Iron deficiency (ID) is the most common nutritional deficiency. ID diagnosis requires ferritin measurement because clinical findings are poor and nonspecific. We studied the diagnostic value of blue ...sclera, which was scarcely reported as a specific and sensitive sign of ID. We enrolled 74 patients suspected of having ID. Pictures of their eyes were taken using a smartphone under similar daylight conditions. Three independent physicians graded the scleral color, and a computer analysis yielded the blue percentile of the sclera image. Final analysis included 67 patients (mean age 59.9 ± 20.1 years). Fifty-one had ID. Subjective blue scleral color was associated with ID for physician 1 (64.5% vs. 86.1%,
= 0.03). Sensitivity was 60.8% (CI95: 46.1%; 74.2%), specificity 68.8% (CI95: 41.3%; 89%), and positive predictive value 86.1% (CI95: 70.5%; 95.3%). A marginal difference was observed for other physicians (
= 0.05). Computer analysis showed higher blue in the ID group (
= 0.04). The area under the receiver operating characteristic (ROC) curve was 0.7 (0.54; 0.85). Sensitivity was 78.4% (CI95: 63.7%; 88.7%), specificity was 50% (CI95: 24.7%; 75.3%). Assessment of blue sclera was not influenced by iris color, sex, or anemia. We showed that blue sclera has good positive predictive value for ID diagnosis, and computer analysis was correlated to clinical assessment. Improvement of this innovative, non-invasive method could provide an easy handling and inexpensive diagnosis tool for ID.
Cardiac sarcoidosis (CS) is a life-threatening condition in which clear recommendations are lacking. We aimed to systematically review the literature on cardiac sarcoidosis treated by corticosteroids ...and/or immunosuppressive agents in order to update the management of CS.
Using PubMed, Embase and Cochrane Library databases, we found original articles on corticosteroid and standard immunosuppressive therapies for CS that provided at least a fair Scottish Intercollegiate Guidelines Network (SIGN) overall assessment of quality and we analysed the relapse rate, major cardiac adverse events (MACEs) and adverse events. We based our methods on the PRISMA statement and checklist.
We retrieved 21 studies. Mean quality provided by SIGN assessment was 6.8 out of 14 (range 5-9). Corticosteroids appeared to have a positive impact on left ventricular function, atrioventricular block and ventricular arrhythmias. For corticosteroids alone, nine studies (45%, n=351) provided data on relapses, representing an incidence of 34% (n=119). Three studies (14%, n=73) provided data on MACEs (n=33), representing 45% of MACEs in patients treated by corticosteroid alone. Nine studies provided data on adjunctive immunosuppressive therapy, of which four studies (n=78) provided data on CS relapse, representing an incidence of 33% (n=26). Limitations consisted of no randomised control trial retrieved and unclear data on MACEs in patients treated by combined immunosuppressive agents and corticosteroids.
Corticosteroids should be started early after diagnosis but the exact scheme is still unclear. Studies concerning adjunctive conventional immunosuppressive therapies are lacking and benefits of adjunctive immunosuppressive therapies are unclear. Homogenous data on CS long-term outcomes under corticosteroids, immunosuppressive therapies and other adjunctive therapies are lacking.
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Introduction: Before the emergence of new treatments, refractory immune thrombocytopenia (ITP) was defined as the failure to achieve a minimum response to splenectomy and the requirement of ...long-term treatments to reduce risk of significant bleeding events. These patients experience a significant morbidity and mortality rate (1). The first aim of this study was to describe the characteristics of patients with multirefractory ITP (multi-ref ITP) according to an updated definition, i.e., patients who failed to respond to splenectomy, monoclonal anti-CD20 antibodies (rituximab, RTX) and both thrombopoietin-receptor agonists (TPO-RAs), as well as to identify associated factors with this phenotype. The second aim was to examine the long-term outcome of these patients.
Patients and Methods: We carried out a multicenter retrospective study in France. Inclusion criteria of patients with multi-ref ITP were failure to splenectomy, rituximab and the two marketed TPO-RAs, or presentation of an absolute contraindication to these treatments. Failure to treatment was defined according to standardized international criteria and bleeding score as described by Khellaf et al. Physicians were interviewed and patients' medical charts collected using the standardized form of the Referral Center for Adult ITP. In order to assess the variables associated with multirefractory occurrences, patients with multi-ref ITP were compared with non-multirefractory patients: for each case, 5 controls were randomly selected from the ITP clinical research database at Henri-Mondor Hospital, matched on the year of diagnosis. This database includes all ITP patients followed in the French national center for autoimmune cytopenias. Univariate and multivariate conditional logistic regression models were performed (backward procedure, α=5%).
Results: Thirty-seven patients (12 men/25 women) with multi-ref ITP and 183 controls were included in the study. Patients with multi-ref ITP have presented more initial bleeding symptoms than controls (75.6% vs 52.75%, p=.012)), had more frequently secondary ITP (35% vs 8.74%, p<.001), presented more clinical/biological auto-immune abnormalities (59.46% vs 28.42%, p=0008) and had more frequently a monoclonal gammopathy of undetermined significance than controls (19% vs 2.89%, p<.001). Only 24 patients with multi-ref ITP (68.57%) achieved initial transient response to steroid therapy (CR: n=10, R: n=12), compared to 91.61% responders in controls (p<.0001). In multivariate analysis, 4 factors were found to be associated with multi-ref ITP occurrence: (1) secondary ITP (OR: 4.81, 95%CI 1.31-17.86, p=.018), (2) presence of monoclonal gammopathy (OR: 5.93, 95%CI 1.08-32.48, p<.04), (3) bleeding symptoms at diagnosis (OR: 3.54 95%CI 1.11-11.22, p=.032) and (4) no response to steroid therapy (OR: 0.38 95%CI 0.20-0.72, p= .003). After a median follow-up of 84 months (range: 12-455), patients with multi-ref ITP have received a median of 10.5 lines of treatments (range: 6-15) including splenectomy, TPO-RAs and RTX, 5 patients (14%) died (intracranial hemorrhage, n=2; sepsis, n=1; breast cancer, n=1; unknown, n=1). Throughout the course of ITP, all patients required hospitalization; 22 (60%) received platelet transfusion, and 6 red-blood cells transfusion, 9 (24%) were admitted to intensive care units, 15 (40%) presented at least one bacterial infection, and 9 experienced at least one thrombosis (arterial, n=3; venous, n=6). At the end of follow-up, 20 patients (54%) were still non responders. Nine patients achieved a complete response: one after autologous hematopoietic stem cell transplantation, 2 after chemotherapy for hematological malignancy, and 5 after a combination of immunosuppressive therapy and TPO-RA.
Conclusion: Our study demonstrated that multirefractory ITP is an extremely serious condition, associated with a high morbidity and mortality. Factors significantly associated with this phenotype were secondary ITP, association with autoimmune disorders, monoclonal gammopathy and no response to steroids. Most of these patients remained non-responsive to alternative lines of rescue treatment, but some successes has been obtained with the combination of immunosuppressive therapy and TPO-RA.
(1) McMillan R, Durette C. Long-term outcomes in adults with chronic ITP after splenectomy failure. Blood 2004;104(4):956-60
Salles:Calistoga Pharmaceuticals, Inc.; Celgene Corporation; Genentech, Inc.; Janssen Pharmaceutica Products, L.P.; Roche: Consultancy; Celgene Corporation; Roche and Gilead Sciences: Research Funding; Celgene Corporation; Roche: Speakers Bureau. Cheze:Novartis: Consultancy, Membership on an entity's Board of Directors or advisory committees. Michel:GSK: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Roche: Research Funding; Novartis: Consultancy, Membership on an entity's Board of Directors or advisory committees; AMGEN: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau. Godeau:Roche: Research Funding; Amgen: Speakers Bureau; Novartis: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau.
Objective
To describe the efficacy and safety of omalizumab, an anti‐IgE monoclonal antibody, in patients with refractory and/or relapsing eosinophilic granulomatosis with polyangiitis ...(Churg‐Strauss) (EGPA).
Methods
We conducted a nationwide retrospective study including EGPA patients who received omalizumab. Response was defined as the absence of asthma and/or sinonasal exacerbations with a prednisone dosage of ≤7.5 mg/day (complete response) or >7.5 mg/day (partial response).
Results
Seventeen patients (median age 45 years) received omalizumab for severe steroid‐dependent asthma (88%) and/or sinonasal involvement (18%). After a median follow‐up of 22 months, 6 patients (35%) achieved a complete response, 5 patients (30%) achieved a partial response, and 6 patients (35%) had no improvement. The median Birmingham Vasculitis Activity Score decreased from 2.5 at baseline to 0.5 at 12 months. The median number of exacerbations per month decreased from 1 at baseline to 0 at 12 months, and the median forced expiratory volume in 1 second increased from 63% of the percent predicted at baseline to 85% of the percent predicted at 12 months. The median prednisone dosage decreased from 16 mg/day at baseline to 11 mg/day at 6 months and 9 mg/day at 12 months. Omalizumab was discontinued in 8 patients (47%) during follow‐up, because of remission (12.5%), adverse event despite disease remission (12.5%), refractory disease (25%), or relapse (50%). Relapses included retrobulbar optic neuritis attributable to EGPA in 2 patients and severe asthma flare in 2 others.
Conclusion
The results of this study suggest that omalizumab may have a corticosteroid‐sparing effect in EGPA patients with asthmatic and/or sinonasal manifestations, but reducing the corticosteroid dose may also increase the risk of severe EGPA flares, which raises the question of the safety of omalizumab in patients with EGPA.
To describe the characteristics, treatment, and outcome of patients with immune thrombocytopenia with clinical significance (ITPCS) associated with systemic lupus erythematosus (SLE).
This ...retrospective multicentre study included SLE patients who experienced ≥1 ITPCS (defined as ITP with attributable bleeding disorders and/or a platelet count <30 x109/L). Other causes of secondary thrombocytopenia were excluded. Major bleeding event (MBG) was defined as Khellaf score>8 and/or WHO score>2.
A total of 90 patients were included, the median (range) follow-up duration was 80 (6-446) months. ITP was diagnosed before SLE in 25 patients. They presented high rate of autoimmune haemolytic anaemia (15%), antiphospholipid antibody (62%), and antiphospholipid syndrome (19%). The 25 (28%) patients who experienced MBG had significantly more bleedings at ITP diagnosis and higher bleeding scores, and serositis and thrombosis during follow-up. They required significantly more treatment lines, transfusions, and hospitalizations. The 11 (12%) patients who experienced no bleeding event presented a significantly more restricted SLE phenotype (cutaneous and/or articular). Patients received a mean (range) of 4.2 (1-11) treatment lines. Corticosteroids and hydroxychloroquine allowed ITPCS overall response in one third of patients. The median relapse-free survival of rituximab (n = 34), azathioprine (n = 19), mycophenolate mofetil (n = 8), thrombopoietin-receptor agonists (n = 16), and splenectomy (n = 19) were 53, 31.5, 61, 24.5, and 78 months, respectively. Four patients experienced thrombotic events after splenectomy and one occurred under thrombopoietin-receptor agonist treatment.
SLE-ITCS patients displayed a high rate of haematological abnormalities and MBG patients exhibited higher morbidity. Management of thrombocytopenia was highly heterogeneous and many options seem viable.
Rituximab is a second‐line option in adults with immune thrombocytopenia (ITP), but the estimated 5‐year response rate, only based on pooled retrospective data, is about 20%, and no studies have ...focused on long‐term safety. We conducted a prospective multicenter registry of 248 adults with ITP treated with rituximab with 5 years of follow‐up to assess its long‐term safety and efficacy. The median follow‐up was 68.4 53.7‐78.5 months. The incidence of severe infections was only 2/100 patient‐years. Profound hypogammaglobulinemia (<5 g/L) developed in five patients at 15 to 31 months after the last rituximab infusion. In total, 25 patients died at a median age of 80 69.5‐83.9 years, corresponding to a mortality rate of 2.3/100 patient‐years. Only three deaths related to infection that occurred 12 to 14 months after rituximab infusions could be due in part to rituximab. At 60 months of follow‐up, 73 (29.4%) patients had a sustained response. On univariate and multivariate analysis, the only factor significantly associated with sustained response was a previous transient response to corticosteroids (P = .022). Overall, 24 patients with an initial response and then relapse received retreatment with rituximab, which gave a response in 92%, with a higher duration of response in 54%. As a result of its safety profile and its sustained response rate, rituximab remains an important option in the current therapeutic armamentarium for adult ITP. Retreatment could be an effective and safe option.
Good syndrome (GS) is a rare condition in which thymoma is associated with hypogammaglobulinemia. It is characterized by increased susceptibility to bacterial, viral, and fungal infections, as well ...as autoimmunity. Most patients have no circulating B cells.
The French DEFicit Immunitaire de l'adulte cohort provides detailed clinical and immunological descriptions of 690 adults with primary hypogammaglobulinemia. Comparisons between patients with GS, those with common variable immunodeficiency (CVID), and those with B(-) CVID (circulating B cells <1%) were performed.
Twenty-one patients had GS and 440 had CVID, including 39 B(-) CVID, with a median age at diagnosis of 60, 35, and 34 years, respectively. Invasive bacterial infections were observed in 90.5% of GS, 54% of CVID, and 72% of B(-) CVID patients. Eight patients with GS had opportunistic infections, despite normal peripheral CD4(+) T-cell numbers. Autoimmune complications were demonstrated in 76% of GS, 29% of CVID, and 26% of B(-) CVID patients. The spectrum of autoimmunity in GS was uncommon, consisting of oral lichen planus, graft-vs-host disease-like colitis, and pure red cell aplasia, different from the pattern observed in CVID patients. GS patients did not display lymphoid hyperplasia nor lymphoma, unlike those with CVID or B(-) CVID.
GS differs notably from CVID and B(-) CVID: very late onset, no familial cases, and absence of lymphoid hyperplasia. The key observation is the very high frequency of invasive bacterial infections in GS, an issue that physicians should be aware of.
Purpose
Deficiency of adenosine deaminase 2 (DADA2) is an inherited inborn error of immunity, characterized by autoinflammation (recurrent fever), vasculopathy (livedo racemosa, polyarteritis nodosa, ...lacunar ischemic strokes, and intracranial hemorrhages), immunodeficiency, lymphoproliferation, immune cytopenias, and bone marrow failure (BMF). Tumor necrosis factor (TNF-α) blockade is the treatment of choice for the vasculopathy, but often fails to reverse refractory cytopenia. We aimed to study the outcome of hematopoietic cell transplantation (HCT) in patients with DADA2.
Methods
We conducted a retrospective study on the outcome of HCT in patients with DADA2. The primary outcome was overall survival (OS).
Results
Thirty DADA2 patients from 12 countries received a total of 38 HCTs. The indications for HCT were BMF, immune cytopenia, malignancy, or immunodeficiency. Median age at HCT was 9 years (range: 2–28 years). The conditioning regimens for the final transplants were myeloablative (
n
= 20), reduced intensity (
n
= 8), or non-myeloablative (
n
= 2). Donors were HLA-matched related (
n
= 4), HLA-matched unrelated (
n
= 16), HLA-haploidentical (
n
= 2), or HLA-mismatched unrelated (
n
= 8). After a median follow-up of 2 years (range: 0.5–16 years), 2-year OS was 97%, and 2-year GvHD-free relapse-free survival was 73%. The hematological and immunological phenotypes resolved, and there were no new vascular events. Plasma ADA2 enzyme activity normalized in 16/17 patients tested. Six patients required more than one HCT.
Conclusion
HCT was an effective treatment for DADA2, successfully reversing the refractory cytopenia, as well as the vasculopathy and immunodeficiency.
Clinical Implications
HCT is a definitive cure for DADA2 with > 95% survival.
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