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Kalita J, Mahajan R, Kumar M. Effect of intravenous immunoglobulin and plasmapheresis on nerve conduction parameters compared to the natural course of Guillain-Barré syndrome. J Clin Neurosci 2024; 125:76-82. [PMID: 38759351 DOI: 10.1016/j.jocn.2024.05.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 05/08/2024] [Accepted: 05/10/2024] [Indexed: 05/19/2024]
Abstract
BACKGROUND Intravenous immunoglobulin (IVIg) and plasmapheresis (PLEX) are recommended in moderate to severe Guillain-Barré Syndrome (GBS), but there is paucity of studies evaluating its effect on nerve conduction studies (NCS). We report the effect of IVIg and PLEX on the NCS parameters and clinical outcomes compared to natural course (NC) of GBS patients. METHOD Moderate to severe GBS patients were included based on clinical, cerebrospinal fluid, and NCS finding. Six motor and sensory nerves were evaluated at admission, one month and 3 months, and NCS subtyping was done. Axonal and demyelination burden in motor nerves and early reversible conduction block (ERCB) were noted. Patients receiving IVIg, PLEX or on NC were noted. Outcome was defined at 3 months into complete, partial and poor using a 0-6 GBS Disability Scale (GBSDS). RESULT Seventy-two patients were included, whose median age was 36 years and 22(30.6 %) were females. 44 patients received IVIg, 9 PLEX and 19 were in NC, and they had comparable peak disability. AIDP was the dominant subtype at admission (58.3 %), which remained so at 3 months (50 %). The shift of subtypes was the highest from the equivocal group followed by AMAN and the least from AIDP. IVIg and PLEX group had more reduction in axonal burden and had ERCB compared to NC. 33(44 %) patients had complete recovery, and 40(55.5 %) patients had concordance in clinical and neurophysiological outcome. CONCLUSION Transition of GBS subtype may occur at follow-up from all the subtypes, the highest from the equivocal and the lowest from the AIDP group. IVIg/PLEX treatment may help in reducing conduction block and axonal burden.
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Affiliation(s)
- Jayantee Kalita
- Department of Neurology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh 226014, India.
| | - Roopali Mahajan
- Department of Neurology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh 226014, India
| | - Mritunjai Kumar
- Department of Neurology, AIIMS Rishikesh, Uttarakhand 249203, India
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2
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Santoro JD, Jafarpour S, Khoshnood MM, Boyd NK, Vogel BN, Nguyen L, Saucier LE, Partridge R, Tiongson E, Ramos-Platt L, Nagesh D, Ho E, Rosser T, Ahsan N, Mitchell WG, Rafii MS. Safety and tolerability of intravenous immunoglobulin infusion in Down syndrome regression disorder. Am J Med Genet A 2024; 194:e63524. [PMID: 38169137 DOI: 10.1002/ajmg.a.63524] [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: 10/16/2023] [Revised: 12/06/2023] [Accepted: 12/16/2023] [Indexed: 01/05/2024]
Abstract
Three large multi-center studies have identified the clinical utility of intravenous immunoglobulin (IVIg) in the treatment of Down syndrome regression disorder (DSRD). Yet the tolerability of infusions in individuals with DS and the safety of IVIg remains unknown in this population. This study sought to evaluate the safety and tolerability of IVIg in individuals with DSRD compared to a real-world cohort of individuals with pediatric onset neuroimmunologic disorders. A single-center, retrospective chart review evaluating clinically documented infusion reactions was performed for individuals meeting international consensus criteria for DSRD and having IVIg infusions between 2019 and 2023. Infusion reactions were evaluated for severity and need for alterations in infusion plan. This cohort was compared against an age and sex matched cohort of children with neuroimmunologic conditions who had also received IVIg infusions. In total, 127 individuals with DSRD and 186 individuals with other neuroimmunologic disorders were enrolled. There was no difference in the overall rate of adverse reactions (AEs) between the DSRD and general neuroimmunology cohorts (p = 0.31, 95% CI: 0.80-2.00), but cardiac-related AEs specifically were more common among the DSRD group (p = 0.02, 95% CI: 1.23-17.54). When AEs did occur, there was no difference in frequency of pharmacologic intervention (p = 0.12, 95% CI: 0.34-1.13) or discontinuation of therapy (p = 0.74, 95% CI: 0.06-7.44). There was a higher incidence of lab abnormalities on IVIG among the general neuroimmunology cohort (p = 0.03, 95% CI: 0.24-0.94) compared to the DSRD cohort. Transaminitis was the most common laboratory abnormality in the DSRD group. In a large cohort of individuals with DSRD, there were no significant differences in the safety and tolerability of IVIg compared to a cohort of children and young adults with neuroimmunologic conditions.
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Affiliation(s)
- Jonathan D Santoro
- Division of Neurology, Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, California, USA
- Department of Neurology, Keck School of Medicine of the University of Southern California, Los Angeles, California, USA
| | - Saba Jafarpour
- Division of Neurology, Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, California, USA
| | - Mellad M Khoshnood
- Department of Pediatrics, Los Angeles General Hospital, Los Angeles, California, USA
| | - Natalie K Boyd
- Division of Neurology, Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, California, USA
| | - Benjamin N Vogel
- Division of Neurology, Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, California, USA
| | - Lina Nguyen
- Division of Neurology, Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, California, USA
| | - Laura E Saucier
- Division of Neurology, Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, California, USA
- Department of Neurology, Keck School of Medicine of the University of Southern California, Los Angeles, California, USA
| | | | - Emmanuelle Tiongson
- Division of Neurology, Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, California, USA
- Department of Neurology, Keck School of Medicine of the University of Southern California, Los Angeles, California, USA
| | - Leigh Ramos-Platt
- Division of Neurology, Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, California, USA
- Department of Neurology, Keck School of Medicine of the University of Southern California, Los Angeles, California, USA
| | - Deepti Nagesh
- Division of Neurology, Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, California, USA
- Department of Neurology, Keck School of Medicine of the University of Southern California, Los Angeles, California, USA
| | - Eugenia Ho
- Division of Neurology, Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, California, USA
- Department of Neurology, Keck School of Medicine of the University of Southern California, Los Angeles, California, USA
| | - Tena Rosser
- Division of Neurology, Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, California, USA
- Department of Neurology, Keck School of Medicine of the University of Southern California, Los Angeles, California, USA
| | - Nusrat Ahsan
- Division of Neurology, Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, California, USA
- Department of Neurology, Keck School of Medicine of the University of Southern California, Los Angeles, California, USA
| | - Wendy G Mitchell
- Division of Neurology, Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, California, USA
- Department of Neurology, Keck School of Medicine of the University of Southern California, Los Angeles, California, USA
| | - Michael S Rafii
- Department of Neurology, Keck School of Medicine of the University of Southern California, Los Angeles, California, USA
- Alzheimer's Therapeutic Research Institute, University of Southern California, San Diego, California, USA
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Somasundaram A, Gupta A, Sathishkumar D, Mathew L, George A, Thomas M. Rapid recovery in a child with febrile ulceronecrotic Mucha-Habermann disease following intravenous immunoglobulin administration. Pediatr Dermatol 2024; 41:518-522. [PMID: 38234081 DOI: 10.1111/pde.15516] [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] [Received: 08/21/2023] [Accepted: 12/16/2023] [Indexed: 01/19/2024]
Abstract
Febrile ulceronecrotic Mucha-Habermann disease (FUMHD), a lymphocyte-mediated inflammatory skin disorder, is considered a severe variant of pityriasis lichenoides et varioliformis acuta that can lead to a fatal outcome if not managed in a timely fashion. Children with FUMHD can have systemic complications involving various organs. The scarcity of reported cases and the absence of well-designed studies or randomized clinical trials to evaluate different therapeutic modalities pose a major challenge in treating this potentially life-threatening disorder. We report a five-year-old child with FUMHD and seizures treated unsuccessfully with a combination of systemic steroids, methotrexate, dapsone, and oral erythromycin, who improved rapidly and achieved disease control with just a single infusion of low-dose intravenous immunoglobulin.
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Affiliation(s)
- Arun Somasundaram
- Department of Dermatology, Venereology & Leprosy, Christian Medical College and Hospital, Vellore, India
| | - Ankan Gupta
- Department of Dermatology, Venereology & Leprosy, Christian Medical College and Hospital, Vellore, India
| | - Dharshini Sathishkumar
- Department of Dermatology, Venereology & Leprosy, Christian Medical College and Hospital, Vellore, India
| | - Lydia Mathew
- Department of Dermatology, Venereology & Leprosy, Christian Medical College and Hospital, Vellore, India
| | - Anju George
- Department of Dermatology, Venereology & Leprosy, Christian Medical College and Hospital, Vellore, India
| | - Meera Thomas
- Department of Pathology, Christian Medical College and Hospital, Vellore, India
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Roy S, Vasileiou E, Barreras P, Ahmadi G, Chen H, Suslovic W, Kornbluh A, Kahn I, Sotirchos ES. Longitudinal evaluation of serum MOG-IgG titers in MOGAD after initiation of maintenance immunoglobulin: A case series. Mult Scler 2024; 30:594-599. [PMID: 38018493 DOI: 10.1177/13524585231211119] [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] [Indexed: 11/30/2023]
Abstract
BACKGROUND Myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD) is a distinct demyelinating disease of the central nervous system. Immunoglobulin (Ig) has been used as a maintenance therapy to prevent relapses in MOGAD, but the impact of Ig on serum MOG-IgG titers is unclear. OBJECTIVE To characterize the variation in serum MOG-IgG titers after initiation of Ig treatment in people with MOGAD. METHODS We conducted a retrospective study of 10 patients with a diagnosis of MOGAD and available serum MOG-IgG titers before and after initiation of maintenance Ig treatment. RESULTS We found that most of the patients remained MOG-IgG seropositive while on Ig treatment with a reduced or unchanged titer, despite a lack of disease activity. CONCLUSIONS This case series suggests that the mechanism of action of Ig therapy in MOGAD is not exclusively dependent on MOG-IgG titer reduction.
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Affiliation(s)
- Shuvro Roy
- Department of Neurology, Johns Hopkins University, Baltimore, MD, USA
| | - Eleni Vasileiou
- Department of Neurology, Johns Hopkins University, Baltimore, MD, USA
| | - Paula Barreras
- Department of Neurology, Johns Hopkins University, Baltimore, MD, USA
| | - Gelareh Ahmadi
- Department of Neurology, Johns Hopkins University, Baltimore, MD, USA
| | - Haiwen Chen
- Department of Neurology, Johns Hopkins University, Baltimore, MD, USA
| | - William Suslovic
- Children's National Hospital, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Alexandra Kornbluh
- Children's National Hospital, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Ilana Kahn
- Children's National Hospital, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Elias S Sotirchos
- Department of Neurology, Johns Hopkins University, Baltimore, MD, USA
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Parthan A, Royston M, Thanataveerat A, East EL, Parzynski CS, Habib AA. Burden of illness and costs in patients with myasthenia gravis currently receiving treatment in the United States. Muscle Nerve 2024; 69:157-165. [PMID: 38018505 DOI: 10.1002/mus.27992] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 10/02/2023] [Accepted: 10/04/2023] [Indexed: 11/30/2023]
Abstract
INTRODUCTION/AIMS If myasthenia gravis (MG) symptoms are inadequately controlled, patients may experience exacerbations or life-threatening myasthenic crises. Patients with inadequately controlled MG symptoms tend to be treated with chronic intravenous immunoglobulin (IVIg) therapy and/or multiple immunosuppressant therapies (ISTs). This study aimed to examine disease burden, healthcare resource utilization, and associated costs in these patients. METHODS This was a retrospective observational study using a claims database. Patients with MG were classified into three cohorts based on treatment over a 1-y follow-up period: (a) treated with four or more IVIg episodes (chronic IVIg cohort); (b) received two or more non-steroidal ISTs (NSISTs) sequentially (multiple NSIST cohort); (c) received neither chronic IVIg nor multiple NSISTs (reference cohort). Incidences of crises and exacerbations and annual healthcare costs in each cohort were estimated. RESULTS In total, 3516 patients with MG were included in the analysis. Compared with the reference cohort (n = 2992), the MG crisis rate was approximately twice as high in both the chronic IVIg (n = 324) and multiple NSIST (n = 291) cohorts (p < 0.001); and the MG exacerbation rate was approximately four-fold higher in the chronic IVIg cohort (p < 0.001) and three-fold higher in the multiple NSIST cohort (p < 0.001). Median annual MG-related inflation-adjusted total healthcare costs were higher in the chronic IVIg ($81,900) and multiple NSIST ($30,300) cohorts than in the reference cohort ($2540). DISCUSSION The burden of crises/exacerbations was substantially higher and healthcare costs were considerably greater in patients with MG treated with chronic IVIg or multiple NSISTs than in patients not receiving these treatments.
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Affiliation(s)
- A Parthan
- Alexion, AstraZeneca Rare Disease, Boston, Massachusetts, USA
| | - M Royston
- Alexion, AstraZeneca Rare Disease, Boston, Massachusetts, USA
| | | | - E L East
- Genesis Research Group, Hoboken, New Jersey, USA
| | | | - A A Habib
- University of California, Irvine, California, USA
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Köse S, Sabetsarvestani R, Geçkil E, Kaleci E, Dönmez H. The Experiences of Children with Primary Immunodeficiency Who Receive Immunoglobulin Subcutaneously Instead of Intravenously. J Pediatr Health Care 2024; 38:13-20. [PMID: 37702646 DOI: 10.1016/j.pedhc.2023.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 07/20/2023] [Accepted: 08/08/2023] [Indexed: 09/14/2023]
Abstract
BACKGROUND Children with primary immunodeficiency disorder have begun receiving subcutaneous immunoglobulin (SCIg) instead of intravenous immunoglobulin (IVIg). So, we aim to explore the experiences of primary immunodeficiency children with regard to receiving SCIg instead of IVIg. METHOD We adopted a phenomenological approach in 2022 in Turkey using semi-structured interviews. We recruited 15 participants using the purposive sampling method. RESULTS The main theme was the sweetness and bitterness of living with SCIg. The first subtheme was sweetness (sense of freedom, having a normal life, saving time, ease of use, and feeling better). The second subtheme was bitterness (worries about taking responsibility for injection, impaired body image due to abdominal edema, and minimal tolerable complications). DISCUSSION The results show these children had more sweet experiences than bitter ones. Being flexible in choosing a method, teaching patients to apply it correctly, and providing enough time to cope are as reasons for this.
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Jiang M, Lam L, Kovoor JG, Kimber J, Gupta AK, Stretton B, Goh R, Bacchi S. Intravenous immunoglobulin alteration in response to adverse reactions in neurological conditions: A retrospective cohort study. Transfus Med 2023; 33:478-482. [PMID: 37964154 DOI: 10.1111/tme.13013] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 09/22/2023] [Accepted: 09/26/2023] [Indexed: 11/16/2023]
Abstract
INTRODUCTION Intravenous immunoglobulin (IVIg) is an important treatment in a range of neurological conditions. There is currently limited evidence regarding the frequency and management of IVIg-associated adverse reactions (AR) in neurological disorders. METHODS A single-centre 18-month retrospective cohort study was conducted for all patients at a single tertiary hospital receiving IVIg as an inpatient or the medical day unit. Electronic medical record AR and alerts were reviewed for entries relating to IVIg, and prescribing records associated with recent IVIg administration were reviewed for the use of premedications. Case note review was undertaken to identify AR associated with alterations in IVIg treatment (such as reduction in rate, use of premedications or cessation of IVIg). Demographic, patient, and treatment factors were analysed for associations with AR necessitating alteration in IVIg treatment. RESULTS This study included 98 individuals who received IVIg during the study period. Of these, 12 (12.1%) patients required an alteration in their IVIg treatment. In total, 3 (3.1%) of the 98 included patients required a reduced rate of IVIg, and 10 (10.2%) patients received premedication. The most common premedications were normal saline at the time of the infusion, cetirizine, and hydrocortisone. No demographic factors, indications or comorbidities were found to be associated with an increased likelihood of AR. However, an IVIg daily dose of >35 g and >45 g were associated with an increased likelihood of requiring IVIg treatment alteration due to AR. CONCLUSIONS Alterations to IVIg treatment due to AR are commonly required in neurology patients, and may be associated with higher daily doses of IVIg.
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Affiliation(s)
- Melinda Jiang
- Neurology Department, Royal Adelaide Hospital, Adelaide, South Australia, Australia
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
| | - Lydia Lam
- Neurology Department, Royal Adelaide Hospital, Adelaide, South Australia, Australia
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
| | - Joshua G Kovoor
- Neurology Department, Royal Adelaide Hospital, Adelaide, South Australia, Australia
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
| | - James Kimber
- Neurology Department, Royal Adelaide Hospital, Adelaide, South Australia, Australia
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
| | - Aashray K Gupta
- Neurology Department, Royal Adelaide Hospital, Adelaide, South Australia, Australia
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
| | - Brandon Stretton
- Neurology Department, Royal Adelaide Hospital, Adelaide, South Australia, Australia
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
| | - Rudy Goh
- Neurology Department, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Stephen Bacchi
- Neurology Department, Royal Adelaide Hospital, Adelaide, South Australia, Australia
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
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Abu Jawdeh BG, Smith ML, Hudson MR, Mour GK, Budhiraja P, Rosenthal JL. Case report: JC polyomavirus nephropathy in simultaneous heart-kidney transplantation: the role of viral-specific in situ hybridization staining. Front Med (Lausanne) 2023; 10:1282827. [PMID: 37928458 PMCID: PMC10622943 DOI: 10.3389/fmed.2023.1282827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Accepted: 09/27/2023] [Indexed: 11/07/2023] Open
Abstract
Introduction JC polyomavirus (JCPyV) is a ubiquitous virus that can be latent in the brain and the kidney. It is the etiologic agent responsible for progressive multifocal leukoencephalopathy, a fatal, demyelinating disease of the central nervous system, and rarely causes polyomavirus nephropathy in immunocompromised kidney transplant recipients. Case description We present the first case of JCPyV nephropathy in a simultaneous heart-kidney transplant patient, where viral-specific in situ hybridization staining of the kidney tissue was utilized to confirm the diagnosis. The patient was diagnosed 6 years after simultaneous heart-kidney transplantation and was treated with immunosuppression reduction and intravenous immunoglobulin. Discussion JCPyV nephropathy should be considered in the differential diagnosis of kidney allograft injury, particularly, with suggestive light microscopy histologic features in the absence of BK polyomavirus viremia and/or viruria. In addition to obtaining JCPyV PCR in the blood, in situ hybridization staining may have a utility in confirming the diagnosis. To date, we lack effective JCPyV-specific therapies, and prompt initiation of immunosuppression reduction remains the mainstay of treatment.
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Affiliation(s)
| | - Maxwell L. Smith
- Division of Anatomic Pathology, Mayo Clinic Arizona, Phoenix, AZ, United States
| | | | - Girish K. Mour
- Division of Nephrology, Mayo Clinic Arizona, Phoenix, AZ, United States
| | - Pooja Budhiraja
- Division of Nephrology, Mayo Clinic Arizona, Phoenix, AZ, United States
| | - Julie L. Rosenthal
- Division of Cardiovascular Diseases, Mayo Clinic Arizona, Phoenix, AZ, United States
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Cintas P, Bouhour F, Cauquil C, Masingue M, Tard C, Sacconi S, Delmont E, Choumert A, Chanson JB, Michaud M, Solé G, Cassereau J, Noury JB, Nicolas G, Bellance R, Péréon Y, Camdessanché JP, Magy L, Attarian S. Current clinical management of CIDP with immunoglobulins in France: An expert opinion. Rev Neurol (Paris) 2023; 179:914-922. [PMID: 37019741 DOI: 10.1016/j.neurol.2023.03.010] [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: 09/13/2022] [Revised: 01/05/2023] [Accepted: 03/13/2023] [Indexed: 04/05/2023]
Abstract
Treatment strategies in chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) must be adapted on a case-to-case basis. Validated and reproducible tools for monitoring treatment response are required at diagnosis, when initiating treatment and throughout follow-up. A task force of French neurologists, experts in neuromuscular disease reference centers, was assembled to provide expert advice on the management of typical CIDP with intravenous immunoglobulins (Ig), and to harmonize treatment practices in public and private hospitals. The task force also referred to the practical experience of treating CIDP with Ig at the diagnostic, induction and follow-up stages, including the assessment and management of Ig dependence, and following the recommendations of the French health agency.
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Affiliation(s)
- P Cintas
- Service de neurologie, CHU de Toulouse Purpan, centre de référence de pathologies neuromusculaires, Toulouse, France
| | - F Bouhour
- Service d'ENMG et de pathologies neuromusculaires, hospices civils de Lyon, hôpital neurologique, Lyon, France
| | - C Cauquil
- Service de neurologie, AP-HP Kremlin-Bicêtre, Paris, France
| | - M Masingue
- Service de neuromyologie, centre de référence des maladies neuromusculaires Nord/Est/Île-de-France, AP-HP Pitié-Salpêtrière, Paris, France
| | - C Tard
- Unité d'expertise cognitivo-motrice, U1172, service de neurologie, CHU de Lille, centre de référence des maladies neuromusculaires Nord/Est/Île-de-France, Lille, France
| | - S Sacconi
- Système nerveux périphérique et muscle, CHU de Nice, université Côte d'Azur, Nice, France
| | - E Delmont
- Service de neurologie, centre de référence des maladies neuromusculaires et SLA, hôpital de la Timone, Marseille, France
| | - A Choumert
- Service des maladies neurologiques rares, CHU de la Réunion, groupe hospitalier Sud Réunion, Saint-Pierre, France
| | - J-B Chanson
- Service de neurologie, CHRU Strasbourg, centre de référence neuromusculaire Nord/Est/Île-de-France, Strasbourg, France
| | - M Michaud
- Service de neurologie, CHU de Nancy, hôpital Central, Nancy, France
| | - G Solé
- Service de neurologie et maladies neuromusculaires, CHU de Bordeaux, centre de référence des maladies neuromusculaires AOC, hôpital Pellegrin, Bordeaux, France
| | - J Cassereau
- CHU d'Angers, centre de référence des maladies neuromusculaires AOC, Angers, France
| | - J-B Noury
- Inserm, LBAI, UMR1227, centre de référence des maladies neuromusculaires AOC, CHRU de Brest, Brest, France
| | - G Nicolas
- Service de neurologie, centre de référence neuromusculaire Nord-Est/Île-de-France , Université UVSQ Paris-Saclay, hôpital Raymond-Poincaré, Garches, France
| | - R Bellance
- CeRCa, site constitutif de centre de référence caribéen des maladies neuromusculaires rares, CHU de Martinique, hôpital P. Zobda-Quitman, Fort-de-France, France
| | - Y Péréon
- Explorations fonctionnelles, Filnemus, Euro-NMD, Nantes université, CHU de Nantes, centre de référence AOC, Nantes, France
| | - J-P Camdessanché
- Service de neurologie, CHU de Saint-Étienne, hôpital Nord, Saint-Étienne, France
| | - L Magy
- Service et laboratoire de neurologie, centre de référence neuropathies périphériques rares, NNerf, UR 20218 NeurIT, CHU de Limoges, hôpital Dupuytren, Limoges, France
| | - S Attarian
- Service de neurologie, centre de référence des maladies neuromusculaires et SLA, hôpital de la Timone, Marseille, France.
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Kapoor R, Chandra T, Singh CP, Singh R, Pandey I. Multisystem Inflammatory Syndrome in Children (MIS-C) Related to SARS-CoV-2 and 1-Year Follow-up. Indian J Pediatr 2023; 90:1008-1012. [PMID: 36482236 PMCID: PMC9734509 DOI: 10.1007/s12098-022-04385-9] [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] [Received: 06/09/2022] [Revised: 08/18/2022] [Accepted: 09/12/2022] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To study the demographics, clinical profile, management, outcome and 1-y follow-up of children with multisystem inflammatory syndrome in children (MIS-C). METHODS This was a retrospective observational study of 54 Children satisfying the WHO MIS-C criteria admitted during the study period. RESULTS Fifty-four children were included in the study, median age was 5.5 (IQR 8.75), 68.5% were males. PICU admissions were 77%. Most involved organ was gastrointestinal (92%), followed by cardiovascular 85%, central nervous system (CNS) 74%, respiratory 72%, mucocutaneous 59%, and renal 31%, and hypotension was the presenting symptom in 43%. Coronary artery dilatation was seen in 1 (1.8%) child. All patients presented with more than three organs involvement. Raised procalcitonin was seen in 100%, raised BNP in 31.5%, low ejection fraction in 83.3%, and abnormal radiograph in 59%. All children were positive for anti-SARS-CoV-2 antibodies and negative for cultures. Methylprednisolone or intravenous immunoglobulin (IVIg) was used in 77%, mechanical ventilation in 18.5%, and inotropic support in 77%. Aspirin was used in 48% and low molecular weight heparin (LMWH) in 54%. The median stay in hospital was 7 d (IQR 2). There was 1 mortality (1.8%). On 7-d follow-up, 98% children had a normal echocardiography; on 6 mo and 1-y follow-up, all children had normal echocardiography. CONCLUSION MIS-C is an important complication of COVID-19 infection. Cardiac involvement resolves completely. Coronary artery involvement is not common.
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Affiliation(s)
- Rashmi Kapoor
- Department of Pediatrics, Regency Hospital, A-2, Sarvodaya Nagar, Kanpur, Uttar Pradesh, 208005, India.
| | - Tarun Chandra
- Department of Pediatrics, Regency Hospital, A-2, Sarvodaya Nagar, Kanpur, Uttar Pradesh, 208005, India
| | - Chandra Prakash Singh
- Department of Pediatrics, Regency Hospital, A-2, Sarvodaya Nagar, Kanpur, Uttar Pradesh, 208005, India
| | - Ruchira Singh
- Department of Pediatrics, Regency Hospital, A-2, Sarvodaya Nagar, Kanpur, Uttar Pradesh, 208005, India
| | - Ishita Pandey
- Department of Pediatrics, Regency Hospital, A-2, Sarvodaya Nagar, Kanpur, Uttar Pradesh, 208005, India
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Papadopoulos VE, Papadimas GK, Androudi S, Anagnostouli M, Evangelopoulos ME. Stiff-Leg Syndrome Associated with Autoimmune Retinopathy and Its Treatment with IVIg-A Case Report and Review of the Literature. Brain Sci 2023; 13:1361. [PMID: 37891730 PMCID: PMC10605544 DOI: 10.3390/brainsci13101361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 09/17/2023] [Accepted: 09/20/2023] [Indexed: 10/29/2023] Open
Abstract
Antibodies to glutamic acid decarboxylase (GAD) have been predominantly associated with stiff-person syndrome (SPS), which is often accompanied by organ-specific autoimmune diseases, such as late-onset type 1 diabetes. Autoimmune retinal pathology in SPS has recently been suggested to coexist in patients suffering from this disease; however, evidence reporting potential treatment options for the neurological and visual symptoms these patients experience remains scarce. We provide a review of the relevant literature, presenting a rare case of a middle-aged woman with autoimmune retinopathy (AIR) followed by stiff-leg syndrome who responded to intravenous immune globulin treatment (IVIg). Our report adds to previously reported data supporting the efficacy of IVIg in SPS spectrum disorders while also proposing the potential effect of IVIg in treating SPS spectrum patients with coexisting AIR.
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Affiliation(s)
- Vassilis E Papadopoulos
- First Department of Neurology, School of Medicine, Eginition Hospital, National and Kapodistrian University of Athens, 11528 Athens, Greece
| | - George K Papadimas
- First Department of Neurology, School of Medicine, Eginition Hospital, National and Kapodistrian University of Athens, 11528 Athens, Greece
| | - Sofia Androudi
- Department of Ophthalmology, University of Thessaly, 41110 Larissa, Greece
| | - Maria Anagnostouli
- First Department of Neurology, School of Medicine, Eginition Hospital, National and Kapodistrian University of Athens, 11528 Athens, Greece
| | - Maria-Eleftheria Evangelopoulos
- First Department of Neurology, School of Medicine, Eginition Hospital, National and Kapodistrian University of Athens, 11528 Athens, Greece
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Lasek-Bal A, Wagner-Kusz A, Rogoż B, Cisowska-Babraj M, Gajewska G. Efficacy and Safety of Intravenous Immunoglobulin Treatment in Selected Neurological Diseases-One Centre's Experience Based on the Therapy of 141 Patients. J Clin Med 2023; 12:5983. [PMID: 37762922 PMCID: PMC10531894 DOI: 10.3390/jcm12185983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 08/28/2023] [Accepted: 09/10/2023] [Indexed: 09/29/2023] Open
Abstract
BACKGROUND Intravenous immunoglobulins (IVIg) are the first-choice drugs for the treatment of certain neuroimmune diseases. The aim of this study was to evaluate the efficacy and safety of IVIg in patients with selected nervous system diseases. METHODS The study enrolled patients who received IVIg in programmes financed by the National Health Fund in Poland. The status of patients upon inclusion and during treatment was assessed using scales dedicated to specific neurological diseases. RESULTS The study enrolled 141 patients aged 56.28 ± 14.72 (51.77% female): 21 patients with myasthenia gravis (MG), 65 with chronic inflammatory demyelinating polyneuropathy (CIDP), 30 with Guillain-Barré syndrome (GBS), 12 with neuromyelitis optica spectrum disorder (NMOSD) and 13 patients with autoimmune encephalitis (AE). Neurological improvement was found in 14 (66.66%) MG patients (with a reduction of at least three points on the Quantitative Myasthenia Gravis Score (QMGS) within 14 days from the completion of the cycle), and in 34 (52.3%) GBS patients (with a reduction of at least one point on the Medical Research Council Scale within 14 days from the completion of the cycle). The parameters with the strongest effect on clinical improvement in MG patients were age [OR 1.033, CI 95% [0.09-1.09], p = 0.049] and baseline QMGS [OR 0.505; CI 95% [0.24-0.87], p = 0.038]. In the majority of CIDP patients (27, 97%) and NMOSD patients (6, 50%), neurological stabilisation was observed (without clinical improvement, defined for CIDP patients as an increase of at least two points on the Lovett Scale after three courses of IVIg were administered, and for NMOSD patients as an increase of at least one point on the Medical Research Council Scale and/or a shift of at least 0.3 logMAR after three courses of treatment). Deep-vein thrombosis was only one serious adverse event in the total group of patients treated with IVIg. CONCLUSIONS The use of IVIg in patients with MG and GBS mostly results in neurological improvement, while in patients with NMOSD and CIDP, it mostly results in disease stabilisation. This could indicate the predominant anti-idiotypic antibody activity of IVIg in acute neuroimmune diseases or during exacerbations in chronic autoimmune diseases. The therapy of AE in comorbid neoplastic disease is burdened with an elevated risk of failure for IVIg. The results of our study confirm the improved safety of IVIg for selected neurological diseases.
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Affiliation(s)
- Anetta Lasek-Bal
- Department of Neurology, School of Health Sciences, Medical University of Silesia in Katowice, Ziołowa Str. 45/47, 40-735 Katowice, Poland;
- Department of Neurology, Upper-Silesian Medical Centre of the Silesian Medical University in Katowice, 40-735 Katowice, Poland; (B.R.); (M.C.-B.); (G.G.)
| | - Anna Wagner-Kusz
- Department of Neurology, School of Health Sciences, Medical University of Silesia in Katowice, Ziołowa Str. 45/47, 40-735 Katowice, Poland;
- Department of Neurology, Upper-Silesian Medical Centre of the Silesian Medical University in Katowice, 40-735 Katowice, Poland; (B.R.); (M.C.-B.); (G.G.)
| | - Barbara Rogoż
- Department of Neurology, Upper-Silesian Medical Centre of the Silesian Medical University in Katowice, 40-735 Katowice, Poland; (B.R.); (M.C.-B.); (G.G.)
| | - Małgorzata Cisowska-Babraj
- Department of Neurology, Upper-Silesian Medical Centre of the Silesian Medical University in Katowice, 40-735 Katowice, Poland; (B.R.); (M.C.-B.); (G.G.)
| | - Gabriela Gajewska
- Department of Neurology, Upper-Silesian Medical Centre of the Silesian Medical University in Katowice, 40-735 Katowice, Poland; (B.R.); (M.C.-B.); (G.G.)
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13
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Koc AS, Can O, Kobak S. Atezolizumab Lung Toxicity and Importance of Combination Treatment: A Case Report. Curr Drug Saf 2023; 18:CDS-EPUB-134021. [PMID: 37622710 DOI: 10.2174/1574886318666230824155341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Revised: 06/26/2023] [Accepted: 07/19/2023] [Indexed: 08/26/2023]
Abstract
BACKGROUND Lung cancer is one of the most common and mortal cancers worldwide. According to pathological and clinical groups, treatments vary, and a tailored approach is considered. Adjuvant therapies, such as chemotherapy, radiation, and immune checkpoint inhibitors (ICI), are recommended by recent guidelines for patients with locally advanced cancer. OBJECTIVE This study aimed to report the case of a patient with stage 2B squamous cell lung carcinoma who was managed for pulmonary toxicity after receiving adjuvant chemotherapy and atezolizumab treatment. CASE REPORT A 66-year-old male patient received chemotherapy and immunotherapy after surgery for squamous cell lung cancer. A diagnosis of atezolizumab-associated pneumonitis was made using laboratory tests and imaging due to the patient's worsening dyspnea after treatment. Due to the patient's rapid progression, pulse steroid and MMF therapy were administered concurrently. When Klebsiella pneumoniae growth was detected in the sputum culture during the follow-up, IVIg was used to supplement the medication. The patient showed significant clinical and radiological improvement. CONCLUSION In this study, we present an atezolizumab-induced pneumonitis case of a squamous cell lung cancer patient. It may be life-saving not to avoid aggressive treatment approaches by combining the steps of guideline recommendations in patients with rapidly progressive pneumonitis.
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Affiliation(s)
- Aysu Sinem Koc
- Istinye University, Faculty of Medicine, Pulmonology Department, Istanbul, Turkey
| | - Orcun Can
- Istinye University, Faculty of Medicine, Medical Oncology Department , Istanbul , Turkey
| | - Senol Kobak
- Istinye University, Faculty of Medicine, Rheumatology Department , Istanbul, Turkey
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Schmugge M, Franzoso FD, Winkler J, Kroiss S, Seiler M, Speer O, Rand ML. IVIg treatment increases thrombin activation of platelets and thrombin generation in paediatric patients with immune thrombocytopenia. Br J Haematol 2023; 201:1209-1219. [PMID: 36861460 DOI: 10.1111/bjh.18702] [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: 06/20/2022] [Revised: 01/30/2023] [Accepted: 02/06/2023] [Indexed: 03/03/2023]
Abstract
Clinical manifestations and laboratory parameters of haemostasis were investigated in 23 children with newly diagnosed immune thrombocytopenia (ITP) before and after intravenous immunoglobulin (IVIg) treatment. ITP patients with platelet counts of less than 20 × 109 /L and mild bleeding symptoms, graded by a standardized bleeding score (BS), were compared with healthy children with normal platelet counts and children with chemotherapy-related thrombocytopenia. Markers of platelet activation and platelet apoptosis in the absence and presence of platelet activators were analysed by flow cytometry; thrombin generation in plasma was determined. ITP patients at diagnosis presented with increased proportions of platelets expressing CD62P and CD63 and activated caspases, and with decreased thrombin generation. Thrombin-induced activation of platelets was reduced in ITP compared with controls, while increased proportions of platelets with activated caspases were observed. Children with a higher BS had lower proportions of CD62P-expressing platelets compared with those with a lower BS. IVIg treatment increased the number of reticulated platelets, the platelet count to more than 20 × 109 /L and improved bleeding in all patients. Decreased thrombin-induced platelet activation, as well as thrombin generation, were ameliorated. Our results indicate that IVIg treatment helps to counteract diminished platelet function and coagulation in children with newly diagnosed ITP.
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Affiliation(s)
- Markus Schmugge
- Division of Hematology, Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland
| | - Francesca Daniela Franzoso
- Division of Hematology, Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland
| | - Jeannine Winkler
- Division of Hematology, Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland
| | - Sabine Kroiss
- Division of Hematology Oncology, Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland
| | - Monika Seiler
- Division of Hematology Emergency Department, Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland
| | - Oliver Speer
- Center for Laboratory Medicine, Center for Laboratory Medicine, St. Gallen, Switzerland
| | - Margaret L Rand
- Division of Haematology/Oncology, Translational Medicine, Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
- Departments of Laboratory Medicine & Pathobiology, Biochemistry, and Paediatrics, University of Toronto, Toronto, Ontario, Canada
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15
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Hudemann C, Hoffmann J, Schmidt E, Hertl M, Eming R. T Regulatory Cell-Associated Tolerance Induction by High-Dose Immunoglobulins in an HLA-Transgenic Mouse Model of Pemphigus. Cells 2023; 12:cells12091340. [PMID: 37174740 PMCID: PMC10177252 DOI: 10.3390/cells12091340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 05/04/2023] [Accepted: 05/05/2023] [Indexed: 05/15/2023] Open
Abstract
Pemphigus vulgaris (PV) is a potentially lethal autoimmune bullous skin disorder caused by IgG autoantibodies against desmoglein 3 (Dsg3) and Dsg1. During the last three decades, high-dose intravenous immunoglobulins (IVIgs) have been applied as an effective and relatively safe treatment regime in severe, therapy-refractory PV. This prompted us to study T- and B- cell polarization by IVIg in a human-Dsg3-dependent mouse model for PV. Using humanized mice transgenic for HLA-DRB1*04:02, which is a highly prevalent haplotype in PV, we employed IVIg in two different experimental approaches: in prevention and quasi-therapeutic settings. Our data show that intraperitoneally applied IVIg was systemically distributed for up to 42 days or longer. IVIg-treated Dsg3-immunized mice exhibited, in contrast to Dsg3-immunized mice without IVIg, significantly less Dsg3-specific IgG, and showed induction of T regulatory cells in lymphatic tissue. Ex vivo splenocyte analysis upon Dsg3-specific stimulation revealed an initial, temporarily reduced antigen-induced cell proliferation, as well as IFN-γ secretion that became less apparent over the course of time. Marginal-zone B cells were initially reduced in the preventive approach but re-expanded over time. In contrast, in the quasi-therapeutic approach, a robust down-regulation in both spleen and lymph nodes was observed. We found a significant down-regulation of the immature transitional 1 (T1) B cells in IVIg-treated mice in the quasi-therapeutic approach, while T2 and T3, representing a healthy stage of B-cell development, appeared to be up-regulated by IVIg. In summary, in two experimental settings employing an active PV mouse model, we demonstrate distinct alterations of T- and B-cell populations upon IVIg treatment, compatible with a tolerance-associated polarization in lymphatic tissue. Our data suggest that the clinical efficacy of IVIg is at least modulated by distinct alterations of T- and B-cell populations compatible with a tolerance-associated polarization in lymphatic tissue.
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Affiliation(s)
- Christoph Hudemann
- Department of Dermatology and Allergology, Philipps-University Marburg, 35037 Marburg, Germany
| | - Jochen Hoffmann
- Department of Dermatology, University of Heidelberg, 69117 Heidelberg, Germany
| | - Enno Schmidt
- Department of Dermatology, University of Lübeck, 23562 Lübeck, Germany
- Lübeck Institute of Experimental Dermatology (LIED), University of Lübeck, 23562 Lübeck, Germany
| | - Michael Hertl
- Department of Dermatology and Allergology, Philipps-University Marburg, 35037 Marburg, Germany
| | - Rüdiger Eming
- Department of Dermatology and Allergology, Philipps-University Marburg, 35037 Marburg, Germany
- Department of Dermatology, Venerology and Allergology, German Armed Forces Central Hospital Koblenz, 56072 Koblenz, Germany
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Sarıkaya Uzan G, Vural A, Yüksel D, Aksoy E, Öztoprak Ü, Canpolat M, Öztürk S, Yıldırım Ç, Güleç A, Per H, Gümüş H, Okuyaz Ç, Çobanoğulları Direk M, Kömür M, Ünalp A, Yılmaz Ü, Bektaş Ö, Teber S, Aliyeva N, Olgaç Dündar N, Gençpınar P, Gürkaş E, Keskin Yılmaz S, Kanmaz S, Tekgül H, Aksoy A, Öz Tuncer G, Acar Arslan E, Tosun A, Ayanoğlu M, Kızılırmak AB, Yousefi M, Bodur M, Ünay B, Hız Kurul S, Yiş U. Pediatric-Onset Chronic Inflammatory Demyelinating Polyneuropathy: A Multicenter Study. Pediatr Neurol 2023; 145:3-10. [PMID: 37245275 DOI: 10.1016/j.pediatrneurol.2023.04.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Revised: 03/31/2023] [Accepted: 04/22/2023] [Indexed: 05/30/2023]
Abstract
BACKGROUND To evaluate the clinical features, demographic features, and treatment modalities of pediatric-onset chronic inflammatory demyelinating polyneuropathy (CIDP) in Turkey. METHODS The clinical data of patients between January 2010 and December 2021 were reviewed retrospectively. The patients were evaluated according to the Joint Task Force of the European Federation of Neurological Societies and the Peripheral Nerve Society Guideline on the management of CIDP (2021). In addition, patients with typical CIDP were divided into two groups according to the first-line treatment modalities (group 1: IVIg only, group 2: IVIg + steroid). The patients were further divided into two separate groups based on their magnetic resonance imaging (MRI) characteristics. RESULTS A total of 43 patients, 22 (51.2%) males and 21 (48.8%) females, were included in the study. There was a significant difference between pretreatment and post-treatment modified Rankin scale (mRS) scores (P < 0.05) of all patients. First-line treatments include intravenous immunoglobulin (IVIg) (n = 19, 44.2%), IVIg + steroids (n = 20, 46.5%), steroids (n = 1, 2.3%), IVIg + steroids + plasmapheresis (n = 1, 2.3%), and IVIg + plasmapheresis (n = 1, 2.3%). Alternative agent therapy consisted of azathioprine (n = 5), rituximab (n = 1), and azathioprine + mycophenolate mofetil + methotrexate (n = 1). There was no difference between the pretreatment and post-treatment mRS scores of groups 1 and 2 (P > 0.05); however, a significant decrease was found in the mRS scores of both groups with treatment (P < 0.05). The patients with abnormal MRI had significantly higher pretreatment mRS scores compared with the group with normal MRI (P < 0.05). CONCLUSIONS This multicenter study demonstrated that first-line immunotherapy modalities (IVIg vs IVIg + steroids) had equal efficacy for the treatment of patients with CIDP. We also determined that MRI features might be associated with profound clinical features, but did not affect treatment response.
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Affiliation(s)
- Gamze Sarıkaya Uzan
- Division of Child Neurology, Department of Pediatrics, Dokuz Eylül University Faculty of Medicine, İzmir, Turkey.
| | - Atay Vural
- Koç University Research Center for Translational Medicine (KUTTAM), İstanbul, Turkey; Department of Neurology, Koç University School of Medicine, İstanbul, Turkey
| | - Deniz Yüksel
- Faculty of Medicine, Department of Pediatric Neurology, Dr. Sami Ulus Maternity Child Health and Diseases Training and Research Hospital, University of Health Sciences, Ankara, Turkey
| | - Erhan Aksoy
- Faculty of Medicine, Department of Pediatric Neurology, Dr. Sami Ulus Maternity Child Health and Diseases Training and Research Hospital, University of Health Sciences, Ankara, Turkey
| | - Ülkühan Öztoprak
- Faculty of Medicine, Department of Pediatric Neurology, Dr. Sami Ulus Maternity Child Health and Diseases Training and Research Hospital, University of Health Sciences, Ankara, Turkey
| | - Mehmet Canpolat
- Division of Child Neurology, Department of Pediatrics, Erciyes University Faculty of Medicine, Kayseri, Turkey
| | - Selcan Öztürk
- Division of Child Neurology, Department of Pediatrics, Erciyes University Faculty of Medicine, Kayseri, Turkey
| | - Çelebi Yıldırım
- Department of Pediatrics, Erciyes University Faculty of Medicine, Kayseri, Turkey
| | - Ayten Güleç
- Division of Child Neurology, Department of Pediatrics, Erciyes University Faculty of Medicine, Kayseri, Turkey
| | - Hüseyin Per
- Division of Child Neurology, Department of Pediatrics, Erciyes University Faculty of Medicine, Kayseri, Turkey
| | - Hakan Gümüş
- Division of Child Neurology, Department of Pediatrics, Erciyes University Faculty of Medicine, Kayseri, Turkey
| | - Çetin Okuyaz
- Division of Child Neurology, Department of Pediatrics, Mersin University Faculty of Medicine, Mersin, Turkey
| | - Meltem Çobanoğulları Direk
- Division of Child Neurology, Department of Pediatrics, Mersin University Faculty of Medicine, Mersin, Turkey
| | - Mustafa Kömür
- Division of Child Neurology, Department of Pediatrics, Mersin University Faculty of Medicine, Mersin, Turkey
| | - Aycan Ünalp
- Division of Pediatric Neurology, Department of Pediatrics, University of Health Sciences Dr. Behçet Uz Child Disease and Pediatric Surgery Training and Research Hospital, Izmir, Turkey
| | - Ünsal Yılmaz
- Division of Pediatric Neurology, Department of Pediatrics, University of Health Sciences Dr. Behçet Uz Child Disease and Pediatric Surgery Training and Research Hospital, Izmir, Turkey
| | - Ömer Bektaş
- Division of Child Neurology, Department of Pediatrics, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Serap Teber
- Division of Child Neurology, Department of Pediatrics, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Nargiz Aliyeva
- Division of Pediatric Neurology, Department of Pediatrics, University of Health Sciences Tepecik Research and Training Hospital, İzmir, Turkey
| | - Nihal Olgaç Dündar
- Division of Child Neurology, Department of Pediatrics, İzmir Katip Çelebi University Faculty of Medicine, İzmir, Turkey
| | - Pınar Gençpınar
- Division of Child Neurology, Department of Pediatrics, İzmir Katip Çelebi University Faculty of Medicine, İzmir, Turkey
| | - Esra Gürkaş
- Department of Pediatric Neurology, Children's Hospital, Ankara City Hospital, Ankara, Turkey
| | - Sanem Keskin Yılmaz
- Division of Child Neurology, Department of Pediatrics, Ege University Faculty of Medicine, İzmir, Turkey
| | - Seda Kanmaz
- Division of Child Neurology, Department of Pediatrics, Ege University Faculty of Medicine, İzmir, Turkey
| | - Hasan Tekgül
- Division of Child Neurology, Department of Pediatrics, Ege University Faculty of Medicine, İzmir, Turkey
| | - Ayşe Aksoy
- Division of Child Neurology, Department of Pediatrics, On Dokuz Mayıs University Faculty of Medicine, Samsun, Turkey
| | - Gökçen Öz Tuncer
- Division of Child Neurology, Department of Pediatrics, On Dokuz Mayıs University Faculty of Medicine, Samsun, Turkey
| | - Elif Acar Arslan
- Division of Child Neurology, Department of Pediatrics, Karadeniz Technical University Faculty of Medicine, Trabzon, Turkey
| | - Ayşe Tosun
- Division of Child Neurology, Department of Pediatrics, Adnan Menderes University Faculty of Medicine, Aydın, Turkey
| | - Müge Ayanoğlu
- Division of Child Neurology, Department of Pediatrics, Adnan Menderes University Faculty of Medicine, Aydın, Turkey
| | - Ali Burak Kızılırmak
- Koç University Research Center for Translational Medicine (KUTTAM), İstanbul, Turkey
| | - Mohammadreza Yousefi
- Koç University Research Center for Translational Medicine (KUTTAM), İstanbul, Turkey
| | - Muhittin Bodur
- Division of Child Neurology, Department of Pediatrics, Uludağ University Faculty of Medicine, Bursa, Turkey
| | - Bülent Ünay
- Gülhane Faculty of Medicine, Department of Pediatric Neurology, University of Health Sciences, Ankara, Turkey
| | - Semra Hız Kurul
- Division of Child Neurology, Department of Pediatrics, Dokuz Eylül University Faculty of Medicine, İzmir, Turkey
| | - Uluç Yiş
- Division of Child Neurology, Department of Pediatrics, Dokuz Eylül University Faculty of Medicine, İzmir, Turkey
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Silsby M, Fois AF, Yiannikas C, Ng K, Kiernan MC, Fung VSC, Vucic S. Chronic inflammatory demyelinating polyradiculoneuropathy-associated tremor: Phenotype and pathogenesis. Eur J Neurol 2023; 30:1059-1068. [PMID: 36692234 DOI: 10.1111/ene.15693] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [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: 11/04/2022] [Revised: 12/16/2022] [Accepted: 12/29/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND AND PURPOSE Tremor in chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) is underrecognized, and the pathophysiology remains incompletely understood. This study evaluated tremor in CIDP and tested the hypothesis, established in other demyelinating neuropathies, that tremor occurs due to mistimed peripheral inputs affecting central motor processing. Additionally, the tremor stability index (TSI) was calculated with the hypothesis that CIDP-related tremor is more variable than other tremor disorders. METHODS Consecutive patients with typical CIDP were prospectively recruited from neuromuscular clinics. Alternative causes of neuropathy and tremor were excluded. Cross-sectional clinical assessment and extensive tremor study recordings were undertaken. Pearson correlation coefficient was used to compare nerve conduction studies and tremor characteristics, and t-test was used for comparisons between groups. RESULTS Twenty-four patients with CIDP were included. Upper limb postural and action tremor was present in 66% and was mild according to the Essential Tremor Rating Assessment Scale. Tremor did not significantly impact disability. Surface electromyography (EMG) found high-frequency spectral peaks in deltoid (13.73 ± 0.66 Hz), biceps brachii (11.82 ± 0.91 Hz), and extensor carpi radialis (11.87 ± 0.91 Hz) muscles, with lower peaks in abductor pollicis brevis EMG (6.07 ± 0.45 Hz) and index finger accelerometry (6.53 ± 0.42 Hz). Tremor was unchanged by weight loading but correlated with ulnar nerve F-wave latency and median nerve sensory amplitude. TSI (2.3 ± 0.1) was significantly higher than essential tremor. CONCLUSIONS Postural tremor is a common feature in CIDP. Tremor was unaffected by weight loading, typical of centrally generated tremors, although there was a correlation with peripheral nerve abnormalities. The high beat-to-beat variability on TSI and gradation of peak frequencies further suggest a complex pathophysiology. These findings may assist clinicians with the diagnosis of neuropathic tremor.
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Affiliation(s)
- Matthew Silsby
- Neurology Department, Westmead Hospital, Sydney, New South Wales, Australia
- Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
- Brain and Nerve Research Centre, University of Sydney, Sydney, New South Wales, Australia
- Neurology Department, Concord Hospital, Sydney, New South Wales, Australia
| | - Alessandro F Fois
- Neurology Department, Westmead Hospital, Sydney, New South Wales, Australia
- Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Con Yiannikas
- Neurology Department, Concord Hospital, Sydney, New South Wales, Australia
- Neurology Department, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Karl Ng
- Neurology Department, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Matthew C Kiernan
- Neurology Department, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Brain and Mind Research Centre, University of Sydney, Sydney, New South Wales, Australia
| | - Victor S C Fung
- Neurology Department, Westmead Hospital, Sydney, New South Wales, Australia
- Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Steve Vucic
- Brain and Nerve Research Centre, University of Sydney, Sydney, New South Wales, Australia
- Neurology Department, Concord Hospital, Sydney, New South Wales, Australia
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Tran A, Marcon K, Zamar D, Mi J, Shad J, Zheng J, Nicolson H, Onell R, Shih AW. Evaluation of immunoglobulin replacement therapy in secondary immunodeficiency at three British Columbia hospitals. Vox Sang 2023; 118:272-280. [PMID: 36717380 DOI: 10.1111/vox.13404] [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: 08/17/2022] [Revised: 01/01/2023] [Accepted: 01/02/2023] [Indexed: 02/01/2023]
Abstract
BACKGROUND AND OBJECTIVES Immunoglobulin (Ig) usage has ongoing shortage concerns. Secondary immunodeficiencies (SIDs) account for a major proportion of usage of Igs in Canada. We audited Ig usage in patients with SID at three British Columbia hospitals to determine whether more stringent local guidelines are necessary. MATERIALS AND METHODS A retrospective chart review was performed for patients who had Ig ordered between 1 January 2018 and 31 December 2019 for any SID indication. Cohorts were stratified into chronic and new users, and the Australian BloodSTAR guidelines were used as the benchmark at the time of conception. Having an eligible primary diagnosis, meeting SID criteria, an appropriate dosage and follow-up immunoglobulin G (IgG) levels encompassed appropriate usage. RESULTS There were no demographic differences between chronic (N = 81) and new (N = 33) cohorts. The new cohort had a higher rate of appropriate usage (45.7% vs. 66.7%, p = 0.06). The most common reason for inappropriate usage in both groups was the lack of follow-up IgG level at 6 or 12 months. Factors, displayed by relative risk (RR), associated with appropriateness included the dispensing hospital (RR: 6.60), use of subcutaneous Ig (RR: 3.84), having an IgG level before starting therapy (RR: 3.51) and documentation of clinical benefit (RR: 4.70). CONCLUSION There are high rates of inappropriate Ig usage in SID patients in both new and chronically treated groups. More stringent local guidelines and processes for assessing initial and ongoing Ig replacement are warranted.
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Affiliation(s)
- Ann Tran
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, Canada
| | - Krista Marcon
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, Canada
- Department of Pathology and Laboratory Medicine, Vancouver Coastal Health Authority, Vancouver, Canada
| | - David Zamar
- School of Population and Public Health, University of British Columbia, Vancouver, Canada
| | - Jian Mi
- Department of Pathology and Laboratory Medicine, Vancouver Coastal Health Authority, Vancouver, Canada
| | - Jodi Shad
- Department of Pathology and Laboratory Medicine, Providence Healthcare, Vancouver, Canada
| | - Joey Zheng
- Faculty of Science, University of British Columbia, Vancouver, Canada
| | - Hamish Nicolson
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, Canada
- Department of Pathology and Laboratory Medicine, Providence Healthcare, Vancouver, Canada
| | - Rodrigo Onell
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, Canada
- Department of Pathology and Laboratory Medicine, Providence Healthcare, Vancouver, Canada
| | - Andrew W Shih
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, Canada
- Department of Pathology and Laboratory Medicine, Vancouver Coastal Health Authority, Vancouver, Canada
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Mahic M, Bozorg A, Rudnik J, Zaremba P, Scowcroft A. Treatment patterns in myasthenia gravis: A United States health claims analysis. Muscle Nerve 2023; 67:297-305. [PMID: 36721910 DOI: 10.1002/mus.27791] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Revised: 01/19/2023] [Accepted: 01/22/2023] [Indexed: 02/02/2023]
Abstract
INTRODUCTION/AIMS Limited knowledge exists on treatment patterns in clinical practice in patients with myasthenia gravis (MG). In this study we examined MG treatment patterns in the United States. METHODS Adult patients newly diagnosed with MG were identified from the IBM MarketScan insurance claims database. Patients with ≥2 MG International Classification of Disease diagnosis codes ≥3 months apart were retrospectively followed from the date of their first MG diagnosis record or start of treatment with acetylcholinesterase inhibitors (AChEI), intravenous (IV) or subcutaneous (SC) immunoglobulin (Ig), or plasma exchange (PLEx) therapy. Based on treatment received at any time during the follow-up period, patients were segmented into six main treatment cohorts. Exacerbations and use of IVIg, SCIg, or PLEx after the index date were identified. RESULTS During 2010 to 2019, 7,194 patients were followed for up to 10 (median, 2.3) years. Of 6,539 treated patients, 6,462 (99%) were ever treated with AChEI and/or corticosteroids (CS); 95% were first treated with AChEI and/or CS only; 33% received ≥1 nonsteroid immunosuppressive treatment (IST) and 2% received a biologic. During treatment with first IST (n = 2,166), patients experienced 42% and 94% higher incidence rates of exacerbations and IVIg, respectively, compared with AChEI and/or CS (n = 6,242), and 33% and 23% higher, respectively, compared with a second IST (n = 353). DISCUSSION Many patients experienced exacerbations and received rescue therapy despite treatment, suggesting current treatments may not provide adequate disease control for some patients and that additional treatment options should be explored.
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Affiliation(s)
- Milada Mahic
- Global Real World Evidence, UCB Pharma, Slough, UK
| | - Ali Bozorg
- Clinical Development, UCB Pharma, Morrisville, North Carolina, USA
| | - Jan Rudnik
- Real World Data Analytics Team, UCB Pharma, Warszawa, Poland
| | - Piotr Zaremba
- Real World Data Analytics Team, UCB Pharma, Katowice, Poland
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20
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Sasaki R, Yunoki T, Nakano Y, Fukui Y, Takemoto M, Morihara R, Katsuyama E, Nishino I, Yamashita T. A young female case of asymptomatic immune-mediated necrotizing myopathy: a potential diagnostic option of antibody testing for rhabdomyolysis. Neuromuscul Disord 2023; 33:183-186. [PMID: 36652875 DOI: 10.1016/j.nmd.2022.12.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 12/09/2022] [Accepted: 12/22/2022] [Indexed: 12/25/2022]
Abstract
Anti-3-hydroxy-3-methylglutaryl-coenzyme A reductase (HMGCR) immune-mediated necrotizing myopathy (IMNM) is a neuromuscular disorder that presents muscle weakness in proximal extremities and/or the trunk with an elevation of creatine kinase (CK). Young and asymptomatic anti-HMGCR IMNM patients are very rare and a treatment regimen has not been established. The present case, a 17-year-old woman without any muscular symptoms, only showed hyperCKemia that was detected by chance. After close examinations, including a muscle biopsy and antibody search, she was diagnosed as anti-HMGCR IMNM, and initial treatment with methotrexate and continuous intravenous immunoglobulin seemed to be effective. The present case is the unusually young asymptomatic case of anti-HMGCR IMNM. The diagnosis was successfully made, leading to the early introduction of a treatment. Given the course of this case, we believe that the preceding antibody testing is one of the diagnostic option for rhabdomyolysis.
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Affiliation(s)
- Ryo Sasaki
- Department of Neurology, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, 2-5-1 Shikata-cho, Kita-ku, Okayama 700-8558, Japan
| | - Taijun Yunoki
- Department of Neurology, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, 2-5-1 Shikata-cho, Kita-ku, Okayama 700-8558, Japan
| | - Yumiko Nakano
- Department of Neurology, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, 2-5-1 Shikata-cho, Kita-ku, Okayama 700-8558, Japan
| | - Yusuke Fukui
- Department of Neurology, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, 2-5-1 Shikata-cho, Kita-ku, Okayama 700-8558, Japan
| | - Mami Takemoto
- Department of Neurology, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, 2-5-1 Shikata-cho, Kita-ku, Okayama 700-8558, Japan
| | - Ryuta Morihara
- Department of Neurology, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, 2-5-1 Shikata-cho, Kita-ku, Okayama 700-8558, Japan
| | - Eri Katsuyama
- Department of Nephrology, Rheumatology, Endocrinology and Metabolism, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, 2-5-1 Shikata-cho, Kita-ku, Okayama 700-8558, Japan
| | - Ichizo Nishino
- Department of Neuromuscular Research, National Institute of Neuroscience, National Center of Neurology and Psychiatry (NCNP), 4-1-1 Ogawahigashi-cho, Kodaira, Tokyo 187-8502, Japan
| | - Toru Yamashita
- Department of Neurology, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, 2-5-1 Shikata-cho, Kita-ku, Okayama 700-8558, Japan.
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21
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Crickx E, Mahévas M, Michel M, Godeau B. Older Adults and Immune Thrombocytopenia: Considerations for the Clinician. Clin Interv Aging 2023; 18:115-130. [PMID: 36726813 PMCID: PMC9885884 DOI: 10.2147/cia.s369574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Accepted: 01/10/2023] [Indexed: 01/28/2023] Open
Abstract
Many epidemiological studies have shown that the incidence of immune thrombocytopenia (ITP) increases after age 60 years and peaks in patients over age 80 years. Therefore, ITP is a concern for physicians taking care of older patients, especially regarding its diagnosis and management. The diagnostic work-up should exclude other causes of thrombocytopenia and secondary ITP, including myelodysplastic syndrome and drug-induced ITP. The treatment decision is influenced by an increased risk of bleeding, infectious diseases and thrombosis in this population and should take into account comorbidities and concomitant medications such as anticoagulant drugs. First-line treatment is based on short corticosteroids courses and intravenous immunoglobulin, which should be reserved for patients with more severe bleeding complications, with their higher risk of toxic effects as compared with younger patients. Second-line treatment should be tailored to the patient's history, comorbidities and preferences. Preferred second-line treatments are thrombopoietin receptor agonists for most groups and guidelines given their good efficacy/tolerance ratio, but the thrombotic risk is increased in older people. Other second-line options that can be good alternatives depending on the clinical context include rituximab, dapsone, fostamatinib or immunosuppressive drugs. Splenectomy is less often performed but remains an option for fit patients with chronic refractory disease. Emerging treatments such as Syk or Bruton tyrosine kinase inhibitors and FcRn antagonists are becoming available for ITP and may modify the treatment algorithm in the near future. The aim of this review is to describe the particularities of the diagnosis and treatment of ITP in older people, including the response and tolerance to the currently available drugs. We also discuss some situations related to co-morbidities that can frequently lead to adapt the management strategy in older patients.
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Affiliation(s)
- Etienne Crickx
- Service de Médecine Interne, Centre national de référence des cytopénies auto-immunes de l’adulte, Hôpital Henri Mondor, Fédération Hospitalo-Universitaire TRUE InnovaTive theRapy for immUne disordErs, Assistance Publique Hôpitaux de Paris (AP-HP), Université Paris Est Créteil, Créteil, France,Université de Paris, Imagine Institute, Laboratory of Immunogenetics of Pediatric Autoimmune Diseases, Paris, F-75015, France
| | - Matthieu Mahévas
- Service de Médecine Interne, Centre national de référence des cytopénies auto-immunes de l’adulte, Hôpital Henri Mondor, Fédération Hospitalo-Universitaire TRUE InnovaTive theRapy for immUne disordErs, Assistance Publique Hôpitaux de Paris (AP-HP), Université Paris Est Créteil, Créteil, France,Institut Necker Enfants Malades (INEM), INSERM U1151/CNRS UMS 8253, ATIP-Avenir Team AI2B, Université de Paris, Université Paris-Est-Créteil, Paris, France,INSERM U955, équipe 2, Université Paris-Est Créteil (UPEC), Créteil, France
| | - Marc Michel
- Service de Médecine Interne, Centre national de référence des cytopénies auto-immunes de l’adulte, Hôpital Henri Mondor, Fédération Hospitalo-Universitaire TRUE InnovaTive theRapy for immUne disordErs, Assistance Publique Hôpitaux de Paris (AP-HP), Université Paris Est Créteil, Créteil, France
| | - Bertrand Godeau
- Service de Médecine Interne, Centre national de référence des cytopénies auto-immunes de l’adulte, Hôpital Henri Mondor, Fédération Hospitalo-Universitaire TRUE InnovaTive theRapy for immUne disordErs, Assistance Publique Hôpitaux de Paris (AP-HP), Université Paris Est Créteil, Créteil, France,Correspondence: Bertrand Godeau, Service de Médecine Interne, Hôpital Henri Mondor, Assistance Publique Hôpitaux de Paris (AP-HP), 51 avenue du maréchal de Lattre de Tassigny, Créteil, 94000, France, Tel +331 49 81 29 05, Fax +331 49 81 29 02, Email
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22
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Liu X, Zhang Y, Lu L, Li X, Wu Y, Yang Y, Li T, Cao W. Benefits of high-dose intravenous immunoglobulin on mortality in patients with severe COVID-19: An updated systematic review and meta-analysis. Front Immunol 2023; 14:1116738. [PMID: 36756131 PMCID: PMC9900022 DOI: 10.3389/fimmu.2023.1116738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 01/10/2023] [Indexed: 01/24/2023] Open
Abstract
Background The clinical benefits of high-dose intravenous immunoglobulin (IVIg) in treating COVID-19 remained controversial. Methods We systematically searched databases up to February 17, 2022, for studies examining the efficacy of IVIg compared to routine care. Meta-analyses were conducted using the random-effects model. Subgroup analysis, meta-regression, and trial series analysis w ere performed to explore heterogeneity and statistical significance. Results A total of 4,711 hospitalized COVID-19 patients (1,925 IVIg treated and 2786 control) were collected from 17 studies, including five randomized controlled trials (RCTs) and 12 cohort studies. The application of IVIg was not associated with all-cause mortality (RR= 0.89 [0.63, 1.26], P= 0.53; I2 = 75%), the length of hospital stays (MD= 0.29 [-3.40, 6.44] days, P= 0.88; I2 = 96%), the needs for mechanical ventilation (RR= 0.93 ([0.73, 1.19], P= 0.31; I2 = 56%), or the incidence of adverse events (RR= 1.15 [0.99, 1.33], P= 0.06; I2 = 20%). Subgroup analyses showed that overall mortality among patients with severe COVID-19 was reduced in the high-dose IVIg subgroup (RR= 0.33 [0.13, 0.86], P= 0.02, I2 = 68%; very low certainty). Conclusions Results of this study suggest that severe hospitalized COVID-19 patients treated with high-dose IVIg would have a lower risk of death than patients with routine care. Systematic review registration https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021231040, identifier CRD42021231040.
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Affiliation(s)
- Xiaosheng Liu
- Tsinghua-Peking Center for Life Sciences, Beijing, China,Department of Basic Medical Sciences, School of Medicine, Tsinghua University, Beijing, China,Department of Infectious Diseases, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Yuelun Zhang
- Medical research center, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Lianfeng Lu
- Department of Infectious Diseases, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Xiaodi Li
- Department of Infectious Diseases, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Yuanni Wu
- Department of Infectious Diseases, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Yang Yang
- Department of Infectious Diseases, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Taisheng Li
- Tsinghua-Peking Center for Life Sciences, Beijing, China,Department of Infectious Diseases, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China,State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Wei Cao
- Department of Infectious Diseases, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China,State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China,*Correspondence: Wei Cao,
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23
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Shahriari N, Mazori DR, Merola JF. Intravenous immunoglobulin-refractory necrobiotic xanthogranuloma successfully treated with tofacitinib 2% cream. JAAD Case Rep 2022; 32:41-43. [PMID: 36632562 PMCID: PMC9826807 DOI: 10.1016/j.jdcr.2022.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Affiliation(s)
- Neda Shahriari
- Department of Dermatology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts,Correspondence to: Neda Shahriari, MD, Department of Dermatology, Brigham and Women’s Hospital, Harvard Medical School, 221 Longwood Avenue Boston, MA 02115.
| | - Daniel R. Mazori
- Ronald O. Perelman Department of Dermatology, New York University Grossman School of Medicine, New York, New York
| | - Joseph F. Merola
- Department of Dermatology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts,Division of Rheumatology, Inflammation, and Immunity, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
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24
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Tocut M, Kolitz T, Shovman O, Haviv Y, Boaz M, Laviel S, Debi S, Nama M, Akria A, Shoenfeld Y, Soroksky A, Zandman-Goddard G. Outcomes of ICU patients treated with intravenous immunoglobulin for sepsis or autoimmune diseases. Clin Exp Rheumatol 2022; 21:103205. [PMID: 36195246 DOI: 10.1016/j.autrev.2022.103205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Accepted: 09/28/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVES To evaluate the outcomes of hospitalized patients in two intensive care units (ICU) treated with intravenous immunoglobulin (IVIg) added to standard-of-care therapy. The indications for IVIg therapy were sepsis or autoimmune disease. METHODS We conducted a retrospective study involving adult patients with sepsis and autoimmune diseases, who received IVIg in the ICU at Wolfson and Sheba Medical Centers. A predefined chart was compiled on Excel to include a complete demographic collection, patient comorbidities, chronic medication use, disease severity scores (Charlson Comorbidity Index; SOFA and APACHE II index scores), indication and dosage of IVIg administration, duration of hospitalization and mortality rates. RESULTS Patients (n - 111) were divided into 2 groups: patients with sepsis only (n-67) and patients with autoimmune disease only (n-44). Septic patients had a shorter ICU stay, received IVIg early, and had reduced mortality if treated with high dose IVIg. Patients with autoimmune diseases did not have a favorable outcome despite IVIg treatment. In this group, IVIg was administered later than in the sepsis group. CONCLUSIONS IVIg therapy improved the outcomes for ICU patients with sepsis.
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Affiliation(s)
- Milena Tocut
- Department of Medicine C, Wolfson Medical Center, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Israel; The Center for Autoimmune Diseases
| | - Tamara Kolitz
- Sackler Faculty of Medicine, Tel-Aviv University, Israel; Institute of Endocrinology, Metabolism and Hypertension, Tel Aviv-Sourasky Medical Center
| | - Ora Shovman
- Sackler Faculty of Medicine, Tel-Aviv University, Israel; The Center for Autoimmune Diseases; Department of Medicine B
| | - Yael Haviv
- Sackler Faculty of Medicine, Tel-Aviv University, Israel; Intensive Care Unit, Sheba Medical Center, Israel
| | - Mona Boaz
- Nutrition Sciences Department, Ariel University, Israel
| | - Shira Laviel
- Department of Medicine C, Wolfson Medical Center, Israel
| | - Stav Debi
- Department of Medicine C, Wolfson Medical Center, Israel
| | - Mona Nama
- Department of Medicine C, Wolfson Medical Center, Israel
| | - Amir Akria
- Department of Medicine C, Wolfson Medical Center, Israel
| | - Yehuda Shoenfeld
- Sackler Faculty of Medicine, Tel-Aviv University, Israel; The Center for Autoimmune Diseases; Ariel University, Ariel, Israel; I.M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation (Sechenov University), Moscow, Russia
| | - Arie Soroksky
- Sackler Faculty of Medicine, Tel-Aviv University, Israel; Intensive Care Unit, Wolfson Medical Center, Israel
| | - Gisele Zandman-Goddard
- Department of Medicine C, Wolfson Medical Center, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Israel.
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25
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Svačina MKR, Meißner A, Schweitzer F, Ladwig A, Sprenger‐Svačina A, Klein I, Wüstenberg H, Kohle F, Schneider C, Grether NB, Wunderlich G, Fink GR, Klein F, Di Cristanziano V, Lehmann HC. Antibody response after COVID-19 vaccination in intravenous immunoglobulin-treated immune neuropathies. Eur J Neurol 2022; 29:3380-3388. [PMID: 35842740 PMCID: PMC9349681 DOI: 10.1111/ene.15508] [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] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 06/24/2022] [Accepted: 07/13/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND PURPOSE This study assessed the prevalence of anti-SARS-CoV-2 antibodies in therapeutic immunoglobulin and their impact on serological response to COVID-19 mRNA vaccine in patients with intravenous immunoglobulin (IVIg)-treated chronic immune neuropathies. METHODS Forty-six samples of different brands or lots of IVIg or subcutaneous IgG were analyzed for anti-SARS-CoV-2 IgG using enzyme-linked immunosorbent assay and chemiluminescent microparticle immunoassay. Blood sera from 16 patients with immune neuropathies were prospectively analyzed for anti-SARS-CoV-2 IgA, IgG, and IgM before and 1 week after IVIg infusion subsequent to consecutive COVID-19 mRNA vaccine doses and after 12 weeks. These were compared to 42 healthy subjects. RESULTS Twenty-four (52%) therapeutic immunoglobulin samples contained anti-SARS-CoV-2 IgG. All patients with immune neuropathies (mean age = 65 ± 16 years, 25% female) were positive for anti-SARS-CoV-2 IgG after COVID-19 vaccination. Anti-SARS-CoV-2 IgA titers significantly decreased 12-14 weeks after vaccination (p = 0.02), whereas IgG titers remained stable (p = 0.2). IVIg did not significantly reduce intraindividual anti-SARS-CoV-2 IgA/IgG serum titers in immune neuropathies (p = 0.69). IVIg-derived anti-SARS-CoV-2 IgG did not alter serum anti-SARS-CoV-2 IgG decrease after IVIg administration (p = 0.67). CONCLUSIONS Our study indicates that IVIg does not impair the antibody response to COVID-19 mRNA vaccine in a short-term observation, when administered a minimum of 2 weeks after each vaccine dose. The infusion of current IVIg preparations that contain anti-SARS-CoV-2 IgG does not significantly alter serum anti-SARS-CoV-2 IgG titers.
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Affiliation(s)
- Martin K. R. Svačina
- Department of Neurology, Faculty of Medicine and University Hospital of CologneUniversity of CologneCologneGermany
| | - Anika Meißner
- Department of Neurology, Faculty of Medicine and University Hospital of CologneUniversity of CologneCologneGermany
| | - Finja Schweitzer
- Department of Neurology, Faculty of Medicine and University Hospital of CologneUniversity of CologneCologneGermany
| | - Anne Ladwig
- Department of Neurology, Faculty of Medicine and University Hospital of CologneUniversity of CologneCologneGermany
| | - Alina Sprenger‐Svačina
- Department of Neurology, Faculty of Medicine and University Hospital of CologneUniversity of CologneCologneGermany
| | - Ines Klein
- Department of Neurology, Faculty of Medicine and University Hospital of CologneUniversity of CologneCologneGermany
| | - Hauke Wüstenberg
- Department of Neurology, Faculty of Medicine and University Hospital of CologneUniversity of CologneCologneGermany
| | - Felix Kohle
- Department of Neurology, Faculty of Medicine and University Hospital of CologneUniversity of CologneCologneGermany
| | - Christian Schneider
- Department of Neurology, Faculty of Medicine and University Hospital of CologneUniversity of CologneCologneGermany
| | - Nicolai B. Grether
- Department of Neurology, Faculty of Medicine and University Hospital of CologneUniversity of CologneCologneGermany
| | - Gilbert Wunderlich
- Department of Neurology, Faculty of Medicine and University Hospital of CologneUniversity of CologneCologneGermany
| | - Gereon R. Fink
- Department of Neurology, Faculty of Medicine and University Hospital of CologneUniversity of CologneCologneGermany
- Cognitive Neuroscience, Research Center JuelichInstitute of Neuroscience and Medicine (INM‐3)JuelichGermany
| | - Florian Klein
- Institute of Virology, Faculty of Medicine and University Hospital of CologneUniversity of CologneCologneGermany
- German Center for Infection Research (DZIF), partner site Bonn‐CologneCologneGermany
| | - Veronica Di Cristanziano
- Institute of Virology, Faculty of Medicine and University Hospital of CologneUniversity of CologneCologneGermany
| | - Helmar C. Lehmann
- Department of Neurology, Faculty of Medicine and University Hospital of CologneUniversity of CologneCologneGermany
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26
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Kapoor M, Carr A, Foiani M, Heslegrave A, Zetterberg H, Malaspina A, Compton L, Hutton E, Rossor A, Reilly MM, Lunn MP. Association of plasma neurofilament light chain with disease activity in chronic inflammatory demyelinating polyradiculoneuropathy. Eur J Neurol 2022; 29:3347-3357. [PMID: 35837802 PMCID: PMC9796374 DOI: 10.1111/ene.15496] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 06/06/2022] [Accepted: 06/25/2022] [Indexed: 01/02/2023]
Abstract
BACKGROUND AND PURPOSE This study was undertaken to explore associations between plasma neurofilament light chain (pNfL) concentration (pg/ml) and disease activity in patients with chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) and examine the usefulness of pNfL concentrations in determining disease remission. METHODS We examined pNfL concentrations in treatment-naïve CIDP patients (n = 10) before and after intravenous immunoglobulin (IVIg) induction treatment, in pNfL concentrations in patients on maintenance IVIg treatment who had stable (n = 15) versus unstable disease (n = 9), and in clinically stable IVIg-treated patients (n = 10) in whom we suspended IVIg to determine disease activity and ongoing need for maintenance IVIg. pNfL concentrations in an age-matched healthy control group were measured for comparison. RESULTS Among treatment-naïve patients, pNfL concentration was higher in patients before IVIg treatment than healthy controls and subsequently reduced to be comparable to control group values after IVIg induction. Among CIDP patients on IVIg treatment, pNfL concentration was significantly higher in unstable patients than stable patients. A pNFL concentration > 16.6 pg/ml distinguished unstable treated CIDP from stable treated CIDP (sensitivity = 86.7%, specificity = 66.7%, area under receiver operating characteristic curve = 0.73). Among the treatment withdrawal group, there was a statistically significant correlation between pNfL concentration at time of IVIg withdrawal and the likelihood of relapse (r = 0.72, p < 0.05), suggesting an association of higher pNfL concentration with active disease. CONCLUSIONS pNfL concentrations may be a sensitive, clinically useful biomarker in assessing subclinical disease activity.
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Affiliation(s)
- Mahima Kapoor
- Department of Neuromuscular DiseasesUniversity College London Queen Square Institute of NeurologyLondonUK
- Department of NeurosciencesCentral Clinical School, Monash University, Alfred CentreMelbourneVictoriaAustralia
| | - Aisling Carr
- Department of Neuromuscular DiseasesUniversity College London Queen Square Institute of NeurologyLondonUK
- Centre for Neuromuscular diseasesNational Hospital for Neurology and NeurosurgeryLondonUK
| | - Martha Foiani
- Department of Neurodegenerative DiseaseUniversity College London Queen Square Institute of NeurologyLondonUK
- UK Dementia Research Institute at University College LondonLondonUK
| | - Amanda Heslegrave
- Department of Neurodegenerative DiseaseUniversity College London Queen Square Institute of NeurologyLondonUK
- UK Dementia Research Institute at University College LondonLondonUK
| | - Henrik Zetterberg
- Department of Neurodegenerative DiseaseUniversity College London Queen Square Institute of NeurologyLondonUK
- UK Dementia Research Institute at University College LondonLondonUK
- Clinical Neurochemistry LaboratorySahlgrenska University HospitalMölndalSweden
- Department of Psychiatry and NeurochemistryInstitute of Neuroscience and Physiology, Sahlgrenska Academy at University of GothenburgMölndalSweden
- Hong Kong Center for Neurodegenerative DiseasesHong KongChina
| | - Andrea Malaspina
- Department of Neuromuscular DiseasesUniversity College London Queen Square Institute of NeurologyLondonUK
- University College London Queen Square Motor Neuron Disease Centre, Queen Square Institute of NeurologyLondonUK
- Centre for Neuroscience and TraumaBlizard Institute, Barts and London School of Medicine and Dentistry, Queen Mary University of LondonLondonUK
- ALS Biomarkers StudyUniversity College LondonLondonUK
| | - Laura Compton
- Centre for Neuromuscular diseasesNational Hospital for Neurology and NeurosurgeryLondonUK
| | - Elspeth Hutton
- Department of NeurosciencesCentral Clinical School, Monash University, Alfred CentreMelbourneVictoriaAustralia
| | - Alexander Rossor
- Department of Neuromuscular DiseasesUniversity College London Queen Square Institute of NeurologyLondonUK
- Centre for Neuromuscular diseasesNational Hospital for Neurology and NeurosurgeryLondonUK
| | - Mary M. Reilly
- Department of Neuromuscular DiseasesUniversity College London Queen Square Institute of NeurologyLondonUK
- Centre for Neuromuscular diseasesNational Hospital for Neurology and NeurosurgeryLondonUK
| | - Michael P. Lunn
- Department of Neuromuscular DiseasesUniversity College London Queen Square Institute of NeurologyLondonUK
- Centre for Neuromuscular diseasesNational Hospital for Neurology and NeurosurgeryLondonUK
- Neuroimmunology and CSF LaboratoryUniversity College London Queen Square Institute of NeurologyLondonUK
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27
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Okubo Y, Miyabayashi T, Sato R, Endo W, Inui T, Togashi N, Haginoya K. A first case of childhood chronic inflammatory demyelinating polyneuropathy associated with alopecia universalis. Brain Dev 2022; 44:748-752. [PMID: 35970688 DOI: 10.1016/j.braindev.2022.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 06/27/2022] [Accepted: 08/01/2022] [Indexed: 11/28/2022]
Abstract
Chronic inflammatory demyelinating polyneuropathy (CIDP) is an acquired demyelinating disease of the peripheral nervous system with unknown etiology. Alopecia universalis, an advanced form of alopecia areata (AA), is a condition characterized by complete hair loss. Here we report the first case of childhood CIDP associated with AA who was successfully treated with a combination of intravenous immunoglobulin (IVIg) and corticosteroids. CASE REPORT: This case describes a nine-year-old Japanese girl who developed alopecia, progressive muscle weakness, and eventually loss of walking ability (at ages 2, 4, and 7, respectively). She was treated with IVIg and prednisolone combination therapy, which improved muscle weakness and alopecia. She was positive for serum IgG-GM2 type anti-glycolipid antibodies, which may be associated with this rare combination of diseases.
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Affiliation(s)
- Yukimune Okubo
- Department of Pediatric Neurology, Miyagi Children's Hospital, Sendai, Japan.
| | - Takuya Miyabayashi
- Department of Pediatric Neurology, Miyagi Children's Hospital, Sendai, Japan
| | - Ryo Sato
- Department of Pediatric Neurology, Miyagi Children's Hospital, Sendai, Japan
| | - Wakaba Endo
- Department of Pediatric Neurology, Miyagi Children's Hospital, Sendai, Japan
| | - Takehiko Inui
- Department of Pediatric Neurology, Miyagi Children's Hospital, Sendai, Japan
| | - Noriko Togashi
- Department of Pediatric Neurology, Miyagi Children's Hospital, Sendai, Japan
| | - Kazuhiro Haginoya
- Department of Pediatric Neurology, Miyagi Children's Hospital, Sendai, Japan.
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28
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Nanatsue K, Takahashi M, Itaya S, Abe K, Inaba A. A case of Miller Fisher syndrome with delayed onset peripheral facial nerve palsy after COVID-19 vaccination: a case report. BMC Neurol 2022; 22:309. [PMID: 35996074 PMCID: PMC9395791 DOI: 10.1186/s12883-022-02838-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Accepted: 08/14/2022] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND To prevent the spread of the novel coronavirus disease 2019 (COVID-19) infection, various vaccines have been developed and used in a large number of people worldwide. One of the most commonly used vaccines is the mRNA vaccine developed by Moderna. Although several studies have shown this vaccine to be safe, the full extent of its side effects has not yet been known. Miller-Fisher syndrome (MFS) is a rare condition that manifests ophthalmoplegia, ataxia, and loss of tendon reflexes. It is a subtype of Guillain-Barré syndrome and an immune-mediated disease related to serum IgG anti-GQ1b antibodies. Several vaccines including those for COVID-19 have been reported to induce MFS. However, there have been no reports of MFS following Moderna COVID-19 vaccine administration. CASE PRESENTATION A 70-year-old man was referred to our hospital due to diplopia that manifested 1 week after receiving the second Moderna vaccine dose. The patient presented with restricted abduction of both eyes, mild ataxia, and loss of tendon reflexes. He was diagnosed with MFS based on his neurological findings and detection of serum anti-GQ1b antibodies. The patient was administered intravenous immunoglobulin, and his symptoms gradually improved. Five days after admission, the patient showed peripheral facial paralysis on the right side. This symptom was suggested to be a delayed onset of peripheral facial nerve palsy following MFS that gradually improved by administration of steroids and antiviral drugs. CONCLUSION There have been no previous reports of MFS after Moderna COVID-19 vaccination. This case may provide new information about the possible neurological side effects of COVID-19 vaccines.
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Affiliation(s)
- Kentaro Nanatsue
- Department of Neurology, Kanto Central Hospital, 6-25-1 Kami-Yoga, Setagaya-ku, Tokyo, 158-8531, Japan
| | - Makoto Takahashi
- Department of Neurology, Kanto Central Hospital, 6-25-1 Kami-Yoga, Setagaya-ku, Tokyo, 158-8531, Japan.
| | - Sakiko Itaya
- Department of Neurology, Kanto Central Hospital, 6-25-1 Kami-Yoga, Setagaya-ku, Tokyo, 158-8531, Japan
| | - Keisuke Abe
- Department of Neurology, Kanto Central Hospital, 6-25-1 Kami-Yoga, Setagaya-ku, Tokyo, 158-8531, Japan
| | - Akira Inaba
- Department of Neurology, Kanto Central Hospital, 6-25-1 Kami-Yoga, Setagaya-ku, Tokyo, 158-8531, Japan
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29
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Cooper DKC, Yamamoto T, Hara H, Pierson RN. The first clinical pig heart transplant: Was IVIg or pig cytomegalovirus detrimental to the outcome? Xenotransplantation 2022; 29:e12771. [PMID: 35942912 PMCID: PMC10124764 DOI: 10.1111/xen.12771] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 07/20/2022] [Indexed: 12/13/2022]
Abstract
The clinical course of the first patient to receive a gene-edited pig heart transplant was recently reported by the University of Maryland team. Although the pig heart functioned well for >40 days, serum anti-pig antibodies then increased, and the patient sadly died after 60 days. Because of his debilitated pre-transplant state, the patient never thrived despite excellent graft function for several weeks, and the cause of his demise continues to be uncertain. A few days before an increase in anti-pig antibodies was observed, the patient had received intravenous human immunoglobulin (IVIg), and whether this played a role in his cardiac deterioration has been discussed. Furthermore, mcfDNA testing indicated an increase in pig cytomegalovirus (CMV), and its possible role in the development of cardiac dysfunction has also been considered. On the basis of the limited data provided in the publication and on our previous investigations into whether IVIg contains anti-TKO pig antibodies and therefore might be deleterious to TKO pig organ xenografts, we suggest that the steady rise in anti-pig antibody titer was more consistent with the failure of the immunosuppressive regimen to prevent elicited anti-TKO pig antibody production, rather than from the passive transfusion of IVIg or the presence of pig CMV in the graft. Although the outcome of the Maryland experience was disappointing, valuable lessons were learned. Our attention was drawn to the potential risks of heart transplantation in a "deconditioned" patient, the administration of IVIg, the transmission of pig CMV, and of the difficulties in interpreting myocardial biopsy findings.
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Affiliation(s)
- David K. C. Cooper
- Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts, USA
| | - Takayuki Yamamoto
- Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts, USA
| | - Hidetaka Hara
- Yunnan Xenotransplantation Engineering Research Center, Yunnan Agricultural University, Kunming, Yunnan, China
| | - Richard N. Pierson
- Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts, USA
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30
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Pruessmann JN, Langan EA, Rupp J, Marquardt J, Terheyden P, Zillikens D, Ludwig RJ, Boch K. Challenge of hepatitis B testing following intravenous immunoglobulin therapy in patients with autoimmune skin diseases. J Dermatol 2022; 49:1049-1051. [PMID: 35726741 DOI: 10.1111/1346-8138.16500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 05/09/2022] [Accepted: 06/05/2022] [Indexed: 11/30/2022]
Abstract
Intravenous immunoglobulin (IVIg) contains pooled immunoglobulins from the plasma of healthy blood donors. All plasma samples are tested for HIV, hepatitis viruses (A, B, and C), and parvovirus B19. As part of this screening step, nucleic acid amplification technology (NAT) is used and allows the presence of specific antibodies targeting viral structures that are commonly used to test for infection status, such as anti-hepatitis B surface antigen (HBs) or anti-hepatitis B virus core (HBc) antibodies. For this reason, manufacturers point to the possibility of false-positive viral serological test results following IVIg treatment due to the passive transfer of antibodies. IVIg therapy is commonly used to manage patients with severe, treatment-refractory autoimmune skin diseases. The aim of this cohort study was to retrospectively quantify newly-discovered positive serological HBV test results after IVIg treatment in patients with autoimmune skin diseases. Between March 2018 and June 2021, 28 patients with autoimmune skin diseases received IVIg therapy, of whom 17 were longitudinally followed-up. None of the patients had evidence of active HBV infection prior to IVIg therapy. All patients (n = 17) had detectable anti-HBs antibodies and 12 patients had anti-HBc antibodies 4 weeks after commencing IVIg treatment. Passive antibody transfer seems the most likely interpretation. Nevertheless, complete serological hepatitis assessment should be performed to exclude a new infection. We recommend hepatitis screening before IVIg therapy to prevent diagnostic confusion which may arise due to passive antibody transfer.
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Affiliation(s)
| | - Ewan A Langan
- Department of Dermatology, University of Lübeck, Lübeck, Germany.,Manchester Sciences, University of Manchester, Manchester, UK
| | - Jan Rupp
- Department of Infectious Diseases and Microbiology, University of Lübeck, Lübeck, Germany
| | - Jens Marquardt
- Department of Medicine I, University Hospital Lübeck, Lübeck, Germany
| | | | - Detlef Zillikens
- Department of Dermatology, University of Lübeck, Lübeck, Germany
| | - Ralf J Ludwig
- Lübeck Institute of Experimental Dermatology, University of Lübeck, Lübeck, Germany
| | - Katharina Boch
- Department of Dermatology, University of Lübeck, Lübeck, Germany
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31
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Dalakas MC. Autoimmune Neurological Disorders with IgG4 Antibodies: a Distinct Disease Spectrum with Unique IgG4 Functions Responding to Anti-B Cell Therapies. Neurotherapeutics 2022; 19:741-752. [PMID: 35290608 PMCID: PMC9294117 DOI: 10.1007/s13311-022-01210-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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] [Accepted: 02/18/2022] [Indexed: 11/26/2022] Open
Abstract
The main IgG4 antibody-mediated neurological disorders (IgG4-ND) include MuSK myasthenia; CIDP with nodal/paranodal antibodies to Neurofascin-155, contactin-1/caspr-1, or pan-neurofascins; anti-LGI1 and CASPR2-associated limbic encephalitis, Morvan syndrome, or neuromyotonia; and several cases of the anti-IgLON5 and anti-DPPX-spectrum CNS diseases. The paper is centered on the clinical spectrum of IgG4-ND and their immunopathogenesis highlighting the unique functional effects of the IgG4 subclass compared to IgG1-3 antibody subclasses. The IgG4 antibodies exert pathogenic effects on their targeted antigens by blocking enzymatic activity or disrupting protein-protein interactions affecting signal transduction pathways, but not by activating complement, binding to inhibitory FcγRIIb receptor or engaging in cross-linking of the targeted antigen with immune complex formation as the IgG1-IgG3 antibody subclasses do. IgG4 can even inhibit the classical complement pathway by affecting the affinity of IgG1-2 subclasses to C1q binding. Because the IgG4 antibodies do not trigger inflammatory processes or complement-mediated immune responses, the conventional anti-inflammatory therapies, especially with IVIg, immunosuppressants, and plasmapheresis, are ineffective or not sufficiently effective in inducing long-term remissions. In contrast, aiming at the activated plasmablasts connected with IgG4 antibody production is a meaningful therapeutic target in IgG4-ND. Indeed, data from large series of patients with MuSK myasthenia, CIDP with nodal/paranodal antibodies, and anti-LGI1 and CASPR2-associated syndromes indicate that B cell depletion therapy with rituximab exerts long-lasting clinical remissions by targeting memory B cells and IgG4-producing CD20-positive short-lived plasma cells. Because IgG4 antibody titers seem reduced in remissions and increased in exacerbation, they may serve as potential biomarkers of treatment response supporting further the pathogenic role of self-reacting B cells. Controlled trials are needed in IgG4-ND not only with rituximab but also with the other anti-B cell agents that target CD19/20, especially those like obexelimab and obinutuzumab, that concurrently activate the inhibitory FcγRIIb receptors which have low binding affinity to IgG4, exerting a more prolonged anti-B cell action affecting also antigen presentation and cytotoxic T cells. Antibody therapies targeting FcRn, testing those anti-FcRn inhibitors that effectively catabolize the IgG4 antibody subclass, may be especially promising.
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Affiliation(s)
- Marinos C Dalakas
- Department of Neurology, Thomas Jefferson University, Philadelphia, PA, USA.
- Neuroimmunology Unit National and Kapodistrian University of Athens Medical School, Athens, Greece.
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32
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Adrichem ME, Lucke IM, Vrancken AFJE, Goedee HS, Wieske L, Dijkgraaf MGW, Voermans NC, Notermans NC, Faber CG, Visser LH, Kuitwaard K, van Doorn PA, Merkies ISJ, de Haan RJ, van Schaik IN, Eftimov F. Withdrawal of intravenous immunoglobulin in chronic inflammatory demyelinating polyradiculoneuropathy. Brain 2022; 145:1641-1652. [PMID: 35139161 PMCID: PMC9166547 DOI: 10.1093/brain/awac054] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 12/07/2021] [Accepted: 12/21/2021] [Indexed: 12/01/2022] Open
Abstract
Intravenous immunoglobulins are an efficacious treatment for chronic inflammatory demyelinating polyradiculoneuropathy. Biomarkers for disease activity are lacking, making the need for ongoing treatment difficult to assess, leading to potential overtreatment and high health-care costs. Our objective was to determine whether intravenous immunoglobulin withdrawal is non-inferior to continuing intravenous immunoglobulin treatment and to determine how often patients are overtreated. We performed a randomized, double-blind, intravenous immunoglobulin-controlled non-inferiority trial in seven centres in the Netherlands (Trial registration: ISRCTN 13637698; www.isrctn.com/ISRCTN13637698). Adults with clinically stable chronic inflammatory demyelinating polyradiculoneuropathy using intravenous immunoglobulin maintenance treatment for at least 6 months were included. Patients received either intravenous immunoglobulin withdrawal (placebo) as investigational treatment or continuation of intravenous immunoglobulin treatment (control). The primary outcome was the mean change in logit scores from baseline to 24-week follow-up on the patient-reported Inflammatory Rasch–Overall Disability Scale. The non-inferiority margin was predefined as between-group difference in mean change scores of −0.65. Patients who deteriorated could reach a relapse end point according to predefined criteria. Patients with a relapse end point after intravenous immunoglobulin withdrawal entered a restabilization phase. All patients from the withdrawal group who remained stable were included in an open-label extension phase of 52 weeks. We included 60 patients, of whom 29 were randomized to intravenous immunoglobulin withdrawal and 31 to continuation of treatment. The mean age was 58 years (SD 14.7) and 67% was male. The between-group difference in mean change Inflammatory Rasch–Overall Disability Scale scores was −0.47 (95% CI −1.24 to 0.31), indicating that non-inferiority of intravenous immunoglobulin withdrawal could not be established. In the intravenous immunoglobulin withdrawal group, 41% remained stable for 24 weeks, compared to 58% in the intravenous immunoglobulin continuation group (−17%; 95% CI −39 to 8). Of the intravenous immunoglobulin withdrawal group, 28% remained stable at the end of the extension phase. Of the patients in the restabilization phase, 94% restabilized within 12 weeks. In conclusion, it remains inconclusive whether intravenous immunoglobulin withdrawal is non-inferior compared to continuing treatment, partly due to larger than expected confidence intervals leading to an underpowered study. Despite these limitations, a considerable proportion of patients could stop treatment and almost all patients who relapsed were restabilized quickly. Unexpectedly, a high proportion of intravenous immunoglobulin-treated patients experienced a relapse end point, emphasizing the need for more objective measures for disease activity in future trials, as the patient-reported outcome measures might not have been able to identify true relapses reliably. Overall, this study suggests that withdrawal attempts are safe and should be performed regularly in clinically stable patients.
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Affiliation(s)
- Max E Adrichem
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9 1105 AZ Amsterdam, The Netherlands
| | - Ilse M Lucke
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9 1105 AZ Amsterdam, The Netherlands
| | - Alexander F J E Vrancken
- Department of Neurology, University Medical Center, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - H Stephan Goedee
- Department of Neurology, University Medical Center, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - Luuk Wieske
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9 1105 AZ Amsterdam, The Netherlands
| | - Marcel G W Dijkgraaf
- Department of Clinical Epidemiology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9 1105 AZ Amsterdam, The Netherlands
| | - Nicol C Voermans
- Department of Neurology, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands
| | - Nicolette C Notermans
- Department of Neurology, University Medical Center, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - Catharina G Faber
- Department of Neurology, Maastricht Academic Medical Center, P. Debyelaan 25, 6229 HX Maastricht, The Netherlands
| | - Leo H Visser
- Department of Neurology, Elisabeth-Tweesteden Hospital, Hilvarenbeekse weg 60, 5022 GC Tilburg, The Netherlands
| | - Krista Kuitwaard
- Department of Neurology, Albert Schweitzer Hospital, Albert Schweitzerplaats 25 3318 AT Dordrecht, The Netherlands
| | - Pieter A van Doorn
- Department of Neurology, Erasmus Medical Center, Doctor Molewaterplein 40, 3015 GD Rotterdam, The Netherlands
| | - Ingemar S J Merkies
- Department of Neurology, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands.,Department of Neurology, Curaçao Medical Center, 193 JHJ. Hamelbergweg, Willemstad, Curacao, The Netherlands
| | - Rob J de Haan
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9 1105 AZ Amsterdam, The Netherlands
| | - Ivo N van Schaik
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9 1105 AZ Amsterdam, The Netherlands.,Board of directors, Spaarne Gasthuis, Boerhaavelaan 22, 2035 RC Haarlem, The Netherlands
| | - Filip Eftimov
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9 1105 AZ Amsterdam, The Netherlands
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33
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Rojas-Jiménez G, Solano D, Segura Á, Sánchez A, Chaves-Araya S, Herrera M, Vargas M, Cerdas M, Calvo G, Alfaro J, Molina S, Bolaños K, Moreira-Soto A, Villalta M, Sánchez A, Cordero D, Durán G, Solano G, Gómez A, Hernández A, Sánchez L, Vargas M, Drexler JF, Alape-Girón A, Díaz C, León G. In vitro Characterization of Anti-SARS-CoV-2 Intravenous Immunoglobulins ( IVIg) Produced From Plasma of Donors Immunized With the BNT162b2 Vaccine and Its Comparison With a Similar Formulation Produced From Plasma of COVID-19 Convalescent Donors. Front Med Technol 2022; 3:772275. [PMID: 35047966 PMCID: PMC8757726 DOI: 10.3389/fmedt.2021.772275] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Accepted: 12/03/2021] [Indexed: 01/01/2023] Open
Abstract
Despite vaccines are the main strategy to control the ongoing global COVID-19 pandemic, their effectiveness could not be enough for individuals with immunosuppression. In these cases, as well as in patients with moderate/severe COVID-19, passive immunization with anti-SARS-CoV-2 immunoglobulins could be a therapeutic alternative. We used caprylic acid precipitation to prepare a pilot-scale batch of anti-SARS-CoV-2 intravenous immunoglobulins (IVIg) from plasma of donors immunized with the BNT162b2 (Pfizer-BioNTech) anti-COVID-19 vaccine (VP-IVIg) and compared their in vitro efficacy and safety with those of a similar formulation produced from plasma of COVID-19 convalescent donors (CP-IVIg). Both formulations showed immunological, physicochemical, biochemical, and microbiological characteristics that meet the specifications of IVIg formulations. Moreover, the concentration of anti-RBD and ACE2-RBD neutralizing antibodies was higher in VP-IVIg than in CP-IVIg. In concordance, plaque reduction neutralization tests showed inhibitory concentrations of 0.03-0.09 g/L in VP-IVIg and of 0.06-0.13 in CP-IVIg. Thus, VP-IVIg has in vitro efficacy and safety profiles that justify their evaluation as therapeutic alternative for clinical cases of COVID-19. Precipitation with caprylic acid could be a simple, feasible, and affordable alternative to produce formulations of anti-SARS-CoV-2 IVIg to be used therapeutically or prophylactically to confront the COVID-19 pandemic in middle and low-income countries.
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Affiliation(s)
- Gabriel Rojas-Jiménez
- Sección de Virología Médica, Departamento de Microbiología e Inmunología, Facultad de Microbiología, Universidad de Costa Rica, San José, Costa Rica
| | - Daniela Solano
- Instituto Clodomiro Picado, Factulad de Microbiología, Universidad de Costa Rica, San José, Costa Rica
| | - Álvaro Segura
- Instituto Clodomiro Picado, Factulad de Microbiología, Universidad de Costa Rica, San José, Costa Rica
| | - Andrés Sánchez
- Instituto Clodomiro Picado, Factulad de Microbiología, Universidad de Costa Rica, San José, Costa Rica
| | - Stephanie Chaves-Araya
- Instituto Clodomiro Picado, Factulad de Microbiología, Universidad de Costa Rica, San José, Costa Rica
| | - María Herrera
- Instituto Clodomiro Picado, Factulad de Microbiología, Universidad de Costa Rica, San José, Costa Rica
| | - Mariángela Vargas
- Instituto Clodomiro Picado, Factulad de Microbiología, Universidad de Costa Rica, San José, Costa Rica
| | - Maykel Cerdas
- Instituto Clodomiro Picado, Factulad de Microbiología, Universidad de Costa Rica, San José, Costa Rica
| | - Gerardo Calvo
- Laboratorio Clínico y Banco de Sangre de la Universidad de Costa Rica, Oficina de Bienestar y Salud, Universidad de Costa Rica, San José, Costa Rica
| | - Jonathan Alfaro
- Laboratorio Clínico y Banco de Sangre de la Universidad de Costa Rica, Oficina de Bienestar y Salud, Universidad de Costa Rica, San José, Costa Rica
| | - Sebastián Molina
- Banco Nacional de Sangre, Gerencia Médica, Caja Costarricense del Seguro Social, San José, Costa Rica
| | - Kimberly Bolaños
- Banco Nacional de Sangre, Gerencia Médica, Caja Costarricense del Seguro Social, San José, Costa Rica
| | - Andrés Moreira-Soto
- Institute of Virology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Centro de Investigación en Enfermedades Tropicales (CIET), Facultad de Microbiología, Universidad de Costa Rica, San Jose, Costa Rica
| | - Mauren Villalta
- Instituto Clodomiro Picado, Factulad de Microbiología, Universidad de Costa Rica, San José, Costa Rica
| | - Adriana Sánchez
- Instituto Clodomiro Picado, Factulad de Microbiología, Universidad de Costa Rica, San José, Costa Rica
| | - Daniel Cordero
- Instituto Clodomiro Picado, Factulad de Microbiología, Universidad de Costa Rica, San José, Costa Rica
| | - Gina Durán
- Instituto Clodomiro Picado, Factulad de Microbiología, Universidad de Costa Rica, San José, Costa Rica
| | - Gabriela Solano
- Instituto Clodomiro Picado, Factulad de Microbiología, Universidad de Costa Rica, San José, Costa Rica
| | - Aarón Gómez
- Instituto Clodomiro Picado, Factulad de Microbiología, Universidad de Costa Rica, San José, Costa Rica
| | - Andrés Hernández
- Instituto Clodomiro Picado, Factulad de Microbiología, Universidad de Costa Rica, San José, Costa Rica
| | - Laura Sánchez
- Instituto Clodomiro Picado, Factulad de Microbiología, Universidad de Costa Rica, San José, Costa Rica
| | - Marco Vargas
- Laboratorio Clínico y Banco de Sangre de la Universidad de Costa Rica, Oficina de Bienestar y Salud, Universidad de Costa Rica, San José, Costa Rica
| | - Jean Felix Drexler
- Institute of Virology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,German Centre for Infection Research (DZIF), Associated Partner Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Alberto Alape-Girón
- Instituto Clodomiro Picado, Factulad de Microbiología, Universidad de Costa Rica, San José, Costa Rica.,Departamento de Bioquímica, Escuela de Medicina, Universidad de Costa Rica, San José, Costa Rica
| | - Cecilia Díaz
- Instituto Clodomiro Picado, Factulad de Microbiología, Universidad de Costa Rica, San José, Costa Rica.,Departamento de Bioquímica, Escuela de Medicina, Universidad de Costa Rica, San José, Costa Rica
| | - Guillermo León
- Instituto Clodomiro Picado, Factulad de Microbiología, Universidad de Costa Rica, San José, Costa Rica
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Colakovic R, Freeman T, Schultz B. Positive hepatitis B serology following IVIg treatment in a patient with mucous membrane pemphigoid. Int J Womens Dermatol 2022; 7:826-827. [PMID: 35028390 PMCID: PMC8714588 DOI: 10.1016/j.ijwd.2021.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Revised: 02/25/2021] [Accepted: 03/02/2021] [Indexed: 11/16/2022] Open
Affiliation(s)
- Ryan Colakovic
- Department of Dermatology, University of Minnesota, Minneapolis, Minnesota
| | - Thomas Freeman
- Department of Dermatology, University of Minnesota, Minneapolis, Minnesota
| | - Brittney Schultz
- Department of Dermatology, University of Minnesota, Minneapolis, Minnesota
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Popovic B, Radovanovic Spurnic A, Velickovic J, Plavsic A, Jecmenica-Lukic M, Glisic T, Ilic D, Jeremic D, Vratonjic J, Samardzic V, Gluvic Z, Adzic-Vukicevic T. Successful Immunomodulatory Treatment of COVID-19 in a Patient With Severe ACTH-Dependent Cushing's Syndrome: A Case Report and Review of Literature. Front Endocrinol (Lausanne) 2022; 13:889928. [PMID: 35813652 PMCID: PMC9257249 DOI: 10.3389/fendo.2022.889928] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Accepted: 05/17/2022] [Indexed: 12/15/2022] Open
Abstract
INTRODUCTION Patients with Cushing's syndrome (CS) represent a highly sensitive group during corona virus disease 2019 (COVID-19) pandemic. The effect of multiple comorbidities and immune system supression make the clinical picture complicated and treatment challenging. CASE REPORT A 70-year-old female was admitted to a covid hospital with a severe form of COVID-19 pneumonia that required oxygen supplementation. Prior to her admission to the hospital she was diagnosed with adrenocorticotropic hormone (ACTH)-dependent CS, and the treatment of hypercortisolism had not been started yet. Since the patient's condition was quickly deteriorating, and with presumend immmune system supression due to CS, we decided on treatement with intraveonus immunoglobulins (IVIg) that enabled quick onset of immunomodulatory effect. All comorbidities were treated with standard of care. The patient's condition quickly stabilized with no direct side effects of a given treatment. CONCLUSION Treatment of COVID-19 in patients with CS faces many challenges due to the complexity of comorbidity effects, immunosupression and potential interactions of available medications both for treatment of COVID-19 and CS. So far, there are no guidelines for treatment of COVID-19 in patients with active CS. It is our opinion that immunomodulating therapies like IVIg might be an effective and safe treatment modality in this particularly fragile group of patients.
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Affiliation(s)
- Bojana Popovic
- Covid Hospital Batajnica, University Clinical Centre of Serbia, Belgrade, Serbia
- Clinic for Endocriniology, Diabetes, and Metabolic Diseases, University Clinical Centre of Serbia, Belgrade, Serbia
- School of Medicine, University of Belgrade, Belgrade, Serbia
- *Correspondence: Bojana Popovic,
| | - Aleksandra Radovanovic Spurnic
- Covid Hospital Batajnica, University Clinical Centre of Serbia, Belgrade, Serbia
- School of Medicine, University of Belgrade, Belgrade, Serbia
- Clinic for Infectious and Tropical Diseases, University Clinical Centre of Serbia, Belgrade, Serbia
| | - Jelena Velickovic
- Covid Hospital Batajnica, University Clinical Centre of Serbia, Belgrade, Serbia
- School of Medicine, University of Belgrade, Belgrade, Serbia
- Centre for Anesthesiology and Reanimation, University Clinical Centre of Serbia, Belgrade, Serbia
| | - Aleksandra Plavsic
- Covid Hospital Batajnica, University Clinical Centre of Serbia, Belgrade, Serbia
- School of Medicine, University of Belgrade, Belgrade, Serbia
- Clinic for Allergology and Immunology, University Clinical Centre of Serbia, Belgrade, Serbia
| | - Milica Jecmenica-Lukic
- Covid Hospital Batajnica, University Clinical Centre of Serbia, Belgrade, Serbia
- School of Medicine, University of Belgrade, Belgrade, Serbia
- Clinic for Neurology, University Clinical Centre of Serbia, Belgrade, Serbia
| | - Tijana Glisic
- Covid Hospital Batajnica, University Clinical Centre of Serbia, Belgrade, Serbia
- School of Medicine, University of Belgrade, Belgrade, Serbia
- Clinic for Gastroenterology and Hepatology, University Clinical Centre of Serbia, Belgrade, Serbia
| | - Dusan Ilic
- Covid Hospital Batajnica, University Clinical Centre of Serbia, Belgrade, Serbia
- Clinic for Endocriniology, Diabetes, and Metabolic Diseases, University Clinical Centre of Serbia, Belgrade, Serbia
| | - Danka Jeremic
- Covid Hospital Batajnica, University Clinical Centre of Serbia, Belgrade, Serbia
- Clinic for Endocriniology, Diabetes, and Metabolic Diseases, University Clinical Centre of Serbia, Belgrade, Serbia
- School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Jelena Vratonjic
- Covid Hospital Batajnica, University Clinical Centre of Serbia, Belgrade, Serbia
| | - Vladimir Samardzic
- Clinic for Internal Medicine, Department of Endocrinology and Diabetes, Zemun Clinical Hospital, Belgrade, Serbia
| | - Zoran Gluvic
- School of Medicine, University of Belgrade, Belgrade, Serbia
- Clinic for Internal Medicine, Department of Endocrinology and Diabetes, Zemun Clinical Hospital, Belgrade, Serbia
| | - Tatjana Adzic-Vukicevic
- Covid Hospital Batajnica, University Clinical Centre of Serbia, Belgrade, Serbia
- School of Medicine, University of Belgrade, Belgrade, Serbia
- Clinic for Pulmology, University Clinical Centre of Serbia, Belgrade, Serbia
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Geng B, Clark K, Evangelista M, Wolford E. Low rates of headache and migraine associated with intravenous immunoglobulin infusion using a 15-minute rate escalation protocol in 123 patients with primary immunodeficiency. Front Immunol 2022; 13:1075527. [PMID: 36818468 PMCID: PMC9932595 DOI: 10.3389/fimmu.2022.1075527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Accepted: 12/16/2022] [Indexed: 02/05/2023] Open
Abstract
Introduction Headache and migraine adverse events are common concerns in the administration of intravenous immune globulins (IVIG). Trials of IVIG for primary immunodeficiency (PI) are typically small and have reported headache and migraine data inconsistently. Methods We analyzed headache and migraine in pooled data from three pivotal trials of Gammaplex® 5% and 10% in PI (NCT00278954 from January 18, 2006; NCT01289847 from January 27, 2011; NCT01963143 from September 13, 2013). The trials were pooled in a retrospective analysis that included two 12-month open-label non-comparative trials of the 5% IVIG product and one 6-month open-label crossover bioequivalence trial comparing the 5% IVIG and 10% IVIG products. The population included adult and pediatric patients, who received IVIG infusions of 300-800 mg/kg/infusion every 21 or 28 days using a 15-minute rate escalation protocol. Results In total, 1482 infusions were administered to 123 patients, with 94.6% of infusions achieving the maximum infusion rate. At least one product-related headache was reported in 6.1% (90/1482) of infusions. At least one product-related migraine was reported in 0.5% (7/1482) of infusions. Headache rates were higher for adults vs pediatric patients, females vs males, and 21-day vs 28-day dosing schedules, but were similar for the 5% and 10% IVIG products. Most headaches and migraines occurred during or within 72 hours of the infusion. Rates decreased after the first few infusions. Discussion Patients receiving this IVIG product on a 15-minute rate escalation protocol had low rates of headache and migraine for both the 5% and 10% formulations.
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Affiliation(s)
- Bob Geng
- Division of Allergy & Immunology, University of California, San Diego, CA, United States
| | - Kim Clark
- Global Medical Department, Bio Products Laboratory, Ltd., Elstree, United Kingdom
| | - Mark Evangelista
- Biostatistics Department, Atlantic Research Group, Charlottesville, VA, United States
| | - Eric Wolford
- Global Medical Department, Bio Products Laboratory, Ltd., Elstree, United Kingdom
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Kromer C, Mitterlechner L, Langer N, Schön MP, Mössner R. Response of recalcitrant generalized morphea to intravenous immunoglobulins ( IVIg): three cases and a review of the literature. Eur J Dermatol 2021; 31:822-9. [PMID: 35107073 DOI: 10.1684/ejd.2021.4173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Generalized morphea and eosinophilic fasciitis are difficult-to-treat inflammatory and sclerosing skin diseases. Few cases have been reported in which intravenous immunoglobulins were of benefit, possibly owing to their immunomodulatory and antifibrotic properties. OBJECTIVES We present three new patients with generalized morphea treated with intravenous immunoglobulins as well as a review of the literature. MATERIALS & METHODS Three hospitalized patients (two men, age 66 and 65 years, respectively, and a 67-year-old woman) with generalized morphea who received therapy for the first time are described. RESULTS The three patients were treated with intravenous immunoglobulins (1.5-2 g/kg body weight over three to four consecutive days every four weeks). This was combined with corticosteroid pulse therapy in all patients, methotrexate in two patients and mycophenolate mofetil in one patient, respectively. Marked and steady improvement of skin sclerosis was evident in all patients, one to five months after treatment initiation. No adverse events were observed. To date, there are 12 reports of 16 patients with generalized morphea or eosinophilic fasciitis treated with intravenous immunoglobulins. The treatment was highly effective in the majority of patients (9/16) and yielded a favourable risk profile. CONCLUSION Our cases add to the hitherto limited evidence that the administration of intravenous immunoglobulins in combination with glucocorticoids and conventional immunosuppressive agents is a safe and effective therapy against morphea. It seems appropriate to verify these results in future high-quality studies.
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Goswami RP, Haldar SN, Chatterjee M, Vij P, van der Kooi AJ, Lim J, Raaphorst J, Bhadu D, Gelardi C, Danieli MG, Kumar U. Efficacy and safety of intravenous and subcutaneous immunoglobulin therapy in idiopathic inflammatory myopathy: A systematic review and meta-analysis. Autoimmun Rev 2021; 21:102997. [PMID: 34800685 DOI: 10.1016/j.autrev.2021.102997] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 11/06/2021] [Accepted: 11/14/2021] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To perform a systematic review and meta-analysis on the efficacy and safety of intravenous (IVIg) and subcutaneous (SCIg) immunoglobulin (Ig) therapy in the treatment of idiopathic inflammatory myopathy (IIM) and juvenile dermatomyositis (JDM). METHODS PubMed, Embase and SCOPUS were searched to identify studies on Ig therapy in patients with IIM and/or JDM (2010-2020). Outcome measures were complete response (CR) or partial response (PR) in terms of muscle power and extramuscular disease activity measures on the International Myositis Assessment and Clinical Studies Group (IMACS) core set domains. RESULTS Twenty-nine studies were included (n = 576, 544 IIM, 32 JDM). Muscle power PR with pooled Ig therapy was 88.5% (95% confidence interval (CI): 80.6-93.5, n = 499) and PR with SCIg treatment was 96.61% (95% CI: 87.43-99.15, n = 59). Pooled PR with first-line use of IVIg was 77.07% (95% CI: 61.25-92.89, n = 80). Overall, mean time to response was 2.9 months (95% CI: 1.9-4.1). Relapse was seen in 22.76% (95% CI: 14.9-33). Studies on cutaneous disease activity and dysphagia showed significant treatment responses. Glucocorticoid and immunosuppressant sparing effect was seen in 40.9% (95% CI: 20-61.7) and 42.2% (95% CI: 20.4-64.1) respectively. Ig therapy was generally safe with low risk of infection (1.37%, 95% CI: 0.1-2.6). CONCLUSIONS Add-on Ig therapy improves muscle strength in patients with refractory IIM, but evidence on Ig therapy in new-onset disease and extramuscular disease activity is uncertain.
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Affiliation(s)
- Rudra Prosad Goswami
- Department of Rheumatology, All India Institute of Medical Sciences, New Delhi, India.
| | - Soumendra Nath Haldar
- Department of Medicine and Microbiology, All India Institute of Medical Sciences, New Delhi, India.
| | - Moumita Chatterjee
- Department of Mathematics and Statistics, Aliah University, Kolkata, India.
| | - Pallavi Vij
- Department of Rheumatology, All India Institute of Medical Sciences, New Delhi, India.
| | - Anneke J van der Kooi
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam Neuroscience, PO Box 22660, 1100DD Amsterdam, the Netherlands.
| | - Johan Lim
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam Neuroscience, PO Box 22660, 1100DD Amsterdam, the Netherlands.
| | - Joost Raaphorst
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam Neuroscience, PO Box 22660, 1100DD Amsterdam, the Netherlands.
| | - Danveer Bhadu
- Department of Rheumatology, All India Institute of Medical Sciences, New Delhi, India.
| | - Chiara Gelardi
- Emergency Medicine, AziendaOspedaliera Marche Nord, Fano, PU 61032, Italy
| | - Maria Giovanna Danieli
- Clinica Medica, Department of Clinical and Molecular Sciences, Polytechnic University of Marche, Torrette di Ancona 60020, Italy.
| | - Uma Kumar
- Department of Rheumatology, All India Institute of Medical Sciences, New Delhi, India.
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Koizumi R, Fukumoto T, Jimbo H, Nishigori C. Intravenous immunoglobulin-induced severe vesicular eczematous eruption successfully treated with narrow band-ultraviolet B therapy. Photodermatol Photoimmunol Photomed 2021; 37:371-373. [PMID: 33559335 DOI: 10.1111/phpp.12666] [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] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 01/19/2021] [Accepted: 02/04/2021] [Indexed: 06/12/2023]
Abstract
Intravenous immunoglobulins (IVIg) are increasingly being used to treat a wide spectrum of dermatological and neurological autoimmune diseases. Although the administration of IVIg does not usually result in severe adverse reactions, side effects of IVIg reportedly occur in 6-13% of patients. Most reported cases were not severe, and IVIg is considered a relatively safe drug. Some reports described a vesicular eczematous eruption caused by IVIg that was cured by applying topical steroid ointments or systemic steroids. Herein, we present, to the best of our knowledge, the first case of severe vesicular eczematous eruption all over the body induced by IVIg that was unresponsive to topical steroid ointment and was subsequently treated with narrow band-ultraviolet B (NB-UVB) therapy successfully. NB-UVB was started at a dose of 400 mJ/cm2 once a week, and swift improvement was observed. The skin rash disappeared in the first 2 months, and the pathogenesis of IVIg-induced eczematous eruption remains unelucidated. No change in eosinophils and complement levels were observed in our case. Given the increase in the widespread use of IVIg, we have shown that NB-UVB therapy is a candidate choice for the treatment of IVIg-induced severe vesicular eczematous eruption.
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Affiliation(s)
- Rina Koizumi
- Division of Dermatology, Department of Internal Related, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Takeshi Fukumoto
- Division of Dermatology, Department of Internal Related, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Haruki Jimbo
- Division of Dermatology, Department of Internal Related, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Chikako Nishigori
- Division of Dermatology, Department of Internal Related, Kobe University Graduate School of Medicine, Kobe, Japan
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Tiraboschi P, Xhani R, Zerbi SM, Corso A, Martinelli I, Fusi L, Grampa G, Lombardo A, Cavalcante P, Cappelletti C, Andreetta F, Sironi A, Redolfi A, Muscio C. Postinfectious Neurologic Complications in COVID-19: A Complex Case Report. J Nucl Med 2021; 62:1171-1176. [PMID: 34016729 PMCID: PMC8833873 DOI: 10.2967/jnumed.120.256099] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Accepted: 03/09/2021] [Indexed: 02/02/2023] Open
Abstract
A 40-y-old woman with severe acute respiratory syndrome coronavirus 2 infection developed neurologic manifestations (confusion, agitation, seizures, dyskinesias, and parkinsonism) a few weeks after the onset of severe acute respiratory syndrome. MRI and cerebrospinal fluid analyses were unremarkable, but 18F-FDG PET/CT showed limbic and extralimbic hypermetabolism. A full recovery, alongside 18F-FDG normalization in previously hypermetabolic areas, was observed after intravenous immunoglobulin administration.
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Affiliation(s)
- Pietro Tiraboschi
- Neurology 5-Neuropathology Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy;
| | - Rubjona Xhani
- Neurology Department of ASST Lariana, Ospedale Sant'Anna, San Fermo della Battaglia, Italy
| | - Simone M Zerbi
- Intensive Care Unit of ASST Lariana, Ospedale Sant'Anna, San Fermo della Battaglia, Italy
| | - Angelo Corso
- Nuclear Medicine Department of ASST Lariana, Ospedale Sant'Anna, San Fermo della Battaglia, Italy
| | - Isabella Martinelli
- Nuclear Medicine Department of ASST Lariana, Ospedale Sant'Anna, San Fermo della Battaglia, Italy
| | - Laura Fusi
- Neurology Department of ASST Lariana, Ospedale Sant'Anna, San Fermo della Battaglia, Italy
| | - Giampiero Grampa
- Neurology Department of ASST Lariana, Ospedale Sant'Anna, San Fermo della Battaglia, Italy
| | - Andrea Lombardo
- Intensive Care Unit of ASST Lariana, Ospedale Sant'Anna, San Fermo della Battaglia, Italy
| | - Paola Cavalcante
- Neurology 4-Neuroimmunology and Neuromuscular Disease Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Cristina Cappelletti
- Neurology 4-Neuroimmunology and Neuromuscular Disease Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Francesca Andreetta
- Neurology 4-Neuroimmunology and Neuromuscular Disease Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Alberto Sironi
- Radiology Department of ASST Lariana, Ospedale Sant'Anna, San Fermo della Battaglia, Italy; and
| | - Alberto Redolfi
- Laboratory of Neuroinformatics, IRCCS Istituto Centro San Giovanni di Dio Fatebenefratelli, Brescia, Italy
| | - Cristina Muscio
- Neurology 5-Neuropathology Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
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Goyal NA, Karam C, Sheikh KA, Dimachkie MM. Subcutaneous immunoglobulin treatment for chronic inflammatory demyelinating polyneuropathy. Muscle Nerve 2021; 64:243-254. [PMID: 34260074 PMCID: PMC8457117 DOI: 10.1002/mus.27356] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 06/11/2021] [Accepted: 06/15/2021] [Indexed: 12/15/2022]
Abstract
Immunoglobulin G (IgG) therapy is an established long‐term treatment in chronic inflammatory demyelinating polyneuropathy (CIDP) that is commonly administered intravenously (IVIg). The subcutaneous immunoglobulin (SCIg) administration route is a safe and effective alternative option, approved by the United States Food and Drug Administration (FDA) in 2018, for maintenance treatment of adults with CIDP. Physicians and patients alike need to be aware of all their treatment options in order to make informed decisions and plan long‐term treatment strategies. In this review, we collate the evidence for SCIg in CIDP from all published studies and discuss their implications and translation to clinical practice. We also provide guidance on the practicalities of how and when to transition patients from IVIg to SCIg and ongoing patient support. Evidence suggests that IVIg and SCIg have comparable long‐term efficacy in CIDP. However, SCIg can provide additional benefits for some patients, including no requirement for venous access or premedication, and reduced frequency of systemic adverse events. Local‐site reactions are more common with SCIg than IVIg, but these are mostly well‐tolerated and abate with subsequent infusions. Data suggest that many patients prefer SCIg following transition from IVIg. SCIg preference may be a result of the independence and flexibility associated with self‐infusion, whereas IVIg preference may be a result of familiarity and reliance on a healthcare professional for infusions. In practice, individualizing maintenance dosing based on disease behavior and determining the minimally effective IgG dose for individuals are key considerations irrespective of the administration route chosen.
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Affiliation(s)
- Namita A Goyal
- Department of Neurology, MDA ALS and Neuromuscular Center, University of California, Irvine, California, USA
| | - Chafic Karam
- Department of Neurology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Kazim A Sheikh
- Department of Neurology, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Mazen M Dimachkie
- Department of Neurology, University of Kansas Medical Center, Kansas City, Kansas, USA
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Kostera-Pruszczyk A, Potulska-Chromik A, Łukawska M, Lipowska M, Hoffman-Zacharska D, Olchowik B, Figlerowicz M, Kanabus K, Rosiak E. Pediatric CIDP: Diagnosis and Management. A Single-Center Experience. Front Neurol 2021; 12:667378. [PMID: 34276534 PMCID: PMC8284159 DOI: 10.3389/fneur.2021.667378] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Accepted: 04/19/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Chronic inflammatory demyelinating polyneuropathy (CIDP) is a rare acquired polyneuropathy that especially among youngest children should be differentiated with hereditary neuropathies. Even though upon diagnosis treatment options are similar in children and adults, diagnostic challenges are faced in the pediatric population. Methods: We conducted a retrospective analysis of clinical symptoms, nerve conduction study results, modes of treatment, and final outcome in 37 children aged 3.5-17 years with a final diagnosis of CIDP (18 girls, 19 boys). We established three groups of patients based on age at onset of CIDP: 0-4, 4-13, and 13-18 years. Follow-up ranged from 10 to 222 months. Results: In our analysis, 19/37 patients (51.4%) had an atypical presentation: distal variant of CIDP in 12/37 patients (32.4%) and pure motor variant of CIDP in 5/37 patients (13.5%), and one patient had a pure sensory variant (1/37, 2.7%). Furthermore, 3/37 patients (8.1%) had additional concurring symptoms, including involuntary movements of face muscles (1/37, 2.7%) or hand tremor (2/37, 5.4%). During the follow-up, 23/37 patients (62.2%) received intravenous immunoglobulin (IVIg); 22/37 patients (59.5%) received steroids, 6/37 patients (16.2%) received IVIg and steroids, and 12/37 patients (32.4%) received immunosuppressive drugs, mostly azathioprine, but also methotrexate and rituximab. One patient was treated with plasmapheresis. Complete remission was achieved in 19/37 patients (51.4%) with CIDP in its typical form. Remission with residual symptoms or minimal deficit was observed in 4/37 patients (10.8%), whereas 14/37 patients (37.8%) remain on treatment with gradual improvement. Conclusion: Childhood CIDP may occur in its typical form, but even ~50% of children can present as an atypical variant including distal, pure motor, or pure sensory. Most children have a good prognosis; however, many of them may require long-term treatment. This highlights the importance of an early diagnosis and treatment for childhood CIDP.
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Affiliation(s)
| | | | | | - Marta Lipowska
- Department of Neurology, Medical University of Warsaw, Warsaw, Poland
| | | | - Beata Olchowik
- Department of Child Neurology and Rehabilitation, Medical University of Białystok, Białystok, Poland
| | - Magdalena Figlerowicz
- Department of Infectious Diseases and Child Neurology, Poznan University of Medical Sciences, Poznań, Poland
| | - Karolina Kanabus
- Department of Medical Genetics, Institute of Mother and Child, Warsaw, Poland
| | - Edyta Rosiak
- Department of Radiology, Medical University of Warsaw, Warsaw, Poland
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Abstract
Data are limited on the incidence and management of streptococcal toxic shock syndrome (TSS) and nonstreptococcal TSS in children. We aimed to define the clinical patterns of TSS at Nationwide Children's Hospital in Ohio as they relate to published criteria, diagnostic decisions, and treatment options. Through retrospective chart reviews, we identified 58 patients with TSS (27 streptococcal, 31 nonstreptococcal) during January 2010-September 2017. We observed clinical and laboratory findings that are not part of TSS criteria, such as pyuria in streptococcal TSS (50% of patients) and pulmonary involvement (85%) and coagulopathy (92%) in nonstreptococcal TSS patients. Recommended treatment with clindamycin and intravenous immunoglobulin was delayed in streptococcal TSS patients without rash (3.37 days vs. 0.87 days in patients with rash), leading to prolonged hospitalization and complications. Incorporation of additional TSS signs and symptoms would be helpful in TSS diagnosis and management.
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Biondo MI, Fiorentino C, Persechino S, Tammaro A, Koverech A, Bartolazzi A, Raffa S, Canzoni M, Picchianti-Diamanti A, Di Rosa R, Di Zenzo G, Scala E, Meneguzzi G, Ferlito C, Markovic M, Caporuscio S, Sorgi ML, Salemi S, Laganà B. May Bacterial Infections Trigger Bullous Pemphigoid? Case Report and Review of Literature. Microorganisms 2021; 9:microorganisms9061235. [PMID: 34200214 PMCID: PMC8229970 DOI: 10.3390/microorganisms9061235] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Revised: 05/29/2021] [Accepted: 06/04/2021] [Indexed: 01/31/2023] Open
Abstract
Bullous pemphigoid (BP) is an autoimmune blistering skin disease, mainly observed in the elderly. Infections have been suggested as possible disease triggers. However, infections may even heavily influence the disease clinical course and mortality. A 75-year-old woman was admitted to hospital for severe erythematosus blistering disease, accompanied by hyper-eosinophilia and hyper-IgE. The culture of bullous fluid was positive for Enterococcus faecalis, the blood culture was positive for Staphylococcus aureus, and the urine culture was positive for Proteus mirabilis and Escherichia coli. Moreover, circulating anti-BP180 IgG was present and the histopathological/ultrastructural examination of a lesional skin biopsy was compatible with BP. High eosinophil levels (up to 3170/µL) were found throughout the clinical course, while values below 1000/µL were associated with clinical improvement. The total IgE was 1273 IU/mL, and specific anti-G/V-penicillin/ampicillin IgE antibodies were positive. The patient had a complete clinical recovery in two months with methyl-prednisolone (40 then 20 mg/day) and low-dose azathioprine (50 mg/day) as a steroid-sparing agent. The steroid treatment was tapered until interruption during a one-year period and intravenous immunoglobulins have been administered for three years in order for azathioprine to also be interrupted. The patient stopped any treatment five years ago and, in this period, has always been in good health. In this case, the contemporaneous onset of different bacterial infections and BP is suggestive of bacterial infections acting as BP trigger(s), with allergic and autoimmune pathways contributing to the disease pathogenesis.
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Affiliation(s)
- Michela Ileen Biondo
- Dipartimento di Medicina Clinica e Molecolare, Sapienza, Università di Roma, AOU S. Andrea, 00189 Roma, Italy; (M.I.B.); (C.F.); (A.K.); (A.B.); (S.R.); (M.C.); (A.P.-D.); (R.D.R.); (G.M.); (C.F.); (M.M.); (S.C.); (M.L.S.)
| | - Chiara Fiorentino
- Dipartimento di Medicina Clinica e Molecolare, Sapienza, Università di Roma, AOU S. Andrea, 00189 Roma, Italy; (M.I.B.); (C.F.); (A.K.); (A.B.); (S.R.); (M.C.); (A.P.-D.); (R.D.R.); (G.M.); (C.F.); (M.M.); (S.C.); (M.L.S.)
| | - Severino Persechino
- UOD di Dermatologia, Sapienza, Università di Roma, AOU S. Andrea, 00189 Roma, Italy; (S.P.); (A.T.)
| | - Antonella Tammaro
- UOD di Dermatologia, Sapienza, Università di Roma, AOU S. Andrea, 00189 Roma, Italy; (S.P.); (A.T.)
| | - Angela Koverech
- Dipartimento di Medicina Clinica e Molecolare, Sapienza, Università di Roma, AOU S. Andrea, 00189 Roma, Italy; (M.I.B.); (C.F.); (A.K.); (A.B.); (S.R.); (M.C.); (A.P.-D.); (R.D.R.); (G.M.); (C.F.); (M.M.); (S.C.); (M.L.S.)
| | - Armando Bartolazzi
- Dipartimento di Medicina Clinica e Molecolare, Sapienza, Università di Roma, AOU S. Andrea, 00189 Roma, Italy; (M.I.B.); (C.F.); (A.K.); (A.B.); (S.R.); (M.C.); (A.P.-D.); (R.D.R.); (G.M.); (C.F.); (M.M.); (S.C.); (M.L.S.)
| | - Salvatore Raffa
- Dipartimento di Medicina Clinica e Molecolare, Sapienza, Università di Roma, AOU S. Andrea, 00189 Roma, Italy; (M.I.B.); (C.F.); (A.K.); (A.B.); (S.R.); (M.C.); (A.P.-D.); (R.D.R.); (G.M.); (C.F.); (M.M.); (S.C.); (M.L.S.)
| | - Marco Canzoni
- Dipartimento di Medicina Clinica e Molecolare, Sapienza, Università di Roma, AOU S. Andrea, 00189 Roma, Italy; (M.I.B.); (C.F.); (A.K.); (A.B.); (S.R.); (M.C.); (A.P.-D.); (R.D.R.); (G.M.); (C.F.); (M.M.); (S.C.); (M.L.S.)
| | - Andrea Picchianti-Diamanti
- Dipartimento di Medicina Clinica e Molecolare, Sapienza, Università di Roma, AOU S. Andrea, 00189 Roma, Italy; (M.I.B.); (C.F.); (A.K.); (A.B.); (S.R.); (M.C.); (A.P.-D.); (R.D.R.); (G.M.); (C.F.); (M.M.); (S.C.); (M.L.S.)
| | - Roberta Di Rosa
- Dipartimento di Medicina Clinica e Molecolare, Sapienza, Università di Roma, AOU S. Andrea, 00189 Roma, Italy; (M.I.B.); (C.F.); (A.K.); (A.B.); (S.R.); (M.C.); (A.P.-D.); (R.D.R.); (G.M.); (C.F.); (M.M.); (S.C.); (M.L.S.)
| | - Giovanni Di Zenzo
- Istituto Dermopatico dell’Immacolata, 00167 Roma, Italy; (G.D.Z.); (E.S.)
| | - Enrico Scala
- Istituto Dermopatico dell’Immacolata, 00167 Roma, Italy; (G.D.Z.); (E.S.)
| | - Giorgia Meneguzzi
- Dipartimento di Medicina Clinica e Molecolare, Sapienza, Università di Roma, AOU S. Andrea, 00189 Roma, Italy; (M.I.B.); (C.F.); (A.K.); (A.B.); (S.R.); (M.C.); (A.P.-D.); (R.D.R.); (G.M.); (C.F.); (M.M.); (S.C.); (M.L.S.)
| | - Claudia Ferlito
- Dipartimento di Medicina Clinica e Molecolare, Sapienza, Università di Roma, AOU S. Andrea, 00189 Roma, Italy; (M.I.B.); (C.F.); (A.K.); (A.B.); (S.R.); (M.C.); (A.P.-D.); (R.D.R.); (G.M.); (C.F.); (M.M.); (S.C.); (M.L.S.)
| | - Milica Markovic
- Dipartimento di Medicina Clinica e Molecolare, Sapienza, Università di Roma, AOU S. Andrea, 00189 Roma, Italy; (M.I.B.); (C.F.); (A.K.); (A.B.); (S.R.); (M.C.); (A.P.-D.); (R.D.R.); (G.M.); (C.F.); (M.M.); (S.C.); (M.L.S.)
| | - Sara Caporuscio
- Dipartimento di Medicina Clinica e Molecolare, Sapienza, Università di Roma, AOU S. Andrea, 00189 Roma, Italy; (M.I.B.); (C.F.); (A.K.); (A.B.); (S.R.); (M.C.); (A.P.-D.); (R.D.R.); (G.M.); (C.F.); (M.M.); (S.C.); (M.L.S.)
| | - Maria Laura Sorgi
- Dipartimento di Medicina Clinica e Molecolare, Sapienza, Università di Roma, AOU S. Andrea, 00189 Roma, Italy; (M.I.B.); (C.F.); (A.K.); (A.B.); (S.R.); (M.C.); (A.P.-D.); (R.D.R.); (G.M.); (C.F.); (M.M.); (S.C.); (M.L.S.)
| | - Simonetta Salemi
- Dipartimento di Medicina Clinica e Molecolare, Sapienza, Università di Roma, AOU S. Andrea, 00189 Roma, Italy; (M.I.B.); (C.F.); (A.K.); (A.B.); (S.R.); (M.C.); (A.P.-D.); (R.D.R.); (G.M.); (C.F.); (M.M.); (S.C.); (M.L.S.)
- Correspondence: (S.S.); (B.L.)
| | - Bruno Laganà
- Dipartimento di Medicina Clinica e Molecolare, Sapienza, Università di Roma, AOU S. Andrea, 00189 Roma, Italy; (M.I.B.); (C.F.); (A.K.); (A.B.); (S.R.); (M.C.); (A.P.-D.); (R.D.R.); (G.M.); (C.F.); (M.M.); (S.C.); (M.L.S.)
- Correspondence: (S.S.); (B.L.)
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45
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Karatas M, Tatar E, Simsek C, Yıldırım AM, Ari A, Zengel B, Uslu A. COVID-19 pneumonia in kidney transplant recipients: A promising treatment algorithm in the absence of a disease-specific drug. J Med Virol 2021; 93:5789-5797. [PMID: 34050953 PMCID: PMC8242395 DOI: 10.1002/jmv.27110] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 04/17/2021] [Accepted: 05/26/2021] [Indexed: 12/16/2022]
Abstract
There is no consensus on the management of coronavirus disease 2019 (COVID‐19) and modification of immunosuppressive therapy in kidney transplant recipients (KTRs). In this study, we examined the clinical outcome of our KTRs with COVID‐19 disease, who were treated with a broad‐spectrum anti‐inflammatory protocol. This protocol is essentially composed of intravenous immunoglobulin +/‐ tocilizumab in KTRs with severe COVID‐19 pneumonia. Among 809 KTRs, 64 patients diagnosed with COVID‐19 disease between April 2020 and February 2021, were evaluated. Twenty‐nine patients with pneumonia confirmed by chest computed tomography (CCT) were hospitalized. The treatment protocol included high‐dose intravenous methylprednisolone, favipiravir, enoxaparin, and empirical antibiotics. Patients with pneumonic involvement of more than 25% on CCT with or without respiratory failure were given a total of 2 g/kg intravenous immunoglobulin (IVIg) therapy. Nonresponders received tocilizumab, an interleukin‐6 receptor antibody. Of the 29 patients with pneumonia, 6 were treated in other hospitals. These six patients did not receive IVIg and 5 of them deceased. In our center, IVIg treatment was applied to 15 of 23 patients. Seven of them required tocilizumab. Respiratory parameters improved significantly in all but one patient after IVIg ± tocilizumab treatment. The mortality rate was 6.6% in patients who received IVIg therapy and 35.7% in those who did not (p = 0.08). The mortality rate was higher in patients who received treatment in external centers (2.2% vs. 26.3%; p = 0.0073). The treatment of KTRs with severe COVID‐19 pneumonia in organ transplant centers with significant experience yields better results. The administration of broad‐spectrum anti‐inflammatory treatment in this patient group was safe and provided excellent outcomes.
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Affiliation(s)
- Murat Karatas
- Department of General Surgery and Transplantation, Izmir Bozyaka Education and Research Hospital, University of Health Sciences, Izmir, Turkey
| | - Erhan Tatar
- Department of Nephrology and Transplantation, Izmir Bozyaka Education and Research Hospital, University of Health Sciences, Izmir, Turkey
| | - Cenk Simsek
- Department of General Surgery and Transplantation, Izmir Bozyaka Education and Research Hospital, University of Health Sciences, Izmir, Turkey
| | - Ali Murat Yıldırım
- Department of General Surgery and Transplantation, Izmir Bozyaka Education and Research Hospital, University of Health Sciences, Izmir, Turkey
| | - Alpay Ari
- Department of Infectious Disease, Izmir Bozyaka Education and Research Hospital, University of Health Sciences, Izmir, Turkey
| | - Baha Zengel
- Department of General Surgery and Transplantation, Izmir Bozyaka Education and Research Hospital, University of Health Sciences, Izmir, Turkey
| | - Adam Uslu
- Department of General Surgery and Transplantation, Izmir Bozyaka Education and Research Hospital, University of Health Sciences, Izmir, Turkey
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Lucke IM, Vrijlandt A, Lim J, van der Kooi AJ, van Schaik IN, Zaaijer HL, Hovius JW, Eftimov F. Borrelia burgdorferi sensu lato seroconversion after intravenous immunoglobulin treatment: A cohort study. Eur J Neurol 2021; 28:2383-2387. [PMID: 33817927 PMCID: PMC8251852 DOI: 10.1111/ene.14853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Revised: 03/19/2021] [Accepted: 03/20/2021] [Indexed: 11/28/2022]
Abstract
Objective Intravenous immunoglobulin (IVIg) consists of pooled donor immunoglobulins (IgG), possibly including anti‐Borrelia burgdorferi (Bbsl) antibodies. Apparent IVIg‐related Bbsl seroconversion could lead to incorrect diagnosis of Lyme borreliosis. This cohort study was designed to determine how often IVIg treatment leads to apparent Bbsl seroconversion and whether antibodies disappear post‐treatment. Methods Sera from chronic inflammatory demyelinating polyneuropathy (CIDP) and myositis patients were analyzed, drawn pre‐treatment and 6–12 weeks after the start of IVIg. In patients with apparent seroconversion, follow‐up samples after treatment withdrawal were analyzed, if available. Patients treated with corticosteroids were included as controls. A two‐tier protocol was used for serological testing consisting of the C6 Lyme ELISA (Oxford Immunotec) and confirmation by immunoglobulin M (IgM) and immunoglobulin G (IgG) immunoblot (Mikrogen®). Results We included 61 patients: 51 patients were treated with IVIg and 10 with dexamethasone. Of the patients treated with IVIg, 42 had CIDP (82%) and were treated with Nanogam® (Sanquin Plasma Products). Nine patients had myositis (18%) and were treated with Privigen® (CSL Behring). Anti‐Bbsl IgG seroprevalence pre‐treatment was 3% (2/61). Apparent seroconversion during IVIg treatment occurred in 39% (20/51) of patients, all treated with Nanogam. Post‐treatment seroreversion occurred in 92% (12/13) of patients with available follow‐up samples; in 78% (7/9) seroreversion was observed within 3 months. Conclusions Transient presence of anti‐Bbsl IgG antibodies after IVIg is regularly observed. This effect appears to be dependent on the IVIg brand, probably reflecting variation in Bbsl exposure of plasma donors. Lyme borreliosis serological testing during, and weeks to months after, IVIg is therefore of limited utility.
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Affiliation(s)
- Ilse M Lucke
- Department of Neurology and Clinical Neurophysiology, Amsterdam UMC, University of Amsterdam, Amsterdam Neuroscience, Amsterdam, The Netherlands
| | - Amber Vrijlandt
- Center for Experimental and Molecular Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Johan Lim
- Department of Neurology and Clinical Neurophysiology, Amsterdam UMC, University of Amsterdam, Amsterdam Neuroscience, Amsterdam, The Netherlands
| | - Anneke J van der Kooi
- Department of Neurology and Clinical Neurophysiology, Amsterdam UMC, University of Amsterdam, Amsterdam Neuroscience, Amsterdam, The Netherlands
| | - Ivo N van Schaik
- Department of Neurology and Clinical Neurophysiology, Amsterdam UMC, University of Amsterdam, Amsterdam Neuroscience, Amsterdam, The Netherlands.,Spaarne Gasthuis, Haarlem, The Netherlands
| | - Hans L Zaaijer
- Department of Medical Microbiology, Amsterdam UMC, University of Amsterdam, and Sanquin Blood Supply Foundation, Amsterdam, The Netherlands
| | - Joppe W Hovius
- Center for Experimental and Molecular Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Filip Eftimov
- Department of Neurology and Clinical Neurophysiology, Amsterdam UMC, University of Amsterdam, Amsterdam Neuroscience, Amsterdam, The Netherlands
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47
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Abstract
Krabbe disease involves the accumulation of neurotoxic metabolites due to lysosomal galactocerebrosidase enzyme deficiency, which results in widespread demyelination of central and peripheral nerves. Generally, Krabbe disease presents as spastic paraplegia with a slow progressive course; however, some cases may show clinical symptoms similar to those of chronic inflammatory demyelinating polyneuropathy (CIDP). No previously reported studies have investigated the efficacy of intravenous immunoglobulin (IVIg) for treating Krabbe disease, and reporting a case involving IVIg treatment may be informative in the clinical setting. A 14-year-old girl who developed Guillain-Barré syndrome-like limb weakness was administered IVIg, and her limb weakness improved. At 16 years old, she developed abnormal sensory perception and weakness of both upper limbs. A nerve conduction study revealed demyelination, which led us to suspect CIDP. IVIg was administered, and her symptoms gradually improved. A nerve biopsy, enzyme activity, and genetic test results indicated adult Krabbe disease. In some cases, IVIg may be an effective treatment for Krabbe disease.
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Affiliation(s)
| | - Hiroki Takeuchi
- Department of Neurology, National Hospital Organization Minami Kyoto Hospital, Japan
| | - Nobuyuki Oka
- Department of Neurology, National Hospital Organization Minami Kyoto Hospital, Japan
| | - Toko Shibuya
- Department of Pediatrics, Osaka University Graduate School of Medicine, Japan
| | - Norio Sakai
- Child Healthcare and Genetic Science Laboratory, Division of Health Sciences, Osaka University Graduate School of Medicine, Japan
| | - Akihiro Fujii
- Department of Neurology, Saiseikai Shiga Hospital, Japan
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48
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Wu HY, Pan CT, Cheng CF, Lin CY, Chang SN, Chen YC, Wang CY, Chen YF, Chen CY, Ma MHM, Hwang JJ. Combined intravenous immunoglobulin and baricitinib treatment for severe COVID-19 with rhabdomyolysis: A case report. J Formos Med Assoc 2021; 120:1777-1781. [PMID: 33838985 PMCID: PMC7988442 DOI: 10.1016/j.jfma.2021.03.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Revised: 03/15/2021] [Accepted: 03/16/2021] [Indexed: 01/20/2023] Open
Abstract
Since December 2019, the outbreak of coronavirus disease 2019 (COVID-19) has spread rapidly around the world. The severity of COVID-19 ranges from asymptomatic carriers to severe acute respiratory distress syndrome (ARDS). Accumulating evidence has shown that COVID-19 may be associated with multiple organ complications including cardiac injury, viral myositis and neurological deficits. Numerous laboratory biomarkers including lymphocytes, platelets, lactate dehydrogenase and creatine kinase (CK) have been associated with the prognostic outcomes of patients with COVID-19. However, dynamic correlations between levels of biomarkers and clinical course have not been studied. Herein, we report a 74-year-old female patient with severe COVID-19 which progressed to ARDS requiring intubation and mechanical ventilation. The laboratory findings showed lymphopenia, hypogammaglobulinemia, and elevated inflammatory biomarkers and CK. She received intensive therapy with hydroxychloroquine, lopinavir/ritonavir, and azithromycin with limited effects. Immunomodulatory treatments with high dose intravenous immunoglobulin and baricitinib were prescribed with satisfactory biochemical, radiographic and clinical recovery. We found an interesting correlation between serum CK elevation and inflammatory biomarkers, which reflected clinical improvement. This case demonstrates that inflammatory biomarkers, cytokines, and CK level correlated with disease severity and treatment response, and combined use of intravenous immunoglobulin and baricitinib is a potential treatment in patients with severe COVID-19.
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Affiliation(s)
- Hao-Yu Wu
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Chien-Ting Pan
- Department of Internal Medicine, National Taiwan University Hospital Yun-Lin Branch, Yun-Lin, Taiwan.
| | - Chiao-Feng Cheng
- Department of Internal Medicine, National Taiwan University Hospital Yun-Lin Branch, Yun-Lin, Taiwan
| | - Chi-Ying Lin
- Department of Internal Medicine, National Taiwan University Hospital Yun-Lin Branch, Yun-Lin, Taiwan
| | - Sheng-Nan Chang
- Department of Internal Medicine, National Taiwan University Hospital Yun-Lin Branch, Yun-Lin, Taiwan
| | - Yi-Chung Chen
- Department of Emergency Medicine, National Taiwan University Hospital Yun-Lin Branch, Yun-Lin, Taiwan
| | - Chih-Yuan Wang
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Yen-Fu Chen
- Department of Internal Medicine, National Taiwan University Hospital Yun-Lin Branch, Yun-Lin, Taiwan
| | - Chung-Yu Chen
- Department of Internal Medicine, National Taiwan University Hospital Yun-Lin Branch, Yun-Lin, Taiwan
| | - Matthew Huei-Ming Ma
- Department of Emergency Medicine, National Taiwan University Hospital Yun-Lin Branch, Yun-Lin, Taiwan
| | - Juey-Jen Hwang
- Department of Internal Medicine, National Taiwan University Hospital Yun-Lin Branch, Yun-Lin, Taiwan.
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49
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Beydoun SR, Sharma KR, Bassam BA, Pulley MT, Shije JZ, Kafal A. Individualizing Therapy in CIDP: A Mini-Review Comparing the Pharmacokinetics of Ig With SCIg and IVIg. Front Neurol 2021; 12:638816. [PMID: 33763019 PMCID: PMC7982536 DOI: 10.3389/fneur.2021.638816] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 02/10/2021] [Indexed: 11/13/2022] Open
Abstract
Immunoglobulin (Ig) therapy is a first-line treatment for CIDP, which can be administered intravenously (IVIg) or subcutaneously (SCIg) and is often required long term. The differences between these modes of administration and how they can affect dosing strategies and treatment optimization need to be understood. In general, the efficacy of IVIg and SCIg appear comparable in CIDP, but SCIg may offer some safety and quality of life advantages to some patients. The differences in pharmacokinetic (PK) profile and infusion regimens account for many of the differences between IVIg and SCIg. IVIg is administered as a large bolus every 3–4 weeks resulting in cyclic fluctuations in Ig concentration that have been linked to systemic adverse events (AEs) (potentially caused by high Ig levels) and end of dose “wear-off” effects (potentially caused by low Ig concentration). SCIg is administered as a smaller weekly, or twice weekly, volume resulting in near steady-state Ig levels that have been linked to continuously maintained function and reduced systemic AEs, but an increase in local reactions at the infusion site. The reduced frequency of systemic AEs observed with SCIg is likely related to the avoidance of high Ig concentrations. Some small studies in immune-mediated neuropathies have focused on serum Ig data to evaluate its potential use as a biomarker to aid clinical decision-making. Analyzing dose data may help understand how establishing and monitoring patients' Ig concentration could aid dose optimization and the transition from IVIg to SCIg therapy.
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Affiliation(s)
- Said R Beydoun
- Neuromuscular Division, Keck School of Medicine of University of Southern California (USC), Los Angeles, CA, United States
| | - Khema R Sharma
- Neurology Department, Miller School of Medicine, University of Miami, Miami, FL, United States
| | - Bassam A Bassam
- Neurology Department, University of South Alabama College of Medicine, Mobile, AL, United States
| | - Michael T Pulley
- Department of Neurology, University of Florida College of Medicine, Jacksonville, FL, United States
| | - Jeffrey Z Shije
- Department of Neurology, University of Florida College of Medicine, Jacksonville, FL, United States
| | - Ayman Kafal
- CSL Behring, King of Prussia, PA, United States
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50
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Patel DD, Bussel JB. Neonatal Fc receptor in human immunity: Function and role in therapeutic intervention. J Allergy Clin Immunol 2021; 146:467-478. [PMID: 32896307 DOI: 10.1016/j.jaci.2020.07.015] [Citation(s) in RCA: 53] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 07/21/2020] [Accepted: 07/23/2020] [Indexed: 02/08/2023]
Abstract
The humoral immune response provides specific, long-lived protection against invading pathogens, via immunoglobulin production and other memory functions. IgG, the most abundant immunoglobulin isotype, has the longest half-life and protects against bacterial and viral infections. The neonatal Fc receptor (FcRn) transports IgG across barriers, for example, the placenta, enhancing fetal humoral immunity to levels similar to their mothers'. Importantly, FcRn, by protecting IgG from intracellular degradation, results in an approximately 21-day circulating IgG half-life and high plasma levels; similarly, FcRn recycles albumin and is the portal of entry for enteric cytopathic human orphan (echo) virus infection. Dysregulated immune responses may lead to antibodies against self-antigens (autoantibodies), resulting in organ-specific or systemic autoimmune diseases. Autoantibody-mediated diseases have been treated by nonspecific immunoglobulin-lowering/modulating therapies, including immunoadsorption, plasma exchange, and high-dose intravenous immunoglobulin. However, targeting FcRn with specific inhibitors results in reduction in only IgG levels. The effectiveness of FcRn inhibitors in autoimmune diseases, including myasthenia gravis and immune thrombocytopenia, provides further evidence that IgG is a primary driver in these autoantibody-mediated diseases. We describe the role of FcRn in human biology, including insights that clinical testing of FcRn inhibitors have provided into FcRn biology and autoimmune disease mechanisms, allowing fact-based speculation on their therapeutic potential.
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Affiliation(s)
- Dhavalkumar D Patel
- UCB Pharma, Brussels, Belgium; University of North Carolina, Chapel Hill, NC.
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