Federica Pulvirenti

A phase II, single-arm multicenter study of low-dose rituximab for refractory mixed cryoglobulinemia secondary to hepatitis C virus infection.

Eradication of hepatitis C virus (HCV) by antiviral therapy is the treatment of choice for mixed cryoglobulinemia secondary to this infection, but many patients fail to achieve sustained viral responses and need second-line treatments. Several studies have demonstrated that the infusion of the anti-CD20 monoclonal antibody rituximab is highly effective for refractory mixed cryoglobulinemia, with a clinical response in approximately 80% of patients, although the relapse rate is high. Virtually all published studies employed a rituximab dosage of 375mg/m(2) given four times, a schedule used for treating non-Hodgkins lymphomas. Based on a prior pilot study, we designed a phase II single-arm two-stage study (EUDRACT n. 2008-000086-38) to evaluate the efficacy of a lower dosage of rituximab, 250mg/m(2) given twice, for refractory mixed cryoglobulinemia. We present here the preliminary results in the first 27 patients enrolled. The overall response rate in 24 evaluable patients was 79%, and the mean time to relapse was 6.5months, similar to the 6.7months reported in studies with high-dose rituximab. Side effects were comparable to those seen in patients treated with high-dose. Increase of HCV viral load, reported in some high-dose studies, was not observed in our patients. Low-dose rituximab may provide a more cost/effective and possibly safer alternative for treating refractory HCV-associated mixed cryoglobulinemia.

Longitudinal study on health-related quality of life in a cohort of 96 patients with common variable immune deficiencies.

Health-related quality of life (HRQoL) in common variable immunodeficiency diseases (CVID) was evaluated by different tools, which were mainly used to compare different schedules of immunoglobulins administration in cross-sectional or short-term longitudinal studies. We assessed the HRQoL and psychological status of CVID patients in a longitudinal study over a 6-year period by a generic, non-disease-specific instrument (SF-36), and by a General Health Questionnaire (GHQ-12) for the risk of depression/anxiety. At baseline, 96 patients were enrolled. After 1 year, a second assessment was performed on 92 patients and, after 6 years, a third assessment was performed on 66 patients. Eighteen patients died during the study time. HRQoL was low, with mental health scales less affected than physical scales. A decline in the score on SF-36 scales was observed between the first and the third assessment for the Physical Functioning, Body Pain, General Health, Social Functioning, and Role-Emotional scales. The General Health scale showed a lower score in these patients, when compared to patients with other chronic diseases. Approximately one-third of the patients were at risk of anxiety/depression at all observation times, a percentage that reached two thirds of the patients, considering only the group of females. Over the 6 years of the study, the health condition of 11/66 patients worsened, passing from “GHQ-negative” to “GHQ-positive”; their score on SF-36 scales also decreased. A decrement of one point in each of the Physical Functioning, Vitality, Social Functioning, and Mental Health SF-36 scales increased the risk of developing anxiety/depression from three to five percent. A negative variation of the Physical Functioning score increased the risk of psychological distress. In a survival analysis with dichotomized variables, Physical Functioning scores <50 were associated with a relative risk (RR) of 4.4, whereas Social Functioning scores <37.5 were associated with a RR of 10.0. In our study, it was the clinical condition, as opposed to the different treatment strategies with immunoglobulins, which had a major role on the deterioration of HRQoL. Moreover, in a quality-of-life evaluation, disorders such as anxiety/depression should be assessed, as they yet often go unrecognized. Our results might be helpful in the interpretation of currently available data on quality of life in CVID patients.

Hemolysis in patients with antibody deficiencies on immunoglobulin replacement treatment

Immunoglobulin (Ig)G replacement with intravenous or subcutaneous immunoglobulins is a lifelong substitutive therapy in patients with primary antibody deficiencies (PADs). Hemolysis after immunoglobulin therapy was described in patients receiving high immunoglobulin dosages. The issue of hemolysis after immunoglobulin administration at replacement doses has been considered of little clinical significance.

Lung Magnetic Resonance Imaging with Diffusion Weighted Imaging Provides Regional Structural as well as Functional Information Without Radiation Exposure in Primary Antibody Deficiencies

PurposePrimary antibody deficiency patients suffer from infectious and non-infectious pulmonary complications leading over time to chronic lung disease. The complexity of this pulmonary involvement poses significant challenge in differential diagnosis in patients with long life disease and increased radio sensitivity. We planned to verify the utility of chest Magnetic Resolution Imaging with Diffusion-Weighted Imaging as a radiation free technique.MethodsProspective evaluation of 18 patients with Common Variable Immunodeficiency and X-linked Agammaglobulinemia. On the same day, patients underwent Magnetic Resonance Imaging with Diffusion Weighted Imaging sequences, High Resolution Computerized Tomography and Pulmonary Function Tests, including diffusing capacity factor for carbon monoxide. Images were scored using a modified version of the Bhalla scoring system.ResultsMagnetic Resonance Imaging was non-inferior to High Resolution Computerized Tomography in the capacity to identify bronchial and parenchymal abnormalities. HRCT had a higher capacity to identify peripheral airways abnormalities, defined as an involvement of bronchial generation up to the fifth and distal (scores 2–3). Bronchial scores negatively related to pulmonary function tests. One third of consolidations and nodules had Diffusion Weighted Imaging restrictions associated with systemic granulomatous disease and systemic lymphadenopathy. Lung Magnetic Resolution Imaging detected an improvement of bronchial and parenchymal abnormalities, in recently diagnosed patients soon after starting Ig replacement.ConclusionsMagnetic Resonance Imaging with Diffusion Weighted Imaging was a reliable technique to detect lung alterations in patients with Primary Antibody Deficiencies.

Idiopathic Non Cirrhotic Portal Hypertension and Spleno-Portal Axis Abnormalities in Patients with Severe Primary Antibody Deficiencies

Background and Aim. Portal hypertension has been reported in association with acquired and primary immune deficiencies without a comprehensive description of associated spleno-portal axis abnormalities. Pathological mechanisms are poorly defined. Methods. Observational, single centre study with the aim of assessing the prevalence of spleno-portal axis abnormalities in an unselected cohort of 123 patients with primary antibody deficiencies and without known causes of liver diseases regularly followed up for a mean time of 18 ± 14 years. A cumulative period of 1867 patients-year was analysed. Clinical and immunological data, abdominal ultrasounds, CT scans, and endoscopy features were included in the analysis. Results. Twenty-five percent of patients with primary antibody deficiencies had signs of portal vein enlargement but only 4% of them had portal hypertension, with portal systemic collaterals. Liver biopsies showed liver sinusoids congestive dilatation, endothelization, and micronodularity fulfilling the criteria for noncirrhotic portal hypertension. Patients with portal vein enlargement had severe clinical and immunological phenotypes. Conclusions. In primary antibody deficient patients, infections, inflammations, splenomegaly, increased blood venous flow, and lymphocyte abnormalities contribute to establishment of liver damage possibly leading to noncirrhotic portal hypertension. Patients with primary antibody deficiency should be considered a good model to give insight into the pathological mechanisms underlying noncirrhotic portal hypertension.

Intravenous immunoglobulin replacement induces an in vivo reduction of inflammatory monocytes and retains the monocyte ability to respond to bacterial stimulation in patients with common variable immunodeficiencies

Intravenous IgG administration induces significant modifications in the innate and adaptive compartment of the immune system including the monocyte/macrophage system. We analyzed the in vivo effect of IgG administered at replacement dosages on the frequency of monocytes subsets, on the modulation of CD11b and sialic acid-binding immunoglobulin-like lectin receptor (Siglec 9) expression and on monocytes production of reactive oxygen species. We showed that patients with Common Variable Immune Deficiency have an increased frequency pro-inflammatory intermediate CD14(++)CD16(+) monocytes and an increased expression of CD11b and Siglec 9 on monocytes. IgG administered at replacement dosages exerted an in vivo anti-inflammatory effect as shown by a reduction of circulating monocytes, of intermediate pro-inflammatory monocytes, of CD11b and Siglec 9 expression and of ex vivo monocytes oxidative burst. Nevertheless, intravenous IgG administration did not affect the monocyte functional ability to respond to a bacterial stimulation in terms of CD11b and Siglec 9 expression and reactive oxygen species production.

Polyvalent immunoglobulins: challenges and perspectives.

Over the past 3 decades, administration of pooled human immunoglobulins (IVIGs) which contain a broad range of antibody specificities, originally in use for antibody replacement therapy, has been extended to other clinical conditions due to their anti-inflammatory and immunomodulatory effects, which were not anticipated when these polyclonal preparations were first developed1. Currently available IVIGs preparations are produced human pools of plasma obtained from several thousand healthy blood donors by using a number of preparatory steps. The large donor pool ensures the diversity of antibody repertoires similar to those present in normal human serum with antibody specificities to a wide spectrum of antigens. Moreover, immunoglobulin preparations contain natural antibodies (NAb), occurring independently of antigenic stimulation and representing a first-line defence against pathogens2–3. The distribution of IgG subclasses in IVIGs is comparable with that of IgG in normal human serum, however, unlike IgG purified from a single individual, therapeutic IVIGs preparations contain substantial amounts of IgG dimers and traces of multimers, due to the idiotype-anti-idiotype complex formation between IgG molecules from different individuals. IVIGs is administered at distinct doses in the clinical settings4–5: whereas patients affected by Primary Immune Deficiencies are treated with replacement levels of IVIGs, patients with autoimmune and inflammatory diseases are treated with high dose of IVIGs. In autoimmune and inflammatory diseases, several mutually non-exclusive mechanisms have been put forward to explain the immunomodulatory effects6–8: IVIGs exerts immunoregulatory functions at multiple levels (Table I), implicating modulation of expression and function of Fc receptors, interference with complement activation and the cytokine profiles, modulation of idiotype network and cell proliferation. While some of these effects may explain the rapid and passive neutralisation of pathogenic autoantibodies, clinically the observed beneficial effects of IVIGs are well beyond the half-life of infused IgG, suggesting that the effect may not be due merely to a passive clearance or competition with pathogenic autoantibodies. Moreover, also at replacement dosages and beside their mere substitutive role, IVIGs have an active role and modulates the function of several cell types of the immune system, including dendritic cells, B lymphocytes, macrophages and T lymphocytes9. Table I Biologic activity and mediators involved in mechanisms Fab-mediated, Fc-mediated, Complement-mediated, Sialylated Fc-mediated, and protein involved in the immune system homeostasis through intravenous immunoglobulins. Replacement treatment: type, dose and timing of treatment Immunoglobulin replacement is the standard therapy for primary antibody deficiencies (PAD) aiming to replace the missing antibodies and thereby to prevent recurrent infections. A number of Ig products are available and deciding which one to use, and in what dose are the points to consider. For PAD patients, a thorough evaluation of immune function before deciding on Ig replacement is important10. We have recently developed an algorithm that might help physicians in the diagnostic process and in the decision on the immunoglobulin replacement starting (Figure 1). Figure 1 Algorithm for diagnosis in patients with hypogammaglobulinemias. After diagnosis, the optimal immunoglobulin replacement dosages required over time to minimise infection risks are not yet definitely established with a consequent wide variation in treatment practices11–14. Debate continues regarding the exact timing and the optimal prophylaxis regimen, knowing that the system of care is itself an important determinant of patient’s outcome. Individualised medicine and personalised health research presents methodological challenges. Different options have been explored to establish how we should individualise immunoglobulin replacement therapy. As with many interventions, there may be specific subgroups of patients who are more likely to benefit from treatment with higher or lower dosages of immunoglobulins. Clinical PAD phenotypes are quite variable within these diseases and patients are susceptible to a wide range of complications other than infections15. In PAD we have identified a clinical phenotype characterised by a high pneumonia risk16: patients who had low IgG and IgA levels at diagnosis; patients who had IgA level <7 mg/dL and who had bronchiectasis and absence of protective IgA and IgM anti-polysaccharide after pneumococcal immunisation, confirming previous data that demonstrate that the loss of function of memory B cells seems to represent the major cause of PAD-associated infectious diseases. We also demonstrated that better patient’s outcome could be achieved by shorting the administration intervals from 3–4 to 2-1 weeks without the need to greatly increase the monthly cumulative Ig dosage in those PAD patients: 1) who present an infectious risk profile, 2) who are affected by bronchiectasis and/or enteropathy; 3) who continue to had adverse events despite pre-medication. On the other hand, in patients with fewer disease-associated complications the immunoglobulin replacement could be done with the widely used interval of 3 or 4 weeks, even administering a low immunoglobulin replacement dosage. Also the adverse events can be greatly reduced by administrating low dosages in a single setting and by shortening the administration intervals17. Thus, the suggested protective high trough IgG level (1,000 mg/dL)18 to be maintained to avoid infections should not be considered a general goal and only large prospective multi-centre studies might help to define the prevalence of patients needing a higher or lower monthly Ig dosage and the best interval between administrations. These considerations have a vast potential to ameliorate the clinical practice of immunoglobulins replacement treatment.

Clinical Associations of Biallelic and Monoallelic TNFRSF13B Variants in Italian Primary Antibody Deficiency Syndromes

We assessed the prevalence of TNFRSF13B mutations and the clinical correlates in an Italian cohort of 189 CVID, 67 IgAD patients, and 330 healthy controls to substantiate the role of TACI genetic testing in diagnostic workup. We found that 11% of CVID and 13% of IgAD carried at least one mutated TNFRSF13B allele. Seven per cent of CVID had monoallelic-mutations and 4% had biallelic-mutations. The frequency of C104R monoallelic-mutations was not higher than that found in healthy controls. Biallelic-mutations were exclusively found in CVID. CVID patients carrying monoallelic-mutations had an increased prevalence of lymphadenopathy, granulomata, and autoimmune cytopenias. CVID carrying biallelic-mutations had a low prevalence of autoimmunity in comparison with TACI wild-type CVID. Moreover, biallelic-mutated CVID had higher frequency of switched memory B-cells and higher IgM and IgA antibodies to polysaccharide antigens than TACI wild-type and monoallelic-mutated CVID. TACI-mutated IgAD patients had only monoallelic-mutations and did not display clinical difference from IgAD wild-type patients. In conclusion, TNFRSF13B genetic screening of antibody deficiencies may allow the identification of mutational patterns. However, as with counseling for risk assessment, geneticists should be aware that the interpretation of genetic testing for TACI mutations is difficult and the potential impact on clinical management is still limited.

Clinical use of polyvalent immunoglobulins.

Intravenous immunoglobulins (IVIG) and subcutaneous (SCIG) are used in treatment of a broad spectrum of diseases. Prepared from the collective plasma of several thousand people, therapeutic immunoglobulin consists mostly of human polyspecific IgG1–4. IgG replacement is the standard therapy for primary antibody deficiencies (PAD) aiming to replace the missing antibodies and thereby to prevent recurrent infections. Replacement therapy generally involves the use of 400–600 mg/kg administered every 3 or 4 weeks5–6. Debate continues regarding the exact timing and the optimal prophylaxis regimen, knowing that the system of care is itself an important determinant of patient outcomes7–8. The use of immunoglobulins as an immunomodulating therapy ranges from transplantation and treatment of autoimmune-haematological diseases to treatment of various neuroimmunological clinical entities9–10. Immunomodulating generally involves the use of 2 g/kg administered over either 2 or 5 consecutive days. US FDA approved IVIGs for the treatment of Primary Immune Deficiencies (PID), immune thrombocytopenic purpura, Kawasaki disease, bone marrow transplantation in patients aged over 20 years, chronic B-cell lymphocytic leukaemia, and paediatric AIDS (Table I). Table I FDA approved indications for the therapeutical usage of polyvalent human immunoglobulins. Similarly, in Italy, the indications for IVIGs treatment include Primary Immune Deficiencies, immune thrombocytopenic purpura, Kawasaki disease, bone marrow transplantation in patients aged over 20 years, chronic B-cell lymphocytic leukaemia and myeloma, paediatric AIDS and Guillain-Barre syndrome, and a new recently introduced indication (Table II). Table II Italian approved indications for the therapeutical usage of polyvalent human immunoglobulins. In addition to its use in primary and secondary immune deficiencies, many other clinical conditions might benefit from IVIGs therapy, all requiring documentation of contraindications to or a lack of response to conventional therapies according to US FDA (Table III). Some of these other conditions are extremely rare, making randomised controlled investigations difficult. Randomised clinical trials are warranted to support the evidence-based use of IVIg, and to identify the ideal administration protocols to maximise the benefits of what is a limited resource, knowing that many health care delivery systems are subjected to economic pressures and that individualised medicine and personalised health research presents methodological challenges11. Table III Clinical conditions that might benefit from immunoglobulin treatment according to Food and Drugs Administration additional approved indications with criteria. In this review we first discussed the issue of substitution treatment in primary antibody deficiencies, the choice of the immunoglobulin dosages, timing and the impact of therapy in survival. Then we discussed the immunoglobulin anti-inflammatory and immuno-modulating results in the treatment of immune-mediated demyelinating diseases, of rheumatological diseases (vasculitis and autoimmune connective tissue diseases), of haematological diseases (autoimmune cytopenias), of dermatological conditions (pemphigus and pemphigoid) and their usage in transplantation. Intentionally we did not address the issue of the off-label immunoglobulin treatments, despite their frequent usage carried on the basis of single case reports or uncontrolled studies.

AB0933 Endocarditis in Patients Under Immunosuppressive Treatment: Don't Stop Believin'

Background Patients with rheumatic disease under immunosuppressive treatment had an high risk of infection. For this subjects, infective disease could have unusual manifestation or could present as co-infection. Moreover, immunocompromised hosts could have untruthfully negative serological tests. For this reason clinicians have to search infections actively also by nested-PCR or microbial culture. Objectives Here we describe a case of endocarditis due to coinfection by Coxiella burnetii and Borrelia burgdorferi in a patients with Systemic Lupus Erythematosus and persistent fever and relapse of arthritis, not responding to immunosuppressive therapy. This case report emphasizes the importance of excluding an infection as a cause of unusual clinical manifestation in a patient under immunosuppressive treatment. Methods Case report. Data from medical files from a patient regularly followed up at the Immunology division of Umberto I Hospital of Rome were collected. Results A 70-year-old female with Systemic Lupus Erythematosus had fever and chills associated with arthritis, fatigue, lymphadenopathy, skin purple lesions and erythema nodosum. The patient was under therapy with methotrexate, adalimumab and methyl prednisone because of her rheumatic disease. Fever continued despite the increase of steroid therapy and antibiotics therapy. Patient underwent to laboratory tests showed pancytopenia and high erythrocyte sedimentation rate while other inflammatory markers were normal. A skin biopsy showed dermal perivascular inflammatory infiltrate with lymphohistiocytic cells and eosinophilic and neutrophilic granulocytes. An extensive infectious diseases laboratory workup, including sets of blood cultures and serological tests, was performed with a negative outcome. A trans-thoracic echocardiogram was performed and no vegetation was remarkable; a trans-esophageal echocardiogram showed a small posterior leaflet mitral valve vegetation. The patient was tested for the main etiologic agents of culture-negative endocarditis by PCR. Because of positivity of both Coxiella burnetii and Borrelia burgdorferi DNA, Chronic Q fever and Lyme disease were diagnosed. An association of doxycycline and hydroxychloroquine was started. After 10 days the fever disappeared and the patient had a progressive improvement of arthritis and skin lesions. Co-infection between C. burneti e B. burgorferi was rarely reported but pathogenically possible because these pathogens can be transmitted by the same species of arthropods. The negative outcome of serological tests for both B. burgdorferi and C. burnetii could be related to the condition of patients immunosoppression. Conclusions This case report emphasizes the importance of excluding an infection as a cause of unusual arthritis. The use of PCR is mandatory in patients under immunosuppressive therapy since serological response could be missing. Disclosure of Interest None declared