunocompromised patients were receiving prophylaxis and had concomitant aspergillosis that caused rapid death in two of them. In 10 other patients, PCP occurred a median of 14.5 months after HSCT. In all these patients, PCP prophylaxis had been discontinued, mainly because of the suspected bone-marrow toxicity of the prophylactic regimen. Median CD4+ T cell count was 131/microl at diagnosis. Seven of these 10 patients were receiving immunosuppressive therapy for chronic graft versus host disease and three had a relapse of their hematological malignancy. One patient died from PCP despite high doses of cotrimoxazole. We conclude that PCP is still occurring after allogeneic HSCT, mainly as a late complication in patients in whom PCP prophylaxis had been prematurely discontinued. Long-term PCP prophylaxis should be maintained in patients receiving immunosuppressive drugs, and in those with low CD4+ T cell counts or a relapse of their hematological malignancy.
Collapse
Affiliation(s)
- N De Castro
- Department of Infectious Diseases, Saint-Louis Hospital, Assistance-Publique Hôpitaux de Paris, Paris, France.
| | | | | | | | | | | | | | | |
Collapse
|
43
|
Minnee RC, Stokkers P, Riemens SC, Hommes DW. [Pneumocystis pneumonia during infliximab treatment for active Crohn's colitis]. Ned Tijdschr Geneeskd 2005; 149:2290-5. [PMID: 16240855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
A 51-year-old man with Crohn's disease for 22 years presented with a dry cough, dyspnoea, fever and diarrhoea. He had steroid-resistant Crohn's disease. Because of nausea complaints, azathioprine was switched to methotrexate with concomitant infliximab induction therapy. During infliximab therapy, symptoms occurred for which the patient was hospitalised and Pneumocystis pneumonia (PCP) was diagnosed by examination of bronchoalveolar lavage fluid; it was successfully treated with co-trimoxazole and prednisolone. The exacerbation of the Crohn's colitis diminished. This is the first Dutch case history of PCP during combination therapy with prednisolone, methotrexate and infliximab. Infliximab treatment has been associated with an increased risk for infectious complications. For patients with Crohn's disease, one should consider giving PCP prophylaxis for the duration of lymphocytopenia on an individual basis, weighing the adverse effects ofco-trimoxazole against the risk of PCP. A CD4-cell count < 0.2 x 10(9)/l or a lymphocyte count < 0.6 x 10(9)/l may be used as a guide.
Collapse
Affiliation(s)
- R C Minnee
- Academisch Medisch Centrum/Universiteit van Amsterdam, afd. Gastroenterologie, Meibergdreefg, lo05 AZ Amsterdam
| | | | | | | |
Collapse
|
44
|
Seddik M, Melliez H, Seguy D, Viget N, Cortot A, Colombel JF. Pneumocystis jiroveci (carinii) pneumonia after initiation of infliximab and azathioprine therapy in a patient with Crohn's disease. Inflamm Bowel Dis 2005; 11:618-20. [PMID: 15905713 DOI: 10.1097/01.mib.0000164002.32735.c2] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
|
45
|
Abstract
BACKGROUND Clinical trials using infliximab have not reported cases of Pneumocystis carinii pneumonia (PCP), and PCP infection during standard medical treatment of inflammatory bowel disease is uncommon. Postmarketing surveillance through June of 2001 has identified 10 cases of PCP occurring during treatment with infliximab; 3 patients died. CASE HISTORY A 19-year-old man with Crohn's colitis developed thrush, leukopenia, fever, shortness of breath, and dry cough 21 months after initiating maintenance therapy with azathioprine and infliximab. Azathioprine had been at a stable dose of 75 mg per day (1 mg/kg) and the patient had received his 14th infusion of infliximab 4 weeks prior to presentation. Evaluation revealed the presence of Pneumocystis carinii on induced sputum. Azathioprine was discontinued, and the patient improved after initiating treatment with steroids and trimethoprim-sulfamethoxazole. Follow-up 2 weeks later confirmed clinical response to therapy. CONCLUSIONS This case report describes the uncommon occurrence of Pneumocystis pneumonia in the setting of maintenance therapy for Crohn's disease using infliximab and azathioprine. Mechanisms by which azathioprine and infliximab may impair the natural defense mechanisms against Pneumocystis are discussed.
Collapse
Affiliation(s)
- Fernando S Velayos
- Division of Gastroenterology and Hepatology, University of California, San Francisco, California, USA
| | | |
Collapse
|
46
|
Sun M, Yang YR, Lu YP, Wang L, Tang KS, Wei Q, Li H. [Diagnosis and therapy of pneumocystosis complicated after renal transplantation]. Zhongguo Ji Sheng Chong Xue Yu Ji Sheng Chong Bing Za Zhi 2004; 22:245-7. [PMID: 15587162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/01/2023]
Abstract
OBJECTIVE To investigate the early diagnosis, treatment and prevention of pneumocystosis complicated after renal transplantation. METHODS Data from 12 cases of kidney transplant recipients who developed pneumocystosis were analyzed by clinical symptoms and signs, results of laboratory examination, imaging, bronchoscopy and biopsy. Combined TMP/SMZ was used for the prevention and treatment. RESULTS Pneumocystis carinii (Pc) detection rate was 16.7% from alveolar douche, 66.7% with bronchoscopy and biopsy. Two cases was diagnosed by PCR method with sputum. Plain chest film showed 58.3% of lung cirrhosis. CT showed 50% frosted glass-like change in lungs and 25% with lung consolidation. Eleven cases were cured but one died. CONCLUSION Pc detection by bronchoscopy and biopsy, and PCR are most helpful in the diagnosis of pneumocystosis complicated with renal transplantation, in addition to plain chest film and CT scaning. Combined TMP/SMZ is effective in the prevention and treatment of pneumocystosis.
Collapse
Affiliation(s)
- Ming Sun
- Department of Urology, Westchina Hospital, Sichuan University, Chengdu 610041, China
| | | | | | | | | | | | | |
Collapse
|
47
|
Seddik M, Meliez H, Seguy D, Viget N, Cortot A, Colombel JF. Pneumocystis jiroveci (carinii) pneumonia following initiation of infliximab and azathioprine therapy in a patient with Crohn's disease. Inflamm Bowel Dis 2004; 10:436-7. [PMID: 15475754 DOI: 10.1097/00054725-200407000-00017] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Anti-TNFalpha therapy is an effective treatment of Crohn's disease. There is an increased risk of infection, including atypical infection associated in infliximab treated patients. We report a case of a young man who developed Pneumocystisjiroveci pneumonia shortly after starting therapy with infliximab. Thus, although rare, prophylaxis against Pneumocystis jiroveci pneumonia might be considered when starting a treatment with infliximab, especially in patients receiving concomitant immunosuppressive agents.
Collapse
Affiliation(s)
- Mimouna Seddik
- Department of Gastroenterology, CHRU Lille, rue Michel Polonovsky, Lille, France
| | | | | | | | | | | |
Collapse
|
48
|
Affiliation(s)
- Hue T Ly
- Infectious Disease Division, Winthrop-University Hospital, Mineola, NY 11501, USA
| | | | | |
Collapse
|
49
|
Abstract
Immunosuppressive drugs lead to an enhanced risk for infection. The impact of these drugs on the immune system can be broad (eg, corticosteroids) or targeted (eg, rituximab). Infections can have serious consequences, particularly if there is a delay in diagnosis. It is hoped that a knowledge of the type of immune defects that are induced by these drugs and the specific infections that have been reported will guide clinicians in the appropriate use of prophylactic regimens and diagnostic considerations in the event of pneumonia.
Collapse
Affiliation(s)
- Dorothy A White
- Pulmonary Section, Memorial Sloan Kettering Cancer Center, New York, NY 10021, USA.
| |
Collapse
|
50
|
Abstract
Primary infection with Pneumocystis carinii usually occurs early in life, and young infants receiving prolonged treatment with high-dose corticosteroids may be at risk for the development of symptomatic disease. Prophylaxis with trimethoprim-sulfamethoxazole is safe and effective and should be considered for such infants, particularly those with underlying airway abnormalities. We describe a 3-month-old immunocompetent infant who developed severe P carinii pneumonia after 6 weeks of high-dose corticosteroid therapy for cervicofacial and airway hemangiomas.
Collapse
Affiliation(s)
- Roger Aviles
- Department of Pediatric and Adolescent Medicine, Mayo Clinic College of Medicine, Rochester, Minn 55905, USA
| | | | | |
Collapse
|