Immunosuppressive Drugs Research Articles

The correlation between rituximab dose reduction and acute relapses of neuromyelitis optica spectrum disorder, lessons from COVID-19 epidemic

BackgroundCOVID-19 was a viral infection that led to a global pandemic in March 2020. At the beginning of the pandemic, clinicians encountered the challenge of how immunosuppressive treatments would affect the course of COVID-19 infection in people with autoimmune diseases. Neuromyelitis optica spectrum disorder is an autoimmune astrocytopathy that is caused by an inflammation in the CNS. Major treatments to prevent acute relapses include immunosuppressive drugs. Rituximab is a well-established immunosuppressive agent in NMOSD maintenance therapy. Some reports suggested that treatment with Rituximab might increase the risk of COVID-19 infection and its mortality in NMOSD. On the other hand, dose reduction or extended interval treatment might lead to acute relapses of NMOSD and permanent disability. MethodsIn this study, we evaluated the correlation between the dose of rituximab and the relapse rate of NMOSD during an epidemic. This was an observational study on 171 patients among whom 55 cases were seropositive. Some patients received full dose rituximab routinely (1000 mg/dose, every 6 months), but others were treated with half dose (500 mg/dose) during the epidemic. Also, some doses were prescribed with a delay, based on the level of CD19 and CD20. ResultsThe Pearson correlation coefficient (r) showed a negative and significant relation (r: - 0.19, p: 0.022) between the amount of drug and the number of relapses in the seropositive group, so low dosage of the drug was related to more acute relapses. In seronegative cases, there was not any valuable relationship. (p: 0.367). ConclusionLower dose of rituximab, especially in seropositive NMOSD patients, can potentially lead to acute relapses. So, the more frequent evaluation of the CD19, CD20, and, CD27 levels, and the general clinical condition of the patients should be considered.

Hemophagocytic Lymphohistiocytosis (HLH)

HLH is a reactive process resulting from prolonged and excessive antigen-presenting cell activation [1]. Hemophagocytosis is a hallmark of activated macrophages/histiocytes. The predominant clinical findings of HLH are fever (often hectic and persistent), cytopenia, hepatitis, and splenomegaly. A case of HLH in a 32-year-old female with no past medical history was presented in the current paper. She was admitted to the medical department with a fever and thrombocytopenia for evaluation. After failure to respond to a brief course of empiric antibiotics, the patient was extensively investigated and finally diagnosed with HLH (bone marrow aspiration showed occasional hemophagocytes). She was started on steroids but, failed to respond and so immunosuppressant drugs were added to the therapy.

Spray-dried cyclophosphamide-loaded polyhydroxyalkanoate microparticles: design and characterization

Background and purpose: Cyclophosphamide (CP) is a widely used antitumor and immunosuppressive drug, but it is highly cytotoxic and has carcinogenic and teratogenic potential. To reduce adverse effects of CP therapy and the frequency of its administration, the microencapsulation of CP into biodegradable polymeric matrices can be performed. However, according to the literature, only a few polymers were found suitable to encapsulate CP and achieve its’ sustained release. Experimental approach: In this research, spray-dried cyclophosphamide-loaded poly(3-hydroxybutyrate-co-3-hydroxyvalerate) (PHBV) microparticles were prepared and characterized in terms of their average hydrodynamic diameter, polydispersity index, surface morphology, zeta potential, encapsulation efficiency, drug loading, thermal properties and cytotoxicity against 3T3 cells. Key results: The obtained CP-loaded microparticles had a regular spherical shape, uniform size distribution with an average diameter of 4.21±0.04 μm and zeta potential of -34.2±0.2 mV. The encap­sulation of cyclophosphamide into the PHBV matrix led to a decrease in melting and degradation tempe­ratures and an increase in diameter, glass transition and cold crystallization temperatures compared to blank microparticles. Moreover, microencapsulation of cyclophosphamide lowered its cytotoxicity compared to the pure drug: the number of dead cells in the culture decreased by 28 %, while their metabolic activity increased by 20 %. The cumulative in vitro drug release studies showed a gradual release of CP up to 18 days, so the obtained microparticle formulation can be used as a sustained-release cyclophosphamide delivery system. Conclusion: In this research, a novel cyclophosphamide-loaded platform based on PHBV micro­particles was established and characterized. Overall, this study offers promising prospects for cancer therapy in the future.

Eculizumab as first-line treatment for patients with severe presentation of complement factor H antibody-mediated hemolytic uremic syndrome.

Complement factor H (FH) antibody-mediated hemolytic uremic syndrome (HUS) has varying prevalence globally. Plasmapheresis and immunosuppressive drugs are the standard treatment. Recently, eculizumab has been reported as an effective alternative. This study aims to report four children with FH antibody-mediated HUS managed with eculizumab plus immunosuppression as first-line therapy. A retrospective chart review was conducted for children aged ≤ 18years old with complement-mediated HUS in two referral centers. Patients with FH antibody-mediated HUS treated with eculizumab as first-line therapy were included. Four children (aged 6-11years old) were included. Dialysis was necessary in three patients. Eculizumab was administered 5-23days after onset. None of them received plasmapheresis. Prednisone and mycophenolate mofetil were added after receiving positive FH antibody results. Hematological signs and kidney function improved after the second eculizumab dose. Eculizumab was discontinued in three patients after 6months. One patient required rituximab due to persistent high FH antibody titers; discontinuation of eculizumab occurred after 15months without recurrence. No treatment-related complications were observed. During a mean 12-month follow-up (range 6-24months), no relapses were recorded and all patients ended with normal GFR. Our data suggest that a short course of 6months of C5 inhibitor might be sufficient to reverse thrombotic microangiopathy symptoms and improve kidney function in patients with severe FH antibody-mediated HUS. Simultaneously, adding immunosuppressive agents might reduce the risk of relapse and allow cessation of C5 inhibition in a shorter period of time.

Preparation and evaluation of novel oral tacrolimus nanocochleates for organ transplantation to reduce individual differences and improve drug safety

After organ transplantation, patients require treatment with immunosuppressive drugs to prevent immune rejection and transplantation failure. Tacrolimus (FK506) is a widely used immunosuppressant known for its potent immunosuppressive effect and narrow therapeutic range. Monitoring of FK506 blood concentrations is essential to avoid nephrotoxicity. In this study, a novel FK506 nanomedicine (FK506 cochleates) was developed using a microfluidic method to reduce variability among individuals and improve drug safety. The particle size of FK506 cochleates was (183.3 ± 1.4) nm, the zeta potential was −(39.28 ± 2.12) mV, and the encapsulation efficiency was more than 85 %. Particle size of FK506 cochleates could be maintained for up to 12 weeks in freeze-dried powder form. Small-angle X-ray scattering (SAXS) experiment confirmed the formation of cochleates by adding calcium solution. In vitro release studies demonstrated a sustained-release profile of FK506 from the cochleates carrier. Furthermore, the cochleates carrier could protect FK506 from the influence of stomach acid and slowly release the drug in the intestine. After oral administration, FK506 cochleates exhibited sustained-release properties in rats, accumulating in the spleen and lymph nodes − key anatomical sites for FK506’s pharmacological action. Importantly, FK506 cochleates significantly prolonged the survival time in the rabbit heart transplantation model while maintaining good safety profiles. In conclusion, the FK506 cochleates showed promising potential for enhancing drug safety in therapeutic organ transplantation.

Treatment of Late-onset Acute Graft-versus-host Disease Following Double Lung Transplantation Using a JAK2 Inhibitor.

Acute graft-versus-host disease (aGVHD) is a rare but potentially life-threatening complication that can occur after solid organ transplantation, particularly in organs with abundant lymphoid tissue like the liver and intestines. While less common in lung transplants, the rising numbers of these procedures have brought more attention to aGVHD, usually appearing within the first 3-mo posttransplant. Given its relative rarity, a clear understanding of the pathophysiology, risk factors, diagnostic, and management strategies remain elusive. These knowledge gaps can lead to delays in diagnosis and the initiation of appropriate treatment leading to predictably inferior outcomes. Managing aGVHD following solid organ transplantation is challenging, and there is no standard approach. Current management involves high-dose steroids and other immunosuppressive drugs. However, these interventions are associated with serious complications, including potentially fatal infections, underscoring the urgent need for more research to refine both diagnostic methods and treatment approaches and ultimately improving patient outcomes. In this report, we aim to deepen our understanding of aGVHD following lung transplants and share our experience with a unique case of aGVHD occurring almost a year after lung transplantation that was successfully managed using ruxolitinib, describing a potential treatment approach modeled on the contemporary management of stem cell transplant associated aGVHD.

Structures for quality assurance and measurements for kidney replacement therapies: A multinational study from the ISN-GKHA.

Optimal care for patients with kidney failure reduces the risks of adverse health outcomes, including cardiovascular events and death. We evaluated data from the third iteration of the International Society of Nephrology Global Kidney Health Atlas (ISN-GKHA) to assess the capacity for quality service delivery for kidney failure care across countries and regions. We explored the quality of kidney failure care delivery and the monitoring of quality indicators from data provided by an international survey of stakeholders from countries affiliated with the ISN from July to September 2022. One hundred and sixty seven countries participated in the survey, representing about 97.4% of the world's population. In countries where haemodialysis (HD) was available, 81% (n = 134) provided standard HD sessions (three times weekly for 3-4 h per session) to patients. Among countries with peritoneal dialysis (PD) services, 61% (n = 101) were able to provide standard PD care (3-4 exchanges per day). In high-income countries, 98% (n = 62) reported that >75% of centers regularly monitored dialysis water quality for bacteria compared to 28% (n = 5) of low-income countries (LICs). Capacity to monitor the administration of immunosuppression drugs was generally available in 21% (n = 4) of LICs, compared to 90% (n = 57) of high-income countries. There was significant variability between and within regions and country income groups in reporting the quality of services utilized for kidney replacement therapies. Quality assurance standards on diagnostic and treatment tools were variable and particularly infrequent in LICs. Standardization of delivered care is essential for improving outcomes for people with kidney failure.

B-156 Extraction strategy for therapeutic drug monitoring of sirolimus and tacrolimus using volumetric absorptive microsampling

Abstract Background Following organ transplantation, patients are placed on immunosuppressant drugs (ISDs) to minimize the risk of rejection. Sirolimus and tacrolimus are two of the most widely used ISDs, however, due to their narrow therapeutic indices, patients require frequent therapeutic drug monitoring (TDM). Recurrent venipuncture can become uncomfortable and disruptive, especially in the pediatric population. Therefore, we describe an extraction method using dried whole blood from volumetric absorptive microsampling (VAMS) devices for the detection of sirolimus and tacrolimus by turbulent flow liquid chromatography tandem mass spectrometry (TFC-MS/MS). The use of VAMS in the clinical laboratory will provide ISD patients with a convenient alternative to traditional blood draws. Methods MassTrak immunosuppressant calibrators based on a whole blood matrix (Waters) were applied to 30 μL VAMS Mitra devices (Neoteryx) and dried overnight. To extract the whole blood off of VAMS tip, we tested various methanol:water solvent ratios, of which 30 μL was added to the device. Tips were extracted using ultrasonication (30 min), vortexing (5 min), and centrifugation. Once extracted from the tip, 25 mM zinc sulfate was added to whole blood extract at a 1:1 (v/v) ratio. An acetonitrile and methanol extraction reagent was then added to the whole blood/zinc sulfate solution at a 2:1 (v/v) ratio. After brief vortexing, samples were centrifuged at 16,060 × g (10 min) and tested using an established TFC-MS/MS method which deploys a TLX-2 system for sample preparation coupled to a Q-Trap tandem mass spectrometer (AB Sciex 5500). Results A 80:20 (v/v) water:methanol extraction solvent yielded the greatest extraction efficacy for both sirolimus and tacrolimus from the VAMS tips compared to other tested ratios. We established a 5-point calibration curve to correlate the measured values of ISDs with known MassTrak calibration standard concentrations. The resulting average calibration curve from 3 independent experiments was highly linear for both sirolimus (R2= 0.992; slope= 1.1; intercept= 0.94) and tacrolimus (R2= 0.996; slope= 1.1; intercept = 0.8819). Our VAMS whole blood extraction strategy was correlated to the established neat whole blood protocol, which utilized all of the sample preparation steps outlined above except the initial extraction from the VAMS tip. The average extraction efficacy was 89.1% for sirolimus with an average coefficient of variation (CV%) of 12.1% across 3 independent experiments. For tacrolimus, we demonstrated an average extraction efficacy of 100.1% with an average CV% of 8.4%, again across 3 independent experiments. Conclusions We demonstrate the feasibility of using a VAMS approach to TDM of sirolimus and tacrolimus. Our results demonstrate favorable recoveries for both of the tested drugs, evidenced by high recoveries of the external calibration standards. Additionally, our method exhibited high extraction efficacy and low variability. Further validation studies, including the utilization of clinical samples is necessary to confirm our preliminary findings.

Belimumab 10 years later: how drug positioning has changed.

We analysed the change in the positioning of belimumab (BLM) in systemic lupus erythematosus (SLE) treatment in the first decade of real-life use, by providing data about patients treated by this biological drug in the Sapienza Lupus Cohort. We evaluated SLE patients treated by BLM according to the current clinical practice. Data of each patient were collected, focusing on previous and concomitant treatments. Finally, the drug retention rate was assessed. Since August 2013, 138 SLE patients started BLM (M/F 7/131; median age 49years, IQR 13.25; median disease duration 214months, IQR 180). To evaluate the change in BLM positioning, we divided patients according to the date of starting treatment as below: patients treated from 2013 to 2018 (period 1) and those treated since 2019 to date (period 2). Indeed, the median number of previous immunosuppressant drugs was significantly higher in patients treated in period 1 [3 (IQR 1.25) versus 1 (IQR 1.75), p = 0.0002]. Furthermore, 15.9% of patients treated in period 2 were not previously treated by immunosuppressant drugs, compared with 5.2% in period 1 (p = 0.01). Finally, the 24-month drug survival was significantly higher in patients previously treated with ≤ 1 immunosuppressant drug in comparison with those treated with ≥ 2 drugs (69.1% versus 43.4%, p = 0.0097, HR 0.49; 95% CI 0.27-0.88). Our data clearly described the progressive anticipation of BLM prescription in the first 10years of clinical practice, underlining as choosing earlier biological agents could positively influence the drug retention rate.

B-115 Software Data Processing and Review LC-MS/MS Workflow Improvements for Clinical Research

Abstract Background In the field of quantitative LC-MS/MS, the need for efficient, accurate and user-friendly data review software is paramount, with the data generated in the clinical laboratory meeting local guidelines, as well as rigorous method performance characteristics defined by the FDA Bioanalytical Method Validation and CLSI C62-Ed2 guidelines. The quantitative LC-MS/MS workflow is dependent on interfacing to LMS/LIMS for sample traceability, batch analysis using matrix-matched external calibrators and quality controls for quantification and acceptance, and stable-isotope labeled internal standards to compensate for sample extraction, recovery, matrix effects and analytical variability. The demands on the laboratory to run multiplexed analyte panels and analyze a greater number of samples produces large amounts of analytical data which must still go through batch and quality review before release from the laboratory to the clinicians. The Waters Quan Review Software significantly reduces the burdensome aspects of batch quality control by introducing a series of innovative features. These include improvements in workflow, a modernized interface, and the ability to flag exceptions based on acceptance criteria. Methods Samples for three multiplexed LC-MS/MS panels with previously defined analytical method performance characteristics were acquired using Waters IVD Systems controlled by MassLynx software. The data was processed, quantified, and reviewed using both the existing TargetLynx XS IVD Application Manager and the new Quan Review Software. The three quantitative LC-MS/MS methods were the analysis of four immunosuppressants drugs in whole blood, a twelve steroid panel in plasma and a urine dilute and shoot method for a drugs of abuse panel containing greater than 80 analytes. Each method used matrix matched calibrators and QCs for quantification and batch control with performance characteristics including calibration linearity, carryover, precision and accuracy. Results The analytical performance data generated using the new MS Quan data review software met the same performance criteria as the TargetLynx XS data. For immunosuppressants, the % difference of the mean repeatability and total precision (%CV) for the individual analyte QCs processed using both software was within ±1.3% and ±4.4% respectively. The mean % bias of External Quality Assurance Samples (n=40) for each immunosuppressant processed using both software was within ±7.9%. The modernized, task-oriented accelerated workflows and focused review by exception reduced review time by up to 50%. Conclusions The new Quan Review Software generated results equivalent to the existing TargetLynx XS Application Manager. The software’s enhanced workflow capabilities streamlined the review process in a new user-friendly interface which reduced the training burden enabling scientists to generate high-quality data quickly and easily. The exception focused review functionality allowed tailored rule sets which reduced the time spent reviewing data by up to 50%. Whilst the batch-level review and task-oriented workflow improved batch acceptance and simplified the review of complicated datasets into easy tasks. By integrating these features, Data Review software offers a comprehensive solution that not only improves the efficiency and accuracy of batch quality control but also contributes to the overall reliability and integrity of quantitative LC-MS/MS analysis. For Research Use Only. Not for Use in Diagnostic Procedures.

B-267 Validation of the Newly Developed Fully Automated Chemiluminescent Enzyme Immunoassay (CLEIA) Reagent for Measurement of Cyclosporine in the Blood

Abstract Background Cyclosporine (CsA) is an immunosuppressive drug requiring therapeutic drug monitoring (TDM) for its narrow-ranged medication level. Approximately 60% of CsA in the blood exist as molecular complexes with proteins like cyclophilin in lymphocytes and erythrocytes. Measurement of CsA in the blood by immunoassay or liquid chromatography-tandem mass spectrometry (LC-MS/MS) requires an extraction process for CsA from the whole blood specimen, which is often manual complicated and time-consuming process causing a risk of variation in the measurement values among different operators. In addition, the small (cyclic polypeptide composed of 11 amino acids) and hydrophobic property of CsA, make it difficult to establish antibodies for a sandwich immunoassay. In this study, we have validated a novel fully automated sandwich immunoassay reagent for measurement of blood CsA that used a combination of newly-established CsA antibodies and iTACT® (immunoassay for total antigen including complex via pretreatment) technology. Methods The reagent was developed and validated on a fully automated immunoassay system, LUMIPULSE® L2400 (FUJIREBIO INC). Twenty uL whole blood specimens are sampled after mixed with suction/discharge stirring to prevent that blood cells settle to the bottom of a container on the analyzer, and then treated with a pretreatment solution to obtain free CsA. The treated samples are assayed by a two-step sandwich immunoassay. Limit of Detection (LoD), Limit of Quantitation (LoQ), within-laboratory precision, linearity, no interference, and the correlation of this assay and LC-MS/MS were validated, following the current CLSI guidelines protocols. Data were analyzed using Microsoft Excel statistical tool Analyse-it. Results The LoD and the LoQ were 2.7 ng/mL and 10.8 ng/mL respectively. The within-laboratory precision showed CV 1.6-2.9 %. Linearity was demonstrated over the range 13.1-2381.5 ng/mL. No interference was observed with unconjugated (≤19.7 mg/dL) or conjugated bilirubin (≤20.1 mg/dL), chyle (≤1480 FTU), RF (rheumatoid factor, ≤1000 IU/mL), and HAMA (human anti-mouse antibody, ≤1010 ng/mL). The correlation coefficient and the regression slope of this assay and LC-MS/MS were 1.0 and 1.0, respectively (N=120). Conclusions The performance of our novel CsA assay, which use LUMIPULSE L2400, was satisfactory for routine analysis. A unique fully-automated process, including the pretreatment process of whole blood specimens, for measurement would contribute the low LoQ and the low Within-laboratory CV. In addition, the results are obtained in 35-minute. We expect this novel immunoassay could reduce the burden on operators and turnaround time.

Toward Analytical Performance Specifications for Immunosuppressive Drug Quantification in Transplantation: An Opinion Article.

Analytical methods require performance that meets the clinical needs. Different approaches for setting up permissible analytical imprecision goals (pCVA%) for drug analyses have been reported. The aim of this study was to calculate the pCVA% for cyclosporine, tacrolimus, everolimus, sirolimus, and mycophenolic acid using 4 alternative approaches, to compare the results and to critically discuss advantages and disadvantages of each model. The approaches to evaluate pCVA% were (A) based on biological variation observed in routine measurement results between 2022 and 2023 in the authors' laboratory, (B) derived from the terminal elimination half-life and dosing interval of the drugs, and (C and D) explored from the width of the therapeutic ranges (TR) by the 2 methods. For approach A, routine measurement data for cyclosporine and tacrolimus, obtained through liquid chromatography-tandem mass spectrometry and electrochemiluminescence immunoassays, were evaluated separately. The 4 alternative approaches for deriving pCVA% yielded similar results, for cyclosporine and tacrolimus in an analytical method dependent manner. The average pCVA% was 5.2%, 5.6%, 5.1%, 4.8%, and 7.7% for cyclosporine, tacrolimus, everolimus, sirolimus, and mycophenolic acid, respectively. The most challenging goals were those using TR-related approaches, while those using the biological variation approach were most easily achievable. Approach B resulted in more stringent goals for drugs with longer elimination half-lives (eg, everolimus and sirolimus). There is no single ideal approach for setting goals of drug analysis. However, the pCVA% values derived from the various approaches are similar and confirm that a <6% target proposed by the International Association of Therapeutic Drug Monitoring and Clinical Toxicology is adequate and realistic in combination with state-of-the-art measurement technologies. In the authors' opinion, approaches based on the width of the TR are preferable, as they represent a common basis for clinical decisions and reflect elements of biological variation and analytics used to establish the TR.

Neglected Pulmonary Infection Caused by Exophiala dermatitidis Misidentified as Rhodotorula spp.

Exophiala dermatitidis is an emerging black fungus that causes pulmonary infections that may be underestimated by conventional culture methods. We encountered one case that initially appeared to be yeast and was misidentified as Rhodotorula spp. using a commercial identification kit. Thus, genetic identification and clinical background investigations were conducted on 46 strains of Rhodotorula spp. The sequences of the internal transcribed spacer and large-subunit RNA genes (D1/D2 regions) of 43 isolates, excluding two environmental isolates and one difficult-to-culture isolate, were determined and genetically identified. Notably, 22 isolates were identified as E. dermatitidis and misidentified as Rhodotorula spp. using the conventional method. Based on the exclusion criteria, the clinical information of 11 patients was retrospectively reviewed. Five cases (definite) had definite exacerbation of pulmonary infections due to E. dermatitidis, and six cases (possible) had undeniable infections. Of the 11 cases of pulmonary infection suggested to be caused by E. dermatitidis, comorbidities included two cases of chronic pulmonary aspergillosis (CPA), three cases of pulmonary non-tuberculous mycobacterial (NTM) infection and one case of pulmonary nocardiosis, suggesting a trend towards simultaneous detection of chronic pulmonary infections. Steroid and immunosuppressive drug use was observed in five cases, and β-D-glucan elevation was observed in three of five definite cases of pulmonary infections due to E. dermatitidis. The possibility of E. dermatitidis infection should be considered when Rhodotorula spp. are isolated from cultures of airway-derived specimens, and, in addition to CPA and NTM, identification of E. dermatitidis may be important in chronic pulmonary infections.

Progressive polyadenylation and m6A modification of Ighg1 mRNA maintain IgG1 antibody homeostasis in antibody-secreting cells

Antigen-specific antibodies are generated by antibody-secreting cells (ASCs). How RNA post-transcriptional modification affects antibody homeostasis remains unclear. Here, we found that mRNA polyadenylations and N6-methyladenosine (m6A) modifications maintain IgG1 antibody production in ASCs. IgG heavy-chain transcripts (Ighg) possessed a long 3' UTR with m6A sites, targeted by the m6A reader YTHDF1. B cell-specific deficiency of YTHDF1 impaired IgG production upon antigen immunization through reducing Ighg1 mRNA abundance in IgG1+ ASCs. Disrupting either the m6A modification of a nuclear-localized splicing intermediate Ighg1 or the nuclear localization of YTHDF1 reduced Ighg1 transcript stability. Single-cell RNA sequencing identified an ASC subset with excessive YTHDF1 expression in systemic lupus erythematosus patients, which was decreased upon therapy with immunosuppressive drugs. In a lupus mouse model, inhibiting YTHDF1-m6A interactions alleviated symptoms. Thus, we highlight a mechanism in ASCs to sustain the homeostasis of IgG antibody transcripts by integrating Ighg1 mRNA polyadenylation and m6A modification.

Human dental mesenchymal stem cells restorate immune response in sera of pemphigus vulgaris patients.

Pemphigus is an IgG-mediated autoimmune condition characterized by autoantibodies targeting desmogleins, leading to acantholysis. Current treatments, including systemic corticosteroids and immunosuppressive drugs, are associated with significant adverse effects. Mesenchymal stem cells (MSCs) offer a promising alternative due to their immunomodulatory properties and low immunogenicity. This study evaluates the immunomodulatory effects of dental follicle mesenchymal stem cells (DF-MSCs) obtained from healthy donors on Pemphigus vulgaris (PV) patients and healthy controls by examining T-cell proliferation, apoptosis, cytokine levels, and anti-desmoglein 1/3 IgG profiles. Peripheral blood mononuclear cells (PBMCs) were isolated from twenty-one symptomatic PV patients and eleven healthy volunteers. DF-MSCs were characterized and differentiated into osteocytes, adipocytes, and chondrocytes. Peripheral blood mononuclear cells (PBMCs) were co-cultured with DF-MSCs, and various assays were conducted to evaluate T-cell proliferation, apoptosis, regulatory T cells, cytokine expression, and autoantibody levels. Results showed that DF-MSC co-cultures significantly reduced lymphocyte proliferation (43.58-16.27%), IL-4 (38.06 ng/L to 32.26 ng/L), TNF-α (32.45 ng/L to 29.41 ng/L), and DSG1 (3.29 ng/ml to 3.00 ng/ml) and DSG3 (262.40 ng/ml to 245.08 ng/ml) levels in PV patients. An increase in regulatory T cells (1.22-3.75%), IL-10 (47.46 pg/ml to 54.94 pg/ml), and IFN-γ (12.39 ng/ml to 19.70 ng/ml) was also observed. No significant changes were noted in healthy controls. These findings suggest that DF-MSCs could potentially offer a curative approach for treating pemphigus by restoring immune balance. However, further clinical trials are necessary to confirm their efficacy.

Complete remission after glucocorticoid therapy in a patient with primary hypophysitis.

Primary hypophysitis is a rare disease that may have variable clinical presentations. The main treatment options are clinical observation, immunosuppressive drugs, and surgery. Glucocorticoids are used as first-line medical therapy; however, non-responsiveness and recurrences are the major problems. We present a 30-year-old male patient who had an excellent radiologic response to a single course of glucocorticoids. The patient presented with malaise and severe headaches of acute onset. Cranial MRI revealed a pituitary mass compressing the optic chiasm. Hormonal evaluation studies were consistent with anterior pituitary hormone dysfunction except for the growth hormone axis. There was a mild compression on the optic chiasm in the pituitary MRI. The patient was started on methylprednisolone therapy at a dose of 80 mg/day. The pituitary MRI revealed complete regression of the mass after 2 months, and there was a complete recovery of pituitary functions after 6 months. There is no consensus on the optimal dose and duration of glucocorticoid therapy for primary hypophysitis in the literature. We report that steroid therapy, even in lower doses, might be effective in mild-to-moderate cases. Primary hypophysitis is a rare disease with a varied clinical course, and hence the treatment strategies should be individualized. There is no consensus on the optimal dose and duration of glucocorticoid therapy. Glucocorticoid therapy may induce complete remission in some patients, especially with a mild-to-moderate disease course and during the acute phase of the disease.

Prolonged eosinophilia caused by Strongyloidiasis in a patient with rheumatoid arthritis treated with Upadacitinib.

Rheumatoid arthritis (RA) is a systemic disease, which is caused by dysregulation of the immune system in the susceptible persons, making them immunocompromised and prone to infections during the course of their disease. The majority of RA patients are being treated with immunosuppressive drugs which render them even more immunocompromised. We present a Caucasian patient living in South-eastern Europe who developed prolonged eosinophilia during the treatment of RA with upadacitinib. After a comprehensive work-up she was diagnosed with Strongyloidiasis although living in non-endemic region of the world. We emphasize the importance of regular follow-up of immunocompromised patients and raise awareness of not only typical but also atypical infections which can occur during the course of the disease.

Clinical Analysis of Reversible Posterior Encephalopathy Syndrome after Allogeneic Hematopoietic Stem Cell Transplantation in Children

To summarize the clinical features of reversible posterior encephalopathy syndrome (PRES) after allogeneic hematopoietic stem cell transplantation (allo-HSCT) in children. The clinical data of six children who developed PRES after undergoing allo-HSCT in the Department of Hematology of Wuhan Children's Hospital from June 2016 to December 2022 were retrospectively analyzed, and their clinical characteristics, imaging examination, laboratory examination, and treatment regression were summarized. Among 281 children underwent allo-HSCT, 6 cases (2.14%) developed PRES, with a median age of 5.1(1.5-9.7) years old. 4 cases underwent related haploidentical donor transplantation, and 2 cases underwent sibling allografting and unrelated donor allografting donor transplantation, respectively. All six children had an acute onset of illness, with clinical manifestations of nausea and vomiting, seizures, psychiatric disorders, visual disturbances. The five cases elevated blood pressure. All children with PRES were treated with oral immunosuppressive drugs during seizures, and 3 cases were combined with different degrees of graft-versus-host disease. Most of the children showed effective improvement in clinical symptoms and imaging after adjusting/discontinuing suspected medications (cyclosporine, etc.) and symptomatic supportive treatments (oral antihypertensive, diazepam for antispasmodic, mannitol to lower cranial blood pressure), and one of them relapsed more than 8 months after the first seizure. PRES is rare after hematopoietic stem cell transplantation in children, and its onset may be related to hypertension, cytotoxic drugs, graft-versus-host disease, etc. Most of them can be recovered after active treatment, but not completely reversible, and the prognosis of those who combined with TMA is poor.

Glucocorticoids Suppress NF-κB-Mediated Neutrophil Control of Aspergillus fumigatus Hyphal Growth.

Glucocorticoids are a major class of therapeutic anti-inflammatory and immunosuppressive drugs prescribed to patients with inflammatory diseases, to avoid transplant rejection, and as part of cancer chemotherapy. However, exposure to these drugs increases the risk of opportunistic infections such as with the fungus Aspergillus fumigatus, which causes mortality in >50% of infected patients. The mechanisms by which glucocorticoids increase susceptibility to A. fumigatus are poorly understood. In this article, we used a zebrafish larva Aspergillus infection model to identify innate immune mechanisms altered by glucocorticoid treatment. Infected larvae exposed to dexamethasone succumb to infection at a significantly higher rate than control larvae. However, both macrophages and neutrophils are still recruited to the site of infection, and dexamethasone treatment does not significantly affect fungal spore killing. Instead, the primary effect of dexamethasone manifests later in infection with treated larvae exhibiting increased invasive hyphal growth. In line with this, dexamethasone predominantly inhibits neutrophil function rather than macrophage function. Dexamethasone-induced mortality also depends on the glucocorticoid receptor. Dexamethasone partially suppresses NF-κB activation at the infection site by inducing the transcription of IκB via the glucocorticoid receptor. Independent CRISPR/Cas9 targeting of IKKγ to prevent NF-κB activation also increases invasive A. fumigatus growth and larval mortality. However, dexamethasone treatment of IKKγ crispant larvae further increases invasive hyphal growth and host mortality, suggesting that dexamethasone may suppress other pathways in addition to NF-κB to promote host susceptibility. Collectively, we find that dexamethasone acts through the glucocorticoid receptor to suppress NF-κB-mediated neutrophil control of A. fumigatus hyphae in zebrafish larvae.

Canine sterile neutrophilic dermatosis (Sweet-like syndrome): A description of 3 cases

Three dogs were presented with a sudden onset of erythematous skin lesions, fever, and various extracutaneous signs, assigned to canine sterile neutrophilic dermatosis by clinical, laboratory, and histopathologic examination. This disease is very rare and comparable to Sweet syndrome in humans. According to the 4 forms of SS, the 1st and 3rd cases in this case report could be classified as classic/idiopathic SS. In this context, the respiratory signs may be a prodromal stage of SS preceding the skin lesions or possibly an infection of the respiratory tract was the trigger for SS. The 2nd case, on the other hand, shows a clear and the 3rd case a possible connection to pathergy as a consequence of a previous surgical treatment (case 2 a tibial plateau levelling osteotomy [TPLO] 20 days previously, case 3 a hemilaminectomy 90 days previously). This way, both may be assigned to the 4th form of SS. In all 3 cases, an adverse drug reaction as a trigger cannot be ruled out with certainty, as medication was used before the diagnosis was made in each case. Besides the most common extracutaneous signs such as fever and neutrophilia, immune-hemolytic anemia occurred in 2 of the patients. As therapeutic options, in addition to the established immunosuppressive drugs such as prednisolone, ciclosporin and azathioprine, oclacitinib is also included in the treatment regimen. In addition, administration of an antiplatelet agent (clopidogrel), which may be interpreted as a lesson learnt from the first of the presented cases, that died of pulmonary thromboembolism. In case 2, all drugs were tapered and eventually stopped over a period of 2.5 years and the patient has been without recurrence for 4 years. Case 3 is recurrence-free under therapy.