A summertime pause in immunoglobulin replacement therapy: a prospective real-world analysis

Aim: To describe the effects of a summertime pause (SP) in immunoglobulin replacement therapy (IgRT). Patients & methods: We conducted a prospective single-center observational study, including 44 patients undergoing intravenous IgRT between May and June 2019 in a French teaching hospital. Results: IgRT was interrupted in 23 patients from June to October. Patients who underwent an SP were older, more likely to have secondary immunodeficiency (SID) and received lower doses of immunoglobulin and more antibiotics during winter. Most patients who did not undergo an SP had severe primary immunodeficiency. The SP did not increase the risk of infection, improved the quality of life and reduced treatment costs. Conclusion: SP in IgRT is a safe practice and should be considered for patients with mild SID.

Myasthenia gravis and paroxysmal nocturnal hemoglobinuria after thymectomy: A rare association

Paroxysmal nocturnal hemoglobinuria (PNH) is a very rare clonal autoimmune disease manifesting with hemolysis, thrombosis, or bone marrow failure. We present an atypical association of myasthenia gravis, aplastic anemia, and PNH occurring years after thymectomy. While this association might be extremely rare, it may not be coincidental as there is a common pathophysiology between PNH and aplastic anemia, with the latter reported in several thymoma/thymectomy cases. Eculizumab was introduced with good efficacy and without safety concern in our patient, leading to long‐term control of PNH without worsening of myasthenia gravis.

Selectins impair regulatory T cell function and contribute to systemic lupus erythematosus pathogenesis

Systemic lupus erythematosus (SLE) is a systemic autoimmune disease characterized by a loss of tolerance toward self-nucleic acids, autoantibody production, interferon expression and signaling, and a defect in the regulatory T (T_reg) cell compartment. In this work, we identified that platelets from patients with active SLE preferentially interacted with T_reg cells via the P-selectin/P-selectin glycoprotein ligand-1 (PSGL-1) axis. Selectin interaction with PSGL-1 blocked the regulatory and suppressive properties of T_reg cells and particularly follicular T_reg cells by triggering Syk phosphorylation and an increase in intracytosolic calcium. Mechanistically, P-selectin engagement on T_reg cells induced a down-regulation of the transforming growth factor-β axis, altering the phenotype of T_reg cells and limiting their immunosuppressive responses. In patients with SLE, we found an up-regulation of P- and E-selectin both on microparticles and in their soluble forms that correlated with disease activity. Last, blocking P-selectin in a mouse model of SLE improved cardinal features of the disease, such as anti-dsDNA antibody concentrations and kidney pathology. Overall, our results identify a P-selectin-dependent pathway that is active in patients with SLE and validate it as a potential therapeutic avenue.

Epidemiology, clinical picture and long-term outcomes of FIP1L1-PDGFRA-positive myeloid neoplasm with eosinophilia: Data from 151 patients

FIP1L1-PDGFRA-positive myeloid neoplasm with eosinophilia (F/P+ MN-eo) is a rare disease: robust epidemiological data are lacking and reported issues are scarce, of low sample-size and limited follow-up. Imatinib mesylate (IM) is highly efficient but no predictive factor of relapse after discontinuation has yet been identified. One hundred and fifty-one patients with F/P+ MN-eo (143 males; mean age at diagnosis 49 years; mean annual incidence: 0.18 case per million population) were included in this retrospective nationwide study involving all French laboratories who perform the search of F/P fusion gene (study period: 2003-2019). The main organs involved included the spleen (44%), skin (32%), lungs (30%), heart (19%) and central nervous system (9%). Serum vitamin B12 and tryptase levels were elevated in 74/79 (94%) and 45/57 (79%) patients, respectively, and none of the 31 patients initially treated with corticosteroids achieved complete hematologic remission. All 148 (98%) IM-treated patients achieved complete hematologic and molecular (when tested, n = 84) responses. Forty-six patients eventually discontinued IM, among whom 20 (57%) relapsed. In multivariate analysis, time to IM initiation (continuous HR: 1,01 [0.99-1,03]; P = .05) and duration of IM treatment (continuous HR: 0,97 [0,95-0,99]; P = .004) were independent factors of relapse after discontinuation of IM. After a mean follow-up of 80 (56) months, the 1, 5- and 10-year overall survival rates in IM-treated patients were 99%, 95% and 84% respectively. In F/P+ MN-eo, prompt initiation of IM and longer treatment durations may prevent relapses after discontinuation of IM.

Syndrome des loges et hypothyroïdie congénitale : quand l’arrêt du traitement entraîne une urgence chirurgicale

L’atteinte musculaire des sujets atteints d’hypothyroïdie sévère est bien connue. En revanche, la survenue d’un syndrome des loges (SL) est exceptionnelle. Nous décrivons ici le cas d’une patiente ayant présenté un SL antérotibial bilatéral après un arrêt de traitement par lévothyroxine.

Case report

Une jeune femme de 28 ans présentant une agénésie thyroïdienne congénitale a interrompu depuis 3 mois son opothérapie substitutive. Lors de la reprise de la marche active à l’issue du confinement lié au COVID-19, une intense douleur musculaire, une paralysie des releveurs du pied, et une rhabdomyolyse sévère (CPK 26 059 UI/L) se sont développées. Une fasciotomie des loges antérieure et externe des deux membres a été réalisée en urgence devant un aspect ischémique des jambiers antérieurs. Aucune étiologie de myosite auto-immune (panel DOT-myosite) ou facteur aggravant n’ont été retrouvés, hormis la constatation d’une hypothyroïdie significative : TSH 93 μUI/mL avec des hormones périphériques indosables. L’IRM postopératoire a retrouvé un œdème marqué des fascias et des muscles des loges antéro-externes. La lévothyroxine a été reprise progressivement. L’évolution postopératoire a été favorable avec une diminution des douleurs et une décroissance biologique des marqueurs de rhabdomyolyse.

Conclusion

Lors d’une hypothyroïdie sévère, les pressions musculaires compartimentales augmentent, et de minimes traumatismes musculaires liés à un effort physique modéré peuvent suffire à entraîner une importante rhabdomyolyse. Cette association favoriserait la survenue d’un syndrome des loges.

Prevention of infection in asplenic adult patients by general practitioners in France between 2013 and 2016 : Care for the asplenic patient in general practice

Background

Guidelines that detail preventive measures against Streptococcus pneumoniae, Neisseria meningitidis, Haemophilus influenzae type b, and influenza are published annually in France to decrease the risk of severe infections in immunocompromised patients. We aimed at describing adherence to these guidelines by GPs in the management of their asplenic patients in France between 2013 and 2016.

Method

We conducted a multicenter retrospective study between January 2013 and December 2016 in three French hospitals: asplenic adults were identified and their GPs were questioned. A descriptive analysis was performed to identify the immunization coverage, type and length of antibiotic prophylaxis, number of infectious episodes, and education of patients.

Results

103 patients were finally included in this study: only 57% were adequately vaccinated against Streptococcus pneumoniae or Neisseria meningitidis, 74% against Haemophilus influenzae type b, and 59% against influenza. Only 24% of patients received a combination of all four vaccinations. Two-thirds of patients received prophylactic antibiotics for at least 2 years. Overall, this study found that 50% of splenectomized patients experienced at least one pulmonary or otorhinolaryngological infection, or contracted influenza.

Conclusions

These data match those reported in other countries, including Australia and the United Kingdom, meaning a still insufficient coverage of preventive measures in asplenic patients. Improved medical data sharing strategies between healthcare professionals, along with educational measures to keep patients and physicians up to date in the prevention of infections after splenectomy would improve health outcomes of asplenic patients.

1083. Long-Term Prognosis of 448 Infectious Endocarditis Followed by an Endocarditis Team

Background

The management of infective endocarditis (IE) by an expert medico-surgical team through multidisciplinary consultation meetings is now recommended. While it seems clear that it can improve the short-term prognosis of patients, long-term data are still scarce.

Methods

All patients hospitalized between 2013 and 2017 in the three teaching hospitals of our center with an IE treated by the multidisciplinary team were followed prospectively at 1, 3, 6, and 12 months. The main objective was to determine the 1-year mortality of the entire cohort treated by the team.

Results

During the study, 493 patients had a certain or possible IE and the outcome at 1 year was known for 448 of them (4 lost to follow-up and 41 followed for less than 1 year): 254 had native valve IE (57%) and 194 had prosthetic valve IE (43%). The median age of IE patients was 69.3 years (155 patients were over 75 years old) and 329 (73%) were men. Healthcare-associated IE (HAIE) accounted for 47% of cases. A microorganism was isolated in 92% of cases (S. aureus = 24%), 252 patients (56%) had an embolic events and 68 (15%) had heart failure. The Charlson Median Comorbidity Index (ICC) was 5.0. Two hundred sixteen patients (48%) underwent surgery. The mortality rates at 1 month, 3 months, 6 months, and 1 year were, respectively, 14.1%, 19.0%, 23.2%, and 27.7%. The ICC at inclusion of patients who died at 1 year was 6.0 vs. 4.0 for survivors. Mortality at 1 year was significantly higher in case of HAIE (33% vs. 23%), documented S. aureus IE (39% vs. 24%), exclusive medical treatment (40% vs. 15%), and heart failure (43% vs. 25%).

Conclusion

While the management of IE by an endocarditis team seems to improve the short-term prognosis of IE, 1-year mortality remains high as patients are increasingly older and have severe comorbidities. Our study confirms that early prognostic factors remain in the long term and that the prognosis is better in community-acquired IE with surgery.

Disclosures

All authors: No reported disclosures.

Graft infection after a Bentall procedure: A case series and systematic review of the literature

INTRODUCTION

The Bentall procedure is a cardiac surgery involving graft replacement of the aortic valve, aortic root and ascending aorta. Graft infection after Bentall's procedure (BGI) is infrequent but severe, and often difficult to diagnose and treat.

PATIENTS AND METHODS

A retrospective cohort study was performed using the Bordeaux endocarditis database of adult patients admitted to the Bordeaux University Medical Hospital for BGI between 2008 and 2014. Published case reports were identified in the literature.

RESULTS

We identified 10 BGI patients in the database and 13 in the literature. The majority of infections were late-onset (20/23) and occurred as a result of gram positive cocci bacterial infection (16/22). Detailed diagnoses of the described BGI were determined using echocardiography, computed tomography (CT) and positron emission tomography/CT (PET/CT). Labeled-leukocyte scintigraphy was not reported in any case. Prolonged antibiotic therapy and surgery were found to be the treatment of choice for BGI; however it was not always possible to perform a surgical intervention. Clinical relapses occurred even with a negative PET/CT, while PET/CT consistently positive for BGI occurred in the absence of clinical relapse. This suggests that the use of PET/CT for follow-up is questionable.

CONCLUSION

Diagnosis of BGI is difficult, due to the combination of clinical, biological, and radiological observations obtained through transesophageal echocardiography and CT. PET/CT is an alternative method to diagnosis BGI, but its impact on clinical management remains unclear. Current data suggests that if surgical replacement of the prosthesis is not possible, patients should be treated with prolonged antibiotic therapy.

Intravenous Immunoglobulin as an Immunomodulating Agent in Antineutrophil Cytoplasmic Antibody-Associated Vasculitides: A French Nationwide Study of Ninety-Two Patients

OBJECTIVE

Intravenous immunoglobulin (IVIG) represents a therapeutic alternative in antineutrophil cytoplasmic antibody-associated vasculitides (AAV), but its efficacy has been evaluated in only 2 small prospective trials. The aim of this study was to evaluate the efficacy and safety of IVIG in patients with AAV.

METHODS

We conducted a nationwide retrospective study of patients who received IVIG as immunomodulatory therapy for AAV.

RESULTS

A total of 92 patients (mean age 51 years) presenting with either granulomatosis with polyangiitis (Wegener's) (68%), eosinophilic granulomatosis with polyangiitis (Churg-Strauss) (22%), or microscopic polyangiitis (10%) received at least 1 course of IVIG. Antineutrophil cytoplasmic antibodies were present in 72% during the flare that required IVIG, as determined by immunofluorescence assay. IVIG was initiated because of relapsing disease in 83% of cases. IVIG was given for a median of 6 months (range 1-156 months) and in combination with corticosteroids in 21% of the patients or with other immunosuppressive agents in 77%. Efficacy of IVIG was assessed in the entire population and in a subset of 34 patients with unmodified background therapy. Remission rates at 6 months were 56% in the entire population and 58% in the unmodified background therapy group. Refractory disease and treatment failure at 6 months were observed in 7% and 18% in the whole population and 3% and 21% in the unmodified background therapy group, respectively. Adverse events (AEs) occurred in 33%, including serious AEs in 12% and AEs leading to discontinuation of IVIG in 7%.

CONCLUSION

This large study shows the clinical benefit of IVIG as adjunctive therapy, with an acceptable tolerance profile, and thus supports its use in AAV patients with refractory or relapsing disease.

Seronegative polyarthritis revealing antisynthetase syndrome: a multicentre study of 40 patients

OBJECTIVE

The aim of this study was to determine the frequency and characteristics of antisynthetase syndrome (ASS) revealed by polyarthritis.

METHODS

First we conducted a retrospective single-centre study to assess the frequency of ASS patients who presented with polyarthritis without pulmonary and/or muscle symptoms. Secondly, we conducted a larger, multicentre study in order to describe the clinical characteristics of these patients. Exclusion criteria were the presence of RF, the presence of ACPA and overlap with another CTD.

RESULTS

In the single-centre study, polyarthritis was the first manifestation in 12 of 45 ASS patients (27%). An additional 28 patients were collected for the multicentre study, resulting in a total population of 40 ASS patients who presented with polyarthritis. The mean delay from polyarthritis onset to ASS diagnosis was 27 months (s.d. 40). Pulmonary and muscle symptoms were uncommon at ASS diagnosis (40% and 32.5%, respectively) and were dramatically delayed [mean delay after polyarthritis onset of 41 months (s.d. 53) and 21 months (s.d. 14), respectively]. Mechanic's hands and cutaneous signs of DM occurred in 25% and 22.5%, respectively, with a mean delay of 10 months (s.d. 10) and 31 months (s.d. 21), respectively. When present (32%), RP was the earliest non-articular manifestation [mean delay 3 months (s.d. 23) after polyarthritis onset]. On HEp-2 cells, antinuclear and/or cytoplasmic fluorescence was found in 70% of cases, with specificity for various anti-aminoacyl tRNA synthetase (anti-ARS) antibodies.

CONCLUSION

ASS may be revealed by polyarthritis. To decrease the delay in diagnosis of ASS, pulmonary and muscle symptoms and anti-ARS antibodies might usefully be searched for in seronegative polyarthritis patients, especially in those with RP.