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What was the outcome of reaction 'Haemorrhage'? | Kingella kingae Intrauterine Infection: An Unusual Cause of Chorioamnionitis and Miscarriage in a Patient with Undifferentiated Connective Tissue Disease.
Kingella kingae is a Gram-negative coccobacillus belonging to the Neisseriaceae family. In children less than 4 years old, K. kingae invasive infection can induce septic arthritis and osteomyelitis, and more rarely endocarditis, meningitis, ocular infections, and pneumonia. In adults, it may be a cause of endocarditis. To date, K. kingae acute chorioamnionitis (AC) leading to preterm rupture of membranes (PPROM) and miscarriage has never been reported. Herein, we describe a case of intrauterine fetal death (IUFD) at 22 weeks' gestation due to K. kingae infection occurred in a patient affected by undifferentiated connective tissue disease (UCTD) in lupus erythematosus systemic (LES) evolution with severe neutropenia. K. kingae was isolated in placental subamnionic swab and tissue cultures as well as fetal ear, nose, and pharyngeal swabs. Placental histological examination showed necrotizing AC and funisitis. In the fetus, neutrophils were observed within the alveoli and in the gastrointestinal lumen. Maternal medical treatment for UCTD was modified according to the K. kingae invasive infection. In the event of IUFD due to AC, microbiological cultures on placenta and fetal tissues should always be carried out in order to isolate the etiologic agent and target the correct medical treatment.
1. Introduction
Kingella kingae is a Gram-negative, facultatively anaerobic coccobacillus of the Neisseriaceae family. It is a slowly growing bacterium also a member of the HACEK group (Haemophilus spp., Aggregatibacter actinomycetemcomitans, Cardiobacterium hominis, Eikenella corrodens, and Kingella kingae) [1,2]. K. kingae is currently recognized as the most common etiology of septic arthritis and osteomyelitis in children between the ages of 6 and 48 months. More rarely, it can cause complicated endocarditis, meningitis, ocular infections, pericarditis, peritonitis, and pneumonia [3,4].
To the best of our knowledge, K. kingae infection has never been reported in pregnancy. Only a case of early onset sepsis (EOS) in a premature infant has been described [5]. Herein, we present an unusual case of preterm premature rupture of membranes (PPROM) at 22 weeks’ gestation with subsequent intrauterine fetal death (IUFD) due to severe acute chorioamnionitis (AC). Placental subamnionic swab and tissue microbiological cultures isolated K. kingae, including fetal ear, nose, and pharyngeal swabs. Moreover, the 31-year-old mother was affected by undifferentiated connective tissue disease (UCTD) in evolution toward lupus erythematosus systemic (LES); severe neutropenia, antinuclear antibodies (ANA), and low titer of anti-neutrophil cytoplasmic antibodies (ANCA) were also present.
2. Case Description
2.1. Mother Clinical Presentation and Treatment
A 31-year-old mother, gravida 2 para 1, presented at 22 weeks’ gestation to the Emergency Department of our Institution for miscarriage. The patient had been suffering from shaking chills, fever (38 °C), stomatitis, sore throat, abdominal pain, and minimal vaginal bleeding for the previous three days. Gynaecological examination revealed on speculum mild fresh blood in vagina and abdominal ultrasound (US) observed IUFD. She was admitted to the hospital, labour was induced and a stillborn female fetus was delivered. Placental microbiological samples and fetal swabs were sent to the Clinical Microbiology laboratory where cultures on different media were immediately performed.
Overall, the patient had a complex clinical history. She had suffered from monoarticular juvenile idiopathic arthritis, completely resolved at 15 years of age.
Six years before the current miscarriage, she had complained of bilateral gonalgia. Laboratory findings had shown severe neutropenia (250 neutrophils) and low titer of ANCA. Antinuclear antibodies (ANA) titer had been 1:160. Anti extractable nuclear antigens (ENA), anti-DNA antibodies, and antiphospholipid antibodies (lupus anticoagulant—LAC; anticardiolipin antibodies—aCL; anti-β2-glycoprotein-1—anti-β2GP-1) had been negative. Bone marrow biopsy had been reported within normal limits.
In the previous six years, although the patient had always been presenting with low neutrophils, she had never contracted opportunistic infections.
One year before the miscarriage, she had had her first pregnancy with a vaginally delivered male infant of 3200 g at 40 weeks + 6 days of gestational age. One month after delivery, she had severe mastitis, which required hospital admission and surgical treatment. After that, she presented with two episodes of bilateral knee arthritis, and then she was put on hydroxychloroquine 200 mg twice a day (tablets).
Regarding the current miscarriage, at hospital admission, maternal laboratory findings were as follows: WBC 2.6 x 1.000/μL and C-reactive protein (CRP) 13.45 mg/dL. During the first day after IUFD, CRP worsened to 18.02 mg/dL, then progressively decreased from 16.46 (2 days), 2.7 mg/dL (3 days), 1.43 mg/dL (5 days) to 0.11 mg/dL (10 days). Blood cultures performed at admission resulted negative.
Maternal medical treatment, started soon after IUFD, consisted of 2 days of meropenem, subsequently switched to piperacillin/tazobactam for 6 days. She fully recovered and was discharged after 10 days.
After hematologic and rheumatologic consult, due to low neutrophil count and recent intrauterine infection, Granulocyte-Colony Stimulating Factor (G-CSF) and cyclosporine (200 mg a day) were added to hydroxychloroquine.
2.2. Fetal Autopsy and Microbiological Results
Postmortem examination revealed a nonmacerated female fetus weighing 420 g and measuring 29 cm in crown-heel length. The other measurements were as follows: Crown-rump length, 19.5 cm; foot length, 3.7 cm; head, chest and abdominal circumference, 18, 16, and 15 cm, respectively. Overall, anthropometric measurements were consistent with 22 weeks’ gestation [6]. External examination showed a normal fetus with mild eyelid and nuchal oedema. On internal examination, intestinal rotation was incomplete (malrotation) with short midgut mesenteric attachment and mobile intestine. No volvulus was observed. Microscopic analysis revealed the presence of intra-alveolar, gastric and intestinal neutrophils (Figure 1); oedema, microhemorrhages and acute tubular necrosis (NTA) of the renal parenchyma were also present.
The placenta was received complete, weighed 137 g, and measured 10 × 10 × 2 cm. The membranes were yellowish and opaque. Microscopically, there was necrotizing AC (Figure 2) corresponding to a maternal inflammatory response stage 3/3 and grade 2/2 [7]. Coccoid bacteria were noted at high magnification within the chorion (Figure 3). Funisitis was also observed with neutrophilic infiltrate of the umbilical vein, and the two arteries with extension to Wharton’s jelly (Figure 4). These findings were consistent with fetal inflammatory response stage 2/3 and grade 2/2 [7]. In addition, in the placental parenchyma some recent infarcts were detected, and in the decidua few spiral arteries presented initial thrombosis.
Autoptical samples were cultured on Columbia blood agar (CBA), McConkey agar (MCA), mannitol salt agar (MSA) and Sabouraud agar (SAB; all these media were incubated at 36 °C, ambient air), chocolate agar (CA, incubated at 36 °C, 5% CO2), and Schaedler agar (SA, incubated at 36 °C, anaerobic atmosphere). After 48 hours from the fetus’s pharyngeal, nose, and ear swabs, small colonies grew on CBA and CA (better on the latter). No growth was observed on MCA. These smooth colonies were catalase negative and oxidase positive. They were identified as K. kingae using the MALDI-ToF technology (Bruker Daltonics, Germany), Biotyper OC software version 3.1. Microbiological cultures on fetal blood and tissues (lung and liver) showed no growth after 72 hours and were discarded as negative. Instead, K. kingae also grew on subamniotic swab and placental tissue cultures. If present, the microorganism grew as a pure culture in all the samples. Antimicrobial susceptibility testing was not performed.
3. Materials and Methods
We searched for (Kingella kingae AND (chorioamnionitis OR genital OR amniotic OR amnios OR placenta OR placental OR funisitis OR fetus OR fetal OR pregnancy OR pregnant OR (membrane AND rupture) OR uterus OR uterine OR intrauterine)) in Pubmed (all fields, 2 results), Scopus (Title/Abstract/Keyword, 9 results) and Web of Science (Topic/Title, 2 results). No limitations were set. The bibliographic research ended on 25 December 2020. Globally, a total of 10 articles resulted from our search. Titles and Abstract of all the articles were screened. All articles were excluded as non-relevant.
4. Discussion
K. kingae is a Gram-negative coccobacillus belonging to the Neisseriaceae family. It is a normal component of the oropharyngeal flora of children less than 4 years old. However, the bacterium, after having colonized and breached the epithelial surface, may disseminate in the bloodstream causing, especially in children, arthritis, osteomyelitis, and endocarditis. This latter complication may also occur in adults [1,8].
Mechanisms of virulence include biofilm formation, pili, RTX toxin production, polysaccharide capsule, and secretion of outer membrane vesicles (OMV).
K. kingae is able to form biofilms, which consist of large quantities of bacteria clustered together in a polysaccharide “slime”, that tightly attaches to the mucosal surface. This kind of colonization allows bacteria to survive in a protected environment preserving them from dehydratation, immune response, and antibiotics [9,10].
K. kingae anchors to the epithelia thanks to type 4 pili, which are proteinaceous fimbriae necessary for efficient adherence to respiratory mucosa and synovia [11].
Moreover, RTX toxin expression exerts a wide-spectrum cytotoxic effect on macrophages, leukocytes, synoviocytes, and respiratory epithelial cells. This toxin plays a key role in infection spreading favouring epithelial disruption and bloodstream dissemination [12,13]. Of note, type a and b polysaccharide capsule predominate in invasive isolates [14]. A further virulence factor possessed by K. kingae is the secretion of OMV, which are small parts of the outer membrane encasing periplasm proteins that bulge away from the bacterium and then are released in the extracellular space. These OMV’s are hemolytic and leukotoxic in an in vitro model and internalized by synoviocytes inducing the synthesis of granulocyte-macrophage colony stimulating factor (GM-CSF) and interleukin 6 (IL-6), likely representing the in vivo immunitary response in joint infections [15].
K. kingae has been recognized as a leading cause of septic arthritis and osteomyelitis in children less than 4 years old, usually with no underlying medical conditions [3,4]. Other rare primary manifestations in pediatric population are: Pneumonia, endocarditis, soft tissue infection, endophtalmitis, orbital cellulitis, and meningitis [1,2,16,17,18,19,20].
Being part of the HACEK group (Haemophilus spp, Aggregatibacter actinomycetemcomitans, Cardiobacterium hominis, Eikenella corrodens, Kingella kingae), K. kingae can cause endocarditis, affecting more frequently children and young adults [21].
Adult patients usually have predisposing conditions in order to develop invasive K. kingae disease, such as malignancies, liver cirrhosis, diabetes, sickle cell anemia, and renal transplant [1,22,23,24,25].
However, to the best of our knowledge, K. kingae infection has never been reported in pregnancy and besides as a cause of PPROM and miscarriage. Moreover, the patient was affected by UCTD in evolution toward LES with severe neutropenia, ANA, and ANCA.
The 31-year-old mother presented to the hospital after having suffered shaking chills, fever (38 °C), stomatitis, sore throat, abdominal pain, and minimal vaginal bleeding for the previous three days. US revealed IUFD. Microbiological cultures on placental subamnionic swab and parenchymal tissue isolated K. kingae. The same agent grew on fetal swabs (ear, nose, and pharyngeal). Fetal tissue cultures (blood, lung and liver) resulted negative. Placental histological examination confirmed severe necrotizing chorioamnionitis and funisitis. Within the chorion, coccoid bacteria were also observed. Fetal histology showed few neutrophils within the alveoli, and gastro-intestinal lumen, respectively.
K. kingae was then considered the etiologic agent responsible for the miscarriage. While other members of the genus Kingella such as K. negevensis and K. denitrificans are known to cause bacterial vaginosis, chorioamnionitis, and pediatric vaginitis [26,27,28]; K. kingae infections of the urogenital tract are extremely rare [29].
However, AC due to K. kingae has never been described. The main microorganisms responsible for AC usually are group B Streptococcus, Fusobacterium nucleatum, Peptostreptococcus, Escherichia coli, Bacteroides species, Ureaplasma urealyticum, and Listeria monocytogenes [30,31]. As K. kingae is not part of the lower genital tract flora, in the case described, an ascending infection was unlikely. The bacterium probably reached the amniotic cavity through the hematogenous pathway from the oropharynx. In fact, the mother presented with sore throat and stomatitis. Although reported in children, K. kingae invasive disease has been associated with recent or concomitant virus infections like coxsackievirus, herpes simplex, varicella zoster, and rhinovirus in the oropharynx and upper respiratory tract [32,33,34,35]. Therefore, a concomitant viral infection in those locations may represent a cofactor in the pathophysiology of invasive K. kingae, probably favoring epithelial breaching and altering the local immune response [36].
In the case we described, it is impossible to differentiate a condition of maternal oropharyngeal carrier exacerbated by a concomitant viral infection or a K. kingae primary oropharyngeal infection turned out to be invasive. Notwithstanding, the mother was affected by UCTD in evolution toward LES with severe neutropenia. To date, K. kingae infection has never been described in this kind of peculiar setting. Only few cases have been observed in a granulocytopenic host [22], LES [37,38,39,40], rheumatoid arthritis [41], and acquired immunodeficiency syndrome (AIDS) [42,43,44,45,46].
Besides, recognition of K. kingae intrauterine infection allowed modifying maternal therapeutic plan, as G-CSF and cyclosporine were added to hydroxychloroquine.
In our specific case, placental cultures and fetal swabs revealed K. kingae infection, but the microorganism was not retrieved from fetal blood and tissues. This may be explained as a low bacterial load or a possible specimen type inhibition. In fact, it is known that recovery of K. kingae from bacteriological solid media may be difficult and nucleic acid amplification is advisable [1]. In our case, polymerase chain reaction (PCR) on the fetal tissues was not performed as infection was clearly demonstrated by neutrophils within the alveoli and in the lumen of gastrointestinal tract.
Usually, in the event of miscarriage due to chorioamnionitis, identification of the correct etiologic agent is of paramount importance as maternal medical treatment can be adjusted accordingly. Placental subamniotic swab and parenchymal cultures as well as fetal blood and tissues microbiological studies should always be carried out as recommended by perinatal autopsy protocols [47,48].
Author Contributions
M.P.B.; carried out the pathological diagnosis and written the manuscript—original draft preparation, review and editing, A.P.; provided the histological pictures and searched for the bibliograhy, G.D.D.; provided the draft preparation and writing, G.C. and G.P.; clinically managed the patient, G.R., G.B., M.B., C.Z., and E.C.; carried out the microbiological diagnosis. All authors have read and agreed to the published version of the manuscript.
Funding
This research received no external funding.
Institutional Review Board Statement
Our investigations were carried out following the rules of the Declaration of Helsinki of 1975, revised in 2013. According to Italian legislation, Ethical Approval for a single case is not required, as long as the data are kept anonymous and the investigations performed do not imply genetic results.
Informed Consent Statement
The current Italian legislation neither requires the family’s consent or ethical approval for a single case, as long as the data are strictly kept anonymous. As summoning the mother was not possible because it would interfere with the grieving process, patient’s consent was completely waived, according to the Italian Authority of Privacy and Data Protection (“Garante della Privacy”: GDPR nr 679/2016; 9/2016 and recent law addition number 424/ 19th of July 2018; http://www.garanteprivacy.it).
Data Availability Statement
The data presented in this study are available on request from the corresponding author.
Conflicts of Interest
The authors declare no conflict of interest.
Figure 1 Fetal lung: A few neutrophils within the alveoli (blue arrows; Hematoxylin Eosin (HE) staining 20×).
Figure 2 Amniochorial membranes: Severe chorioamnionitis with amnion necrosis (blue arrow; HE staining 10×).
Figure 3 Chorion: Abundant coccoid bacteria within the chorionic stroma (HE staining 40×).
Figure 4 Umbilical artery acute vasculitis: Neutrophils within the arterial wall (blue star) with extension to Warthon’s jelly (red star) (HE staining, 4×).
Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations. | Fatal | ReactionOutcome | CC BY | 33557386 | 20,145,774 | 2021-02-04 |
What was the outcome of reaction 'Intestinal malrotation'? | Kingella kingae Intrauterine Infection: An Unusual Cause of Chorioamnionitis and Miscarriage in a Patient with Undifferentiated Connective Tissue Disease.
Kingella kingae is a Gram-negative coccobacillus belonging to the Neisseriaceae family. In children less than 4 years old, K. kingae invasive infection can induce septic arthritis and osteomyelitis, and more rarely endocarditis, meningitis, ocular infections, and pneumonia. In adults, it may be a cause of endocarditis. To date, K. kingae acute chorioamnionitis (AC) leading to preterm rupture of membranes (PPROM) and miscarriage has never been reported. Herein, we describe a case of intrauterine fetal death (IUFD) at 22 weeks' gestation due to K. kingae infection occurred in a patient affected by undifferentiated connective tissue disease (UCTD) in lupus erythematosus systemic (LES) evolution with severe neutropenia. K. kingae was isolated in placental subamnionic swab and tissue cultures as well as fetal ear, nose, and pharyngeal swabs. Placental histological examination showed necrotizing AC and funisitis. In the fetus, neutrophils were observed within the alveoli and in the gastrointestinal lumen. Maternal medical treatment for UCTD was modified according to the K. kingae invasive infection. In the event of IUFD due to AC, microbiological cultures on placenta and fetal tissues should always be carried out in order to isolate the etiologic agent and target the correct medical treatment.
1. Introduction
Kingella kingae is a Gram-negative, facultatively anaerobic coccobacillus of the Neisseriaceae family. It is a slowly growing bacterium also a member of the HACEK group (Haemophilus spp., Aggregatibacter actinomycetemcomitans, Cardiobacterium hominis, Eikenella corrodens, and Kingella kingae) [1,2]. K. kingae is currently recognized as the most common etiology of septic arthritis and osteomyelitis in children between the ages of 6 and 48 months. More rarely, it can cause complicated endocarditis, meningitis, ocular infections, pericarditis, peritonitis, and pneumonia [3,4].
To the best of our knowledge, K. kingae infection has never been reported in pregnancy. Only a case of early onset sepsis (EOS) in a premature infant has been described [5]. Herein, we present an unusual case of preterm premature rupture of membranes (PPROM) at 22 weeks’ gestation with subsequent intrauterine fetal death (IUFD) due to severe acute chorioamnionitis (AC). Placental subamnionic swab and tissue microbiological cultures isolated K. kingae, including fetal ear, nose, and pharyngeal swabs. Moreover, the 31-year-old mother was affected by undifferentiated connective tissue disease (UCTD) in evolution toward lupus erythematosus systemic (LES); severe neutropenia, antinuclear antibodies (ANA), and low titer of anti-neutrophil cytoplasmic antibodies (ANCA) were also present.
2. Case Description
2.1. Mother Clinical Presentation and Treatment
A 31-year-old mother, gravida 2 para 1, presented at 22 weeks’ gestation to the Emergency Department of our Institution for miscarriage. The patient had been suffering from shaking chills, fever (38 °C), stomatitis, sore throat, abdominal pain, and minimal vaginal bleeding for the previous three days. Gynaecological examination revealed on speculum mild fresh blood in vagina and abdominal ultrasound (US) observed IUFD. She was admitted to the hospital, labour was induced and a stillborn female fetus was delivered. Placental microbiological samples and fetal swabs were sent to the Clinical Microbiology laboratory where cultures on different media were immediately performed.
Overall, the patient had a complex clinical history. She had suffered from monoarticular juvenile idiopathic arthritis, completely resolved at 15 years of age.
Six years before the current miscarriage, she had complained of bilateral gonalgia. Laboratory findings had shown severe neutropenia (250 neutrophils) and low titer of ANCA. Antinuclear antibodies (ANA) titer had been 1:160. Anti extractable nuclear antigens (ENA), anti-DNA antibodies, and antiphospholipid antibodies (lupus anticoagulant—LAC; anticardiolipin antibodies—aCL; anti-β2-glycoprotein-1—anti-β2GP-1) had been negative. Bone marrow biopsy had been reported within normal limits.
In the previous six years, although the patient had always been presenting with low neutrophils, she had never contracted opportunistic infections.
One year before the miscarriage, she had had her first pregnancy with a vaginally delivered male infant of 3200 g at 40 weeks + 6 days of gestational age. One month after delivery, she had severe mastitis, which required hospital admission and surgical treatment. After that, she presented with two episodes of bilateral knee arthritis, and then she was put on hydroxychloroquine 200 mg twice a day (tablets).
Regarding the current miscarriage, at hospital admission, maternal laboratory findings were as follows: WBC 2.6 x 1.000/μL and C-reactive protein (CRP) 13.45 mg/dL. During the first day after IUFD, CRP worsened to 18.02 mg/dL, then progressively decreased from 16.46 (2 days), 2.7 mg/dL (3 days), 1.43 mg/dL (5 days) to 0.11 mg/dL (10 days). Blood cultures performed at admission resulted negative.
Maternal medical treatment, started soon after IUFD, consisted of 2 days of meropenem, subsequently switched to piperacillin/tazobactam for 6 days. She fully recovered and was discharged after 10 days.
After hematologic and rheumatologic consult, due to low neutrophil count and recent intrauterine infection, Granulocyte-Colony Stimulating Factor (G-CSF) and cyclosporine (200 mg a day) were added to hydroxychloroquine.
2.2. Fetal Autopsy and Microbiological Results
Postmortem examination revealed a nonmacerated female fetus weighing 420 g and measuring 29 cm in crown-heel length. The other measurements were as follows: Crown-rump length, 19.5 cm; foot length, 3.7 cm; head, chest and abdominal circumference, 18, 16, and 15 cm, respectively. Overall, anthropometric measurements were consistent with 22 weeks’ gestation [6]. External examination showed a normal fetus with mild eyelid and nuchal oedema. On internal examination, intestinal rotation was incomplete (malrotation) with short midgut mesenteric attachment and mobile intestine. No volvulus was observed. Microscopic analysis revealed the presence of intra-alveolar, gastric and intestinal neutrophils (Figure 1); oedema, microhemorrhages and acute tubular necrosis (NTA) of the renal parenchyma were also present.
The placenta was received complete, weighed 137 g, and measured 10 × 10 × 2 cm. The membranes were yellowish and opaque. Microscopically, there was necrotizing AC (Figure 2) corresponding to a maternal inflammatory response stage 3/3 and grade 2/2 [7]. Coccoid bacteria were noted at high magnification within the chorion (Figure 3). Funisitis was also observed with neutrophilic infiltrate of the umbilical vein, and the two arteries with extension to Wharton’s jelly (Figure 4). These findings were consistent with fetal inflammatory response stage 2/3 and grade 2/2 [7]. In addition, in the placental parenchyma some recent infarcts were detected, and in the decidua few spiral arteries presented initial thrombosis.
Autoptical samples were cultured on Columbia blood agar (CBA), McConkey agar (MCA), mannitol salt agar (MSA) and Sabouraud agar (SAB; all these media were incubated at 36 °C, ambient air), chocolate agar (CA, incubated at 36 °C, 5% CO2), and Schaedler agar (SA, incubated at 36 °C, anaerobic atmosphere). After 48 hours from the fetus’s pharyngeal, nose, and ear swabs, small colonies grew on CBA and CA (better on the latter). No growth was observed on MCA. These smooth colonies were catalase negative and oxidase positive. They were identified as K. kingae using the MALDI-ToF technology (Bruker Daltonics, Germany), Biotyper OC software version 3.1. Microbiological cultures on fetal blood and tissues (lung and liver) showed no growth after 72 hours and were discarded as negative. Instead, K. kingae also grew on subamniotic swab and placental tissue cultures. If present, the microorganism grew as a pure culture in all the samples. Antimicrobial susceptibility testing was not performed.
3. Materials and Methods
We searched for (Kingella kingae AND (chorioamnionitis OR genital OR amniotic OR amnios OR placenta OR placental OR funisitis OR fetus OR fetal OR pregnancy OR pregnant OR (membrane AND rupture) OR uterus OR uterine OR intrauterine)) in Pubmed (all fields, 2 results), Scopus (Title/Abstract/Keyword, 9 results) and Web of Science (Topic/Title, 2 results). No limitations were set. The bibliographic research ended on 25 December 2020. Globally, a total of 10 articles resulted from our search. Titles and Abstract of all the articles were screened. All articles were excluded as non-relevant.
4. Discussion
K. kingae is a Gram-negative coccobacillus belonging to the Neisseriaceae family. It is a normal component of the oropharyngeal flora of children less than 4 years old. However, the bacterium, after having colonized and breached the epithelial surface, may disseminate in the bloodstream causing, especially in children, arthritis, osteomyelitis, and endocarditis. This latter complication may also occur in adults [1,8].
Mechanisms of virulence include biofilm formation, pili, RTX toxin production, polysaccharide capsule, and secretion of outer membrane vesicles (OMV).
K. kingae is able to form biofilms, which consist of large quantities of bacteria clustered together in a polysaccharide “slime”, that tightly attaches to the mucosal surface. This kind of colonization allows bacteria to survive in a protected environment preserving them from dehydratation, immune response, and antibiotics [9,10].
K. kingae anchors to the epithelia thanks to type 4 pili, which are proteinaceous fimbriae necessary for efficient adherence to respiratory mucosa and synovia [11].
Moreover, RTX toxin expression exerts a wide-spectrum cytotoxic effect on macrophages, leukocytes, synoviocytes, and respiratory epithelial cells. This toxin plays a key role in infection spreading favouring epithelial disruption and bloodstream dissemination [12,13]. Of note, type a and b polysaccharide capsule predominate in invasive isolates [14]. A further virulence factor possessed by K. kingae is the secretion of OMV, which are small parts of the outer membrane encasing periplasm proteins that bulge away from the bacterium and then are released in the extracellular space. These OMV’s are hemolytic and leukotoxic in an in vitro model and internalized by synoviocytes inducing the synthesis of granulocyte-macrophage colony stimulating factor (GM-CSF) and interleukin 6 (IL-6), likely representing the in vivo immunitary response in joint infections [15].
K. kingae has been recognized as a leading cause of septic arthritis and osteomyelitis in children less than 4 years old, usually with no underlying medical conditions [3,4]. Other rare primary manifestations in pediatric population are: Pneumonia, endocarditis, soft tissue infection, endophtalmitis, orbital cellulitis, and meningitis [1,2,16,17,18,19,20].
Being part of the HACEK group (Haemophilus spp, Aggregatibacter actinomycetemcomitans, Cardiobacterium hominis, Eikenella corrodens, Kingella kingae), K. kingae can cause endocarditis, affecting more frequently children and young adults [21].
Adult patients usually have predisposing conditions in order to develop invasive K. kingae disease, such as malignancies, liver cirrhosis, diabetes, sickle cell anemia, and renal transplant [1,22,23,24,25].
However, to the best of our knowledge, K. kingae infection has never been reported in pregnancy and besides as a cause of PPROM and miscarriage. Moreover, the patient was affected by UCTD in evolution toward LES with severe neutropenia, ANA, and ANCA.
The 31-year-old mother presented to the hospital after having suffered shaking chills, fever (38 °C), stomatitis, sore throat, abdominal pain, and minimal vaginal bleeding for the previous three days. US revealed IUFD. Microbiological cultures on placental subamnionic swab and parenchymal tissue isolated K. kingae. The same agent grew on fetal swabs (ear, nose, and pharyngeal). Fetal tissue cultures (blood, lung and liver) resulted negative. Placental histological examination confirmed severe necrotizing chorioamnionitis and funisitis. Within the chorion, coccoid bacteria were also observed. Fetal histology showed few neutrophils within the alveoli, and gastro-intestinal lumen, respectively.
K. kingae was then considered the etiologic agent responsible for the miscarriage. While other members of the genus Kingella such as K. negevensis and K. denitrificans are known to cause bacterial vaginosis, chorioamnionitis, and pediatric vaginitis [26,27,28]; K. kingae infections of the urogenital tract are extremely rare [29].
However, AC due to K. kingae has never been described. The main microorganisms responsible for AC usually are group B Streptococcus, Fusobacterium nucleatum, Peptostreptococcus, Escherichia coli, Bacteroides species, Ureaplasma urealyticum, and Listeria monocytogenes [30,31]. As K. kingae is not part of the lower genital tract flora, in the case described, an ascending infection was unlikely. The bacterium probably reached the amniotic cavity through the hematogenous pathway from the oropharynx. In fact, the mother presented with sore throat and stomatitis. Although reported in children, K. kingae invasive disease has been associated with recent or concomitant virus infections like coxsackievirus, herpes simplex, varicella zoster, and rhinovirus in the oropharynx and upper respiratory tract [32,33,34,35]. Therefore, a concomitant viral infection in those locations may represent a cofactor in the pathophysiology of invasive K. kingae, probably favoring epithelial breaching and altering the local immune response [36].
In the case we described, it is impossible to differentiate a condition of maternal oropharyngeal carrier exacerbated by a concomitant viral infection or a K. kingae primary oropharyngeal infection turned out to be invasive. Notwithstanding, the mother was affected by UCTD in evolution toward LES with severe neutropenia. To date, K. kingae infection has never been described in this kind of peculiar setting. Only few cases have been observed in a granulocytopenic host [22], LES [37,38,39,40], rheumatoid arthritis [41], and acquired immunodeficiency syndrome (AIDS) [42,43,44,45,46].
Besides, recognition of K. kingae intrauterine infection allowed modifying maternal therapeutic plan, as G-CSF and cyclosporine were added to hydroxychloroquine.
In our specific case, placental cultures and fetal swabs revealed K. kingae infection, but the microorganism was not retrieved from fetal blood and tissues. This may be explained as a low bacterial load or a possible specimen type inhibition. In fact, it is known that recovery of K. kingae from bacteriological solid media may be difficult and nucleic acid amplification is advisable [1]. In our case, polymerase chain reaction (PCR) on the fetal tissues was not performed as infection was clearly demonstrated by neutrophils within the alveoli and in the lumen of gastrointestinal tract.
Usually, in the event of miscarriage due to chorioamnionitis, identification of the correct etiologic agent is of paramount importance as maternal medical treatment can be adjusted accordingly. Placental subamniotic swab and parenchymal cultures as well as fetal blood and tissues microbiological studies should always be carried out as recommended by perinatal autopsy protocols [47,48].
Author Contributions
M.P.B.; carried out the pathological diagnosis and written the manuscript—original draft preparation, review and editing, A.P.; provided the histological pictures and searched for the bibliograhy, G.D.D.; provided the draft preparation and writing, G.C. and G.P.; clinically managed the patient, G.R., G.B., M.B., C.Z., and E.C.; carried out the microbiological diagnosis. All authors have read and agreed to the published version of the manuscript.
Funding
This research received no external funding.
Institutional Review Board Statement
Our investigations were carried out following the rules of the Declaration of Helsinki of 1975, revised in 2013. According to Italian legislation, Ethical Approval for a single case is not required, as long as the data are kept anonymous and the investigations performed do not imply genetic results.
Informed Consent Statement
The current Italian legislation neither requires the family’s consent or ethical approval for a single case, as long as the data are strictly kept anonymous. As summoning the mother was not possible because it would interfere with the grieving process, patient’s consent was completely waived, according to the Italian Authority of Privacy and Data Protection (“Garante della Privacy”: GDPR nr 679/2016; 9/2016 and recent law addition number 424/ 19th of July 2018; http://www.garanteprivacy.it).
Data Availability Statement
The data presented in this study are available on request from the corresponding author.
Conflicts of Interest
The authors declare no conflict of interest.
Figure 1 Fetal lung: A few neutrophils within the alveoli (blue arrows; Hematoxylin Eosin (HE) staining 20×).
Figure 2 Amniochorial membranes: Severe chorioamnionitis with amnion necrosis (blue arrow; HE staining 10×).
Figure 3 Chorion: Abundant coccoid bacteria within the chorionic stroma (HE staining 40×).
Figure 4 Umbilical artery acute vasculitis: Neutrophils within the arterial wall (blue star) with extension to Warthon’s jelly (red star) (HE staining, 4×).
Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations. | Fatal | ReactionOutcome | CC BY | 33557386 | 20,145,774 | 2021-02-04 |
What was the outcome of reaction 'Low birth weight baby'? | Kingella kingae Intrauterine Infection: An Unusual Cause of Chorioamnionitis and Miscarriage in a Patient with Undifferentiated Connective Tissue Disease.
Kingella kingae is a Gram-negative coccobacillus belonging to the Neisseriaceae family. In children less than 4 years old, K. kingae invasive infection can induce septic arthritis and osteomyelitis, and more rarely endocarditis, meningitis, ocular infections, and pneumonia. In adults, it may be a cause of endocarditis. To date, K. kingae acute chorioamnionitis (AC) leading to preterm rupture of membranes (PPROM) and miscarriage has never been reported. Herein, we describe a case of intrauterine fetal death (IUFD) at 22 weeks' gestation due to K. kingae infection occurred in a patient affected by undifferentiated connective tissue disease (UCTD) in lupus erythematosus systemic (LES) evolution with severe neutropenia. K. kingae was isolated in placental subamnionic swab and tissue cultures as well as fetal ear, nose, and pharyngeal swabs. Placental histological examination showed necrotizing AC and funisitis. In the fetus, neutrophils were observed within the alveoli and in the gastrointestinal lumen. Maternal medical treatment for UCTD was modified according to the K. kingae invasive infection. In the event of IUFD due to AC, microbiological cultures on placenta and fetal tissues should always be carried out in order to isolate the etiologic agent and target the correct medical treatment.
1. Introduction
Kingella kingae is a Gram-negative, facultatively anaerobic coccobacillus of the Neisseriaceae family. It is a slowly growing bacterium also a member of the HACEK group (Haemophilus spp., Aggregatibacter actinomycetemcomitans, Cardiobacterium hominis, Eikenella corrodens, and Kingella kingae) [1,2]. K. kingae is currently recognized as the most common etiology of septic arthritis and osteomyelitis in children between the ages of 6 and 48 months. More rarely, it can cause complicated endocarditis, meningitis, ocular infections, pericarditis, peritonitis, and pneumonia [3,4].
To the best of our knowledge, K. kingae infection has never been reported in pregnancy. Only a case of early onset sepsis (EOS) in a premature infant has been described [5]. Herein, we present an unusual case of preterm premature rupture of membranes (PPROM) at 22 weeks’ gestation with subsequent intrauterine fetal death (IUFD) due to severe acute chorioamnionitis (AC). Placental subamnionic swab and tissue microbiological cultures isolated K. kingae, including fetal ear, nose, and pharyngeal swabs. Moreover, the 31-year-old mother was affected by undifferentiated connective tissue disease (UCTD) in evolution toward lupus erythematosus systemic (LES); severe neutropenia, antinuclear antibodies (ANA), and low titer of anti-neutrophil cytoplasmic antibodies (ANCA) were also present.
2. Case Description
2.1. Mother Clinical Presentation and Treatment
A 31-year-old mother, gravida 2 para 1, presented at 22 weeks’ gestation to the Emergency Department of our Institution for miscarriage. The patient had been suffering from shaking chills, fever (38 °C), stomatitis, sore throat, abdominal pain, and minimal vaginal bleeding for the previous three days. Gynaecological examination revealed on speculum mild fresh blood in vagina and abdominal ultrasound (US) observed IUFD. She was admitted to the hospital, labour was induced and a stillborn female fetus was delivered. Placental microbiological samples and fetal swabs were sent to the Clinical Microbiology laboratory where cultures on different media were immediately performed.
Overall, the patient had a complex clinical history. She had suffered from monoarticular juvenile idiopathic arthritis, completely resolved at 15 years of age.
Six years before the current miscarriage, she had complained of bilateral gonalgia. Laboratory findings had shown severe neutropenia (250 neutrophils) and low titer of ANCA. Antinuclear antibodies (ANA) titer had been 1:160. Anti extractable nuclear antigens (ENA), anti-DNA antibodies, and antiphospholipid antibodies (lupus anticoagulant—LAC; anticardiolipin antibodies—aCL; anti-β2-glycoprotein-1—anti-β2GP-1) had been negative. Bone marrow biopsy had been reported within normal limits.
In the previous six years, although the patient had always been presenting with low neutrophils, she had never contracted opportunistic infections.
One year before the miscarriage, she had had her first pregnancy with a vaginally delivered male infant of 3200 g at 40 weeks + 6 days of gestational age. One month after delivery, she had severe mastitis, which required hospital admission and surgical treatment. After that, she presented with two episodes of bilateral knee arthritis, and then she was put on hydroxychloroquine 200 mg twice a day (tablets).
Regarding the current miscarriage, at hospital admission, maternal laboratory findings were as follows: WBC 2.6 x 1.000/μL and C-reactive protein (CRP) 13.45 mg/dL. During the first day after IUFD, CRP worsened to 18.02 mg/dL, then progressively decreased from 16.46 (2 days), 2.7 mg/dL (3 days), 1.43 mg/dL (5 days) to 0.11 mg/dL (10 days). Blood cultures performed at admission resulted negative.
Maternal medical treatment, started soon after IUFD, consisted of 2 days of meropenem, subsequently switched to piperacillin/tazobactam for 6 days. She fully recovered and was discharged after 10 days.
After hematologic and rheumatologic consult, due to low neutrophil count and recent intrauterine infection, Granulocyte-Colony Stimulating Factor (G-CSF) and cyclosporine (200 mg a day) were added to hydroxychloroquine.
2.2. Fetal Autopsy and Microbiological Results
Postmortem examination revealed a nonmacerated female fetus weighing 420 g and measuring 29 cm in crown-heel length. The other measurements were as follows: Crown-rump length, 19.5 cm; foot length, 3.7 cm; head, chest and abdominal circumference, 18, 16, and 15 cm, respectively. Overall, anthropometric measurements were consistent with 22 weeks’ gestation [6]. External examination showed a normal fetus with mild eyelid and nuchal oedema. On internal examination, intestinal rotation was incomplete (malrotation) with short midgut mesenteric attachment and mobile intestine. No volvulus was observed. Microscopic analysis revealed the presence of intra-alveolar, gastric and intestinal neutrophils (Figure 1); oedema, microhemorrhages and acute tubular necrosis (NTA) of the renal parenchyma were also present.
The placenta was received complete, weighed 137 g, and measured 10 × 10 × 2 cm. The membranes were yellowish and opaque. Microscopically, there was necrotizing AC (Figure 2) corresponding to a maternal inflammatory response stage 3/3 and grade 2/2 [7]. Coccoid bacteria were noted at high magnification within the chorion (Figure 3). Funisitis was also observed with neutrophilic infiltrate of the umbilical vein, and the two arteries with extension to Wharton’s jelly (Figure 4). These findings were consistent with fetal inflammatory response stage 2/3 and grade 2/2 [7]. In addition, in the placental parenchyma some recent infarcts were detected, and in the decidua few spiral arteries presented initial thrombosis.
Autoptical samples were cultured on Columbia blood agar (CBA), McConkey agar (MCA), mannitol salt agar (MSA) and Sabouraud agar (SAB; all these media were incubated at 36 °C, ambient air), chocolate agar (CA, incubated at 36 °C, 5% CO2), and Schaedler agar (SA, incubated at 36 °C, anaerobic atmosphere). After 48 hours from the fetus’s pharyngeal, nose, and ear swabs, small colonies grew on CBA and CA (better on the latter). No growth was observed on MCA. These smooth colonies were catalase negative and oxidase positive. They were identified as K. kingae using the MALDI-ToF technology (Bruker Daltonics, Germany), Biotyper OC software version 3.1. Microbiological cultures on fetal blood and tissues (lung and liver) showed no growth after 72 hours and were discarded as negative. Instead, K. kingae also grew on subamniotic swab and placental tissue cultures. If present, the microorganism grew as a pure culture in all the samples. Antimicrobial susceptibility testing was not performed.
3. Materials and Methods
We searched for (Kingella kingae AND (chorioamnionitis OR genital OR amniotic OR amnios OR placenta OR placental OR funisitis OR fetus OR fetal OR pregnancy OR pregnant OR (membrane AND rupture) OR uterus OR uterine OR intrauterine)) in Pubmed (all fields, 2 results), Scopus (Title/Abstract/Keyword, 9 results) and Web of Science (Topic/Title, 2 results). No limitations were set. The bibliographic research ended on 25 December 2020. Globally, a total of 10 articles resulted from our search. Titles and Abstract of all the articles were screened. All articles were excluded as non-relevant.
4. Discussion
K. kingae is a Gram-negative coccobacillus belonging to the Neisseriaceae family. It is a normal component of the oropharyngeal flora of children less than 4 years old. However, the bacterium, after having colonized and breached the epithelial surface, may disseminate in the bloodstream causing, especially in children, arthritis, osteomyelitis, and endocarditis. This latter complication may also occur in adults [1,8].
Mechanisms of virulence include biofilm formation, pili, RTX toxin production, polysaccharide capsule, and secretion of outer membrane vesicles (OMV).
K. kingae is able to form biofilms, which consist of large quantities of bacteria clustered together in a polysaccharide “slime”, that tightly attaches to the mucosal surface. This kind of colonization allows bacteria to survive in a protected environment preserving them from dehydratation, immune response, and antibiotics [9,10].
K. kingae anchors to the epithelia thanks to type 4 pili, which are proteinaceous fimbriae necessary for efficient adherence to respiratory mucosa and synovia [11].
Moreover, RTX toxin expression exerts a wide-spectrum cytotoxic effect on macrophages, leukocytes, synoviocytes, and respiratory epithelial cells. This toxin plays a key role in infection spreading favouring epithelial disruption and bloodstream dissemination [12,13]. Of note, type a and b polysaccharide capsule predominate in invasive isolates [14]. A further virulence factor possessed by K. kingae is the secretion of OMV, which are small parts of the outer membrane encasing periplasm proteins that bulge away from the bacterium and then are released in the extracellular space. These OMV’s are hemolytic and leukotoxic in an in vitro model and internalized by synoviocytes inducing the synthesis of granulocyte-macrophage colony stimulating factor (GM-CSF) and interleukin 6 (IL-6), likely representing the in vivo immunitary response in joint infections [15].
K. kingae has been recognized as a leading cause of septic arthritis and osteomyelitis in children less than 4 years old, usually with no underlying medical conditions [3,4]. Other rare primary manifestations in pediatric population are: Pneumonia, endocarditis, soft tissue infection, endophtalmitis, orbital cellulitis, and meningitis [1,2,16,17,18,19,20].
Being part of the HACEK group (Haemophilus spp, Aggregatibacter actinomycetemcomitans, Cardiobacterium hominis, Eikenella corrodens, Kingella kingae), K. kingae can cause endocarditis, affecting more frequently children and young adults [21].
Adult patients usually have predisposing conditions in order to develop invasive K. kingae disease, such as malignancies, liver cirrhosis, diabetes, sickle cell anemia, and renal transplant [1,22,23,24,25].
However, to the best of our knowledge, K. kingae infection has never been reported in pregnancy and besides as a cause of PPROM and miscarriage. Moreover, the patient was affected by UCTD in evolution toward LES with severe neutropenia, ANA, and ANCA.
The 31-year-old mother presented to the hospital after having suffered shaking chills, fever (38 °C), stomatitis, sore throat, abdominal pain, and minimal vaginal bleeding for the previous three days. US revealed IUFD. Microbiological cultures on placental subamnionic swab and parenchymal tissue isolated K. kingae. The same agent grew on fetal swabs (ear, nose, and pharyngeal). Fetal tissue cultures (blood, lung and liver) resulted negative. Placental histological examination confirmed severe necrotizing chorioamnionitis and funisitis. Within the chorion, coccoid bacteria were also observed. Fetal histology showed few neutrophils within the alveoli, and gastro-intestinal lumen, respectively.
K. kingae was then considered the etiologic agent responsible for the miscarriage. While other members of the genus Kingella such as K. negevensis and K. denitrificans are known to cause bacterial vaginosis, chorioamnionitis, and pediatric vaginitis [26,27,28]; K. kingae infections of the urogenital tract are extremely rare [29].
However, AC due to K. kingae has never been described. The main microorganisms responsible for AC usually are group B Streptococcus, Fusobacterium nucleatum, Peptostreptococcus, Escherichia coli, Bacteroides species, Ureaplasma urealyticum, and Listeria monocytogenes [30,31]. As K. kingae is not part of the lower genital tract flora, in the case described, an ascending infection was unlikely. The bacterium probably reached the amniotic cavity through the hematogenous pathway from the oropharynx. In fact, the mother presented with sore throat and stomatitis. Although reported in children, K. kingae invasive disease has been associated with recent or concomitant virus infections like coxsackievirus, herpes simplex, varicella zoster, and rhinovirus in the oropharynx and upper respiratory tract [32,33,34,35]. Therefore, a concomitant viral infection in those locations may represent a cofactor in the pathophysiology of invasive K. kingae, probably favoring epithelial breaching and altering the local immune response [36].
In the case we described, it is impossible to differentiate a condition of maternal oropharyngeal carrier exacerbated by a concomitant viral infection or a K. kingae primary oropharyngeal infection turned out to be invasive. Notwithstanding, the mother was affected by UCTD in evolution toward LES with severe neutropenia. To date, K. kingae infection has never been described in this kind of peculiar setting. Only few cases have been observed in a granulocytopenic host [22], LES [37,38,39,40], rheumatoid arthritis [41], and acquired immunodeficiency syndrome (AIDS) [42,43,44,45,46].
Besides, recognition of K. kingae intrauterine infection allowed modifying maternal therapeutic plan, as G-CSF and cyclosporine were added to hydroxychloroquine.
In our specific case, placental cultures and fetal swabs revealed K. kingae infection, but the microorganism was not retrieved from fetal blood and tissues. This may be explained as a low bacterial load or a possible specimen type inhibition. In fact, it is known that recovery of K. kingae from bacteriological solid media may be difficult and nucleic acid amplification is advisable [1]. In our case, polymerase chain reaction (PCR) on the fetal tissues was not performed as infection was clearly demonstrated by neutrophils within the alveoli and in the lumen of gastrointestinal tract.
Usually, in the event of miscarriage due to chorioamnionitis, identification of the correct etiologic agent is of paramount importance as maternal medical treatment can be adjusted accordingly. Placental subamniotic swab and parenchymal cultures as well as fetal blood and tissues microbiological studies should always be carried out as recommended by perinatal autopsy protocols [47,48].
Author Contributions
M.P.B.; carried out the pathological diagnosis and written the manuscript—original draft preparation, review and editing, A.P.; provided the histological pictures and searched for the bibliograhy, G.D.D.; provided the draft preparation and writing, G.C. and G.P.; clinically managed the patient, G.R., G.B., M.B., C.Z., and E.C.; carried out the microbiological diagnosis. All authors have read and agreed to the published version of the manuscript.
Funding
This research received no external funding.
Institutional Review Board Statement
Our investigations were carried out following the rules of the Declaration of Helsinki of 1975, revised in 2013. According to Italian legislation, Ethical Approval for a single case is not required, as long as the data are kept anonymous and the investigations performed do not imply genetic results.
Informed Consent Statement
The current Italian legislation neither requires the family’s consent or ethical approval for a single case, as long as the data are strictly kept anonymous. As summoning the mother was not possible because it would interfere with the grieving process, patient’s consent was completely waived, according to the Italian Authority of Privacy and Data Protection (“Garante della Privacy”: GDPR nr 679/2016; 9/2016 and recent law addition number 424/ 19th of July 2018; http://www.garanteprivacy.it).
Data Availability Statement
The data presented in this study are available on request from the corresponding author.
Conflicts of Interest
The authors declare no conflict of interest.
Figure 1 Fetal lung: A few neutrophils within the alveoli (blue arrows; Hematoxylin Eosin (HE) staining 20×).
Figure 2 Amniochorial membranes: Severe chorioamnionitis with amnion necrosis (blue arrow; HE staining 10×).
Figure 3 Chorion: Abundant coccoid bacteria within the chorionic stroma (HE staining 40×).
Figure 4 Umbilical artery acute vasculitis: Neutrophils within the arterial wall (blue star) with extension to Warthon’s jelly (red star) (HE staining, 4×).
Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations. | Fatal | ReactionOutcome | CC BY | 33557386 | 20,145,774 | 2021-02-04 |
What was the outcome of reaction 'Nuchal rigidity'? | Kingella kingae Intrauterine Infection: An Unusual Cause of Chorioamnionitis and Miscarriage in a Patient with Undifferentiated Connective Tissue Disease.
Kingella kingae is a Gram-negative coccobacillus belonging to the Neisseriaceae family. In children less than 4 years old, K. kingae invasive infection can induce septic arthritis and osteomyelitis, and more rarely endocarditis, meningitis, ocular infections, and pneumonia. In adults, it may be a cause of endocarditis. To date, K. kingae acute chorioamnionitis (AC) leading to preterm rupture of membranes (PPROM) and miscarriage has never been reported. Herein, we describe a case of intrauterine fetal death (IUFD) at 22 weeks' gestation due to K. kingae infection occurred in a patient affected by undifferentiated connective tissue disease (UCTD) in lupus erythematosus systemic (LES) evolution with severe neutropenia. K. kingae was isolated in placental subamnionic swab and tissue cultures as well as fetal ear, nose, and pharyngeal swabs. Placental histological examination showed necrotizing AC and funisitis. In the fetus, neutrophils were observed within the alveoli and in the gastrointestinal lumen. Maternal medical treatment for UCTD was modified according to the K. kingae invasive infection. In the event of IUFD due to AC, microbiological cultures on placenta and fetal tissues should always be carried out in order to isolate the etiologic agent and target the correct medical treatment.
1. Introduction
Kingella kingae is a Gram-negative, facultatively anaerobic coccobacillus of the Neisseriaceae family. It is a slowly growing bacterium also a member of the HACEK group (Haemophilus spp., Aggregatibacter actinomycetemcomitans, Cardiobacterium hominis, Eikenella corrodens, and Kingella kingae) [1,2]. K. kingae is currently recognized as the most common etiology of septic arthritis and osteomyelitis in children between the ages of 6 and 48 months. More rarely, it can cause complicated endocarditis, meningitis, ocular infections, pericarditis, peritonitis, and pneumonia [3,4].
To the best of our knowledge, K. kingae infection has never been reported in pregnancy. Only a case of early onset sepsis (EOS) in a premature infant has been described [5]. Herein, we present an unusual case of preterm premature rupture of membranes (PPROM) at 22 weeks’ gestation with subsequent intrauterine fetal death (IUFD) due to severe acute chorioamnionitis (AC). Placental subamnionic swab and tissue microbiological cultures isolated K. kingae, including fetal ear, nose, and pharyngeal swabs. Moreover, the 31-year-old mother was affected by undifferentiated connective tissue disease (UCTD) in evolution toward lupus erythematosus systemic (LES); severe neutropenia, antinuclear antibodies (ANA), and low titer of anti-neutrophil cytoplasmic antibodies (ANCA) were also present.
2. Case Description
2.1. Mother Clinical Presentation and Treatment
A 31-year-old mother, gravida 2 para 1, presented at 22 weeks’ gestation to the Emergency Department of our Institution for miscarriage. The patient had been suffering from shaking chills, fever (38 °C), stomatitis, sore throat, abdominal pain, and minimal vaginal bleeding for the previous three days. Gynaecological examination revealed on speculum mild fresh blood in vagina and abdominal ultrasound (US) observed IUFD. She was admitted to the hospital, labour was induced and a stillborn female fetus was delivered. Placental microbiological samples and fetal swabs were sent to the Clinical Microbiology laboratory where cultures on different media were immediately performed.
Overall, the patient had a complex clinical history. She had suffered from monoarticular juvenile idiopathic arthritis, completely resolved at 15 years of age.
Six years before the current miscarriage, she had complained of bilateral gonalgia. Laboratory findings had shown severe neutropenia (250 neutrophils) and low titer of ANCA. Antinuclear antibodies (ANA) titer had been 1:160. Anti extractable nuclear antigens (ENA), anti-DNA antibodies, and antiphospholipid antibodies (lupus anticoagulant—LAC; anticardiolipin antibodies—aCL; anti-β2-glycoprotein-1—anti-β2GP-1) had been negative. Bone marrow biopsy had been reported within normal limits.
In the previous six years, although the patient had always been presenting with low neutrophils, she had never contracted opportunistic infections.
One year before the miscarriage, she had had her first pregnancy with a vaginally delivered male infant of 3200 g at 40 weeks + 6 days of gestational age. One month after delivery, she had severe mastitis, which required hospital admission and surgical treatment. After that, she presented with two episodes of bilateral knee arthritis, and then she was put on hydroxychloroquine 200 mg twice a day (tablets).
Regarding the current miscarriage, at hospital admission, maternal laboratory findings were as follows: WBC 2.6 x 1.000/μL and C-reactive protein (CRP) 13.45 mg/dL. During the first day after IUFD, CRP worsened to 18.02 mg/dL, then progressively decreased from 16.46 (2 days), 2.7 mg/dL (3 days), 1.43 mg/dL (5 days) to 0.11 mg/dL (10 days). Blood cultures performed at admission resulted negative.
Maternal medical treatment, started soon after IUFD, consisted of 2 days of meropenem, subsequently switched to piperacillin/tazobactam for 6 days. She fully recovered and was discharged after 10 days.
After hematologic and rheumatologic consult, due to low neutrophil count and recent intrauterine infection, Granulocyte-Colony Stimulating Factor (G-CSF) and cyclosporine (200 mg a day) were added to hydroxychloroquine.
2.2. Fetal Autopsy and Microbiological Results
Postmortem examination revealed a nonmacerated female fetus weighing 420 g and measuring 29 cm in crown-heel length. The other measurements were as follows: Crown-rump length, 19.5 cm; foot length, 3.7 cm; head, chest and abdominal circumference, 18, 16, and 15 cm, respectively. Overall, anthropometric measurements were consistent with 22 weeks’ gestation [6]. External examination showed a normal fetus with mild eyelid and nuchal oedema. On internal examination, intestinal rotation was incomplete (malrotation) with short midgut mesenteric attachment and mobile intestine. No volvulus was observed. Microscopic analysis revealed the presence of intra-alveolar, gastric and intestinal neutrophils (Figure 1); oedema, microhemorrhages and acute tubular necrosis (NTA) of the renal parenchyma were also present.
The placenta was received complete, weighed 137 g, and measured 10 × 10 × 2 cm. The membranes were yellowish and opaque. Microscopically, there was necrotizing AC (Figure 2) corresponding to a maternal inflammatory response stage 3/3 and grade 2/2 [7]. Coccoid bacteria were noted at high magnification within the chorion (Figure 3). Funisitis was also observed with neutrophilic infiltrate of the umbilical vein, and the two arteries with extension to Wharton’s jelly (Figure 4). These findings were consistent with fetal inflammatory response stage 2/3 and grade 2/2 [7]. In addition, in the placental parenchyma some recent infarcts were detected, and in the decidua few spiral arteries presented initial thrombosis.
Autoptical samples were cultured on Columbia blood agar (CBA), McConkey agar (MCA), mannitol salt agar (MSA) and Sabouraud agar (SAB; all these media were incubated at 36 °C, ambient air), chocolate agar (CA, incubated at 36 °C, 5% CO2), and Schaedler agar (SA, incubated at 36 °C, anaerobic atmosphere). After 48 hours from the fetus’s pharyngeal, nose, and ear swabs, small colonies grew on CBA and CA (better on the latter). No growth was observed on MCA. These smooth colonies were catalase negative and oxidase positive. They were identified as K. kingae using the MALDI-ToF technology (Bruker Daltonics, Germany), Biotyper OC software version 3.1. Microbiological cultures on fetal blood and tissues (lung and liver) showed no growth after 72 hours and were discarded as negative. Instead, K. kingae also grew on subamniotic swab and placental tissue cultures. If present, the microorganism grew as a pure culture in all the samples. Antimicrobial susceptibility testing was not performed.
3. Materials and Methods
We searched for (Kingella kingae AND (chorioamnionitis OR genital OR amniotic OR amnios OR placenta OR placental OR funisitis OR fetus OR fetal OR pregnancy OR pregnant OR (membrane AND rupture) OR uterus OR uterine OR intrauterine)) in Pubmed (all fields, 2 results), Scopus (Title/Abstract/Keyword, 9 results) and Web of Science (Topic/Title, 2 results). No limitations were set. The bibliographic research ended on 25 December 2020. Globally, a total of 10 articles resulted from our search. Titles and Abstract of all the articles were screened. All articles were excluded as non-relevant.
4. Discussion
K. kingae is a Gram-negative coccobacillus belonging to the Neisseriaceae family. It is a normal component of the oropharyngeal flora of children less than 4 years old. However, the bacterium, after having colonized and breached the epithelial surface, may disseminate in the bloodstream causing, especially in children, arthritis, osteomyelitis, and endocarditis. This latter complication may also occur in adults [1,8].
Mechanisms of virulence include biofilm formation, pili, RTX toxin production, polysaccharide capsule, and secretion of outer membrane vesicles (OMV).
K. kingae is able to form biofilms, which consist of large quantities of bacteria clustered together in a polysaccharide “slime”, that tightly attaches to the mucosal surface. This kind of colonization allows bacteria to survive in a protected environment preserving them from dehydratation, immune response, and antibiotics [9,10].
K. kingae anchors to the epithelia thanks to type 4 pili, which are proteinaceous fimbriae necessary for efficient adherence to respiratory mucosa and synovia [11].
Moreover, RTX toxin expression exerts a wide-spectrum cytotoxic effect on macrophages, leukocytes, synoviocytes, and respiratory epithelial cells. This toxin plays a key role in infection spreading favouring epithelial disruption and bloodstream dissemination [12,13]. Of note, type a and b polysaccharide capsule predominate in invasive isolates [14]. A further virulence factor possessed by K. kingae is the secretion of OMV, which are small parts of the outer membrane encasing periplasm proteins that bulge away from the bacterium and then are released in the extracellular space. These OMV’s are hemolytic and leukotoxic in an in vitro model and internalized by synoviocytes inducing the synthesis of granulocyte-macrophage colony stimulating factor (GM-CSF) and interleukin 6 (IL-6), likely representing the in vivo immunitary response in joint infections [15].
K. kingae has been recognized as a leading cause of septic arthritis and osteomyelitis in children less than 4 years old, usually with no underlying medical conditions [3,4]. Other rare primary manifestations in pediatric population are: Pneumonia, endocarditis, soft tissue infection, endophtalmitis, orbital cellulitis, and meningitis [1,2,16,17,18,19,20].
Being part of the HACEK group (Haemophilus spp, Aggregatibacter actinomycetemcomitans, Cardiobacterium hominis, Eikenella corrodens, Kingella kingae), K. kingae can cause endocarditis, affecting more frequently children and young adults [21].
Adult patients usually have predisposing conditions in order to develop invasive K. kingae disease, such as malignancies, liver cirrhosis, diabetes, sickle cell anemia, and renal transplant [1,22,23,24,25].
However, to the best of our knowledge, K. kingae infection has never been reported in pregnancy and besides as a cause of PPROM and miscarriage. Moreover, the patient was affected by UCTD in evolution toward LES with severe neutropenia, ANA, and ANCA.
The 31-year-old mother presented to the hospital after having suffered shaking chills, fever (38 °C), stomatitis, sore throat, abdominal pain, and minimal vaginal bleeding for the previous three days. US revealed IUFD. Microbiological cultures on placental subamnionic swab and parenchymal tissue isolated K. kingae. The same agent grew on fetal swabs (ear, nose, and pharyngeal). Fetal tissue cultures (blood, lung and liver) resulted negative. Placental histological examination confirmed severe necrotizing chorioamnionitis and funisitis. Within the chorion, coccoid bacteria were also observed. Fetal histology showed few neutrophils within the alveoli, and gastro-intestinal lumen, respectively.
K. kingae was then considered the etiologic agent responsible for the miscarriage. While other members of the genus Kingella such as K. negevensis and K. denitrificans are known to cause bacterial vaginosis, chorioamnionitis, and pediatric vaginitis [26,27,28]; K. kingae infections of the urogenital tract are extremely rare [29].
However, AC due to K. kingae has never been described. The main microorganisms responsible for AC usually are group B Streptococcus, Fusobacterium nucleatum, Peptostreptococcus, Escherichia coli, Bacteroides species, Ureaplasma urealyticum, and Listeria monocytogenes [30,31]. As K. kingae is not part of the lower genital tract flora, in the case described, an ascending infection was unlikely. The bacterium probably reached the amniotic cavity through the hematogenous pathway from the oropharynx. In fact, the mother presented with sore throat and stomatitis. Although reported in children, K. kingae invasive disease has been associated with recent or concomitant virus infections like coxsackievirus, herpes simplex, varicella zoster, and rhinovirus in the oropharynx and upper respiratory tract [32,33,34,35]. Therefore, a concomitant viral infection in those locations may represent a cofactor in the pathophysiology of invasive K. kingae, probably favoring epithelial breaching and altering the local immune response [36].
In the case we described, it is impossible to differentiate a condition of maternal oropharyngeal carrier exacerbated by a concomitant viral infection or a K. kingae primary oropharyngeal infection turned out to be invasive. Notwithstanding, the mother was affected by UCTD in evolution toward LES with severe neutropenia. To date, K. kingae infection has never been described in this kind of peculiar setting. Only few cases have been observed in a granulocytopenic host [22], LES [37,38,39,40], rheumatoid arthritis [41], and acquired immunodeficiency syndrome (AIDS) [42,43,44,45,46].
Besides, recognition of K. kingae intrauterine infection allowed modifying maternal therapeutic plan, as G-CSF and cyclosporine were added to hydroxychloroquine.
In our specific case, placental cultures and fetal swabs revealed K. kingae infection, but the microorganism was not retrieved from fetal blood and tissues. This may be explained as a low bacterial load or a possible specimen type inhibition. In fact, it is known that recovery of K. kingae from bacteriological solid media may be difficult and nucleic acid amplification is advisable [1]. In our case, polymerase chain reaction (PCR) on the fetal tissues was not performed as infection was clearly demonstrated by neutrophils within the alveoli and in the lumen of gastrointestinal tract.
Usually, in the event of miscarriage due to chorioamnionitis, identification of the correct etiologic agent is of paramount importance as maternal medical treatment can be adjusted accordingly. Placental subamniotic swab and parenchymal cultures as well as fetal blood and tissues microbiological studies should always be carried out as recommended by perinatal autopsy protocols [47,48].
Author Contributions
M.P.B.; carried out the pathological diagnosis and written the manuscript—original draft preparation, review and editing, A.P.; provided the histological pictures and searched for the bibliograhy, G.D.D.; provided the draft preparation and writing, G.C. and G.P.; clinically managed the patient, G.R., G.B., M.B., C.Z., and E.C.; carried out the microbiological diagnosis. All authors have read and agreed to the published version of the manuscript.
Funding
This research received no external funding.
Institutional Review Board Statement
Our investigations were carried out following the rules of the Declaration of Helsinki of 1975, revised in 2013. According to Italian legislation, Ethical Approval for a single case is not required, as long as the data are kept anonymous and the investigations performed do not imply genetic results.
Informed Consent Statement
The current Italian legislation neither requires the family’s consent or ethical approval for a single case, as long as the data are strictly kept anonymous. As summoning the mother was not possible because it would interfere with the grieving process, patient’s consent was completely waived, according to the Italian Authority of Privacy and Data Protection (“Garante della Privacy”: GDPR nr 679/2016; 9/2016 and recent law addition number 424/ 19th of July 2018; http://www.garanteprivacy.it).
Data Availability Statement
The data presented in this study are available on request from the corresponding author.
Conflicts of Interest
The authors declare no conflict of interest.
Figure 1 Fetal lung: A few neutrophils within the alveoli (blue arrows; Hematoxylin Eosin (HE) staining 20×).
Figure 2 Amniochorial membranes: Severe chorioamnionitis with amnion necrosis (blue arrow; HE staining 10×).
Figure 3 Chorion: Abundant coccoid bacteria within the chorionic stroma (HE staining 40×).
Figure 4 Umbilical artery acute vasculitis: Neutrophils within the arterial wall (blue star) with extension to Warthon’s jelly (red star) (HE staining, 4×).
Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations. | Fatal | ReactionOutcome | CC BY | 33557386 | 20,145,774 | 2021-02-04 |
What was the outcome of reaction 'Premature baby'? | Kingella kingae Intrauterine Infection: An Unusual Cause of Chorioamnionitis and Miscarriage in a Patient with Undifferentiated Connective Tissue Disease.
Kingella kingae is a Gram-negative coccobacillus belonging to the Neisseriaceae family. In children less than 4 years old, K. kingae invasive infection can induce septic arthritis and osteomyelitis, and more rarely endocarditis, meningitis, ocular infections, and pneumonia. In adults, it may be a cause of endocarditis. To date, K. kingae acute chorioamnionitis (AC) leading to preterm rupture of membranes (PPROM) and miscarriage has never been reported. Herein, we describe a case of intrauterine fetal death (IUFD) at 22 weeks' gestation due to K. kingae infection occurred in a patient affected by undifferentiated connective tissue disease (UCTD) in lupus erythematosus systemic (LES) evolution with severe neutropenia. K. kingae was isolated in placental subamnionic swab and tissue cultures as well as fetal ear, nose, and pharyngeal swabs. Placental histological examination showed necrotizing AC and funisitis. In the fetus, neutrophils were observed within the alveoli and in the gastrointestinal lumen. Maternal medical treatment for UCTD was modified according to the K. kingae invasive infection. In the event of IUFD due to AC, microbiological cultures on placenta and fetal tissues should always be carried out in order to isolate the etiologic agent and target the correct medical treatment.
1. Introduction
Kingella kingae is a Gram-negative, facultatively anaerobic coccobacillus of the Neisseriaceae family. It is a slowly growing bacterium also a member of the HACEK group (Haemophilus spp., Aggregatibacter actinomycetemcomitans, Cardiobacterium hominis, Eikenella corrodens, and Kingella kingae) [1,2]. K. kingae is currently recognized as the most common etiology of septic arthritis and osteomyelitis in children between the ages of 6 and 48 months. More rarely, it can cause complicated endocarditis, meningitis, ocular infections, pericarditis, peritonitis, and pneumonia [3,4].
To the best of our knowledge, K. kingae infection has never been reported in pregnancy. Only a case of early onset sepsis (EOS) in a premature infant has been described [5]. Herein, we present an unusual case of preterm premature rupture of membranes (PPROM) at 22 weeks’ gestation with subsequent intrauterine fetal death (IUFD) due to severe acute chorioamnionitis (AC). Placental subamnionic swab and tissue microbiological cultures isolated K. kingae, including fetal ear, nose, and pharyngeal swabs. Moreover, the 31-year-old mother was affected by undifferentiated connective tissue disease (UCTD) in evolution toward lupus erythematosus systemic (LES); severe neutropenia, antinuclear antibodies (ANA), and low titer of anti-neutrophil cytoplasmic antibodies (ANCA) were also present.
2. Case Description
2.1. Mother Clinical Presentation and Treatment
A 31-year-old mother, gravida 2 para 1, presented at 22 weeks’ gestation to the Emergency Department of our Institution for miscarriage. The patient had been suffering from shaking chills, fever (38 °C), stomatitis, sore throat, abdominal pain, and minimal vaginal bleeding for the previous three days. Gynaecological examination revealed on speculum mild fresh blood in vagina and abdominal ultrasound (US) observed IUFD. She was admitted to the hospital, labour was induced and a stillborn female fetus was delivered. Placental microbiological samples and fetal swabs were sent to the Clinical Microbiology laboratory where cultures on different media were immediately performed.
Overall, the patient had a complex clinical history. She had suffered from monoarticular juvenile idiopathic arthritis, completely resolved at 15 years of age.
Six years before the current miscarriage, she had complained of bilateral gonalgia. Laboratory findings had shown severe neutropenia (250 neutrophils) and low titer of ANCA. Antinuclear antibodies (ANA) titer had been 1:160. Anti extractable nuclear antigens (ENA), anti-DNA antibodies, and antiphospholipid antibodies (lupus anticoagulant—LAC; anticardiolipin antibodies—aCL; anti-β2-glycoprotein-1—anti-β2GP-1) had been negative. Bone marrow biopsy had been reported within normal limits.
In the previous six years, although the patient had always been presenting with low neutrophils, she had never contracted opportunistic infections.
One year before the miscarriage, she had had her first pregnancy with a vaginally delivered male infant of 3200 g at 40 weeks + 6 days of gestational age. One month after delivery, she had severe mastitis, which required hospital admission and surgical treatment. After that, she presented with two episodes of bilateral knee arthritis, and then she was put on hydroxychloroquine 200 mg twice a day (tablets).
Regarding the current miscarriage, at hospital admission, maternal laboratory findings were as follows: WBC 2.6 x 1.000/μL and C-reactive protein (CRP) 13.45 mg/dL. During the first day after IUFD, CRP worsened to 18.02 mg/dL, then progressively decreased from 16.46 (2 days), 2.7 mg/dL (3 days), 1.43 mg/dL (5 days) to 0.11 mg/dL (10 days). Blood cultures performed at admission resulted negative.
Maternal medical treatment, started soon after IUFD, consisted of 2 days of meropenem, subsequently switched to piperacillin/tazobactam for 6 days. She fully recovered and was discharged after 10 days.
After hematologic and rheumatologic consult, due to low neutrophil count and recent intrauterine infection, Granulocyte-Colony Stimulating Factor (G-CSF) and cyclosporine (200 mg a day) were added to hydroxychloroquine.
2.2. Fetal Autopsy and Microbiological Results
Postmortem examination revealed a nonmacerated female fetus weighing 420 g and measuring 29 cm in crown-heel length. The other measurements were as follows: Crown-rump length, 19.5 cm; foot length, 3.7 cm; head, chest and abdominal circumference, 18, 16, and 15 cm, respectively. Overall, anthropometric measurements were consistent with 22 weeks’ gestation [6]. External examination showed a normal fetus with mild eyelid and nuchal oedema. On internal examination, intestinal rotation was incomplete (malrotation) with short midgut mesenteric attachment and mobile intestine. No volvulus was observed. Microscopic analysis revealed the presence of intra-alveolar, gastric and intestinal neutrophils (Figure 1); oedema, microhemorrhages and acute tubular necrosis (NTA) of the renal parenchyma were also present.
The placenta was received complete, weighed 137 g, and measured 10 × 10 × 2 cm. The membranes were yellowish and opaque. Microscopically, there was necrotizing AC (Figure 2) corresponding to a maternal inflammatory response stage 3/3 and grade 2/2 [7]. Coccoid bacteria were noted at high magnification within the chorion (Figure 3). Funisitis was also observed with neutrophilic infiltrate of the umbilical vein, and the two arteries with extension to Wharton’s jelly (Figure 4). These findings were consistent with fetal inflammatory response stage 2/3 and grade 2/2 [7]. In addition, in the placental parenchyma some recent infarcts were detected, and in the decidua few spiral arteries presented initial thrombosis.
Autoptical samples were cultured on Columbia blood agar (CBA), McConkey agar (MCA), mannitol salt agar (MSA) and Sabouraud agar (SAB; all these media were incubated at 36 °C, ambient air), chocolate agar (CA, incubated at 36 °C, 5% CO2), and Schaedler agar (SA, incubated at 36 °C, anaerobic atmosphere). After 48 hours from the fetus’s pharyngeal, nose, and ear swabs, small colonies grew on CBA and CA (better on the latter). No growth was observed on MCA. These smooth colonies were catalase negative and oxidase positive. They were identified as K. kingae using the MALDI-ToF technology (Bruker Daltonics, Germany), Biotyper OC software version 3.1. Microbiological cultures on fetal blood and tissues (lung and liver) showed no growth after 72 hours and were discarded as negative. Instead, K. kingae also grew on subamniotic swab and placental tissue cultures. If present, the microorganism grew as a pure culture in all the samples. Antimicrobial susceptibility testing was not performed.
3. Materials and Methods
We searched for (Kingella kingae AND (chorioamnionitis OR genital OR amniotic OR amnios OR placenta OR placental OR funisitis OR fetus OR fetal OR pregnancy OR pregnant OR (membrane AND rupture) OR uterus OR uterine OR intrauterine)) in Pubmed (all fields, 2 results), Scopus (Title/Abstract/Keyword, 9 results) and Web of Science (Topic/Title, 2 results). No limitations were set. The bibliographic research ended on 25 December 2020. Globally, a total of 10 articles resulted from our search. Titles and Abstract of all the articles were screened. All articles were excluded as non-relevant.
4. Discussion
K. kingae is a Gram-negative coccobacillus belonging to the Neisseriaceae family. It is a normal component of the oropharyngeal flora of children less than 4 years old. However, the bacterium, after having colonized and breached the epithelial surface, may disseminate in the bloodstream causing, especially in children, arthritis, osteomyelitis, and endocarditis. This latter complication may also occur in adults [1,8].
Mechanisms of virulence include biofilm formation, pili, RTX toxin production, polysaccharide capsule, and secretion of outer membrane vesicles (OMV).
K. kingae is able to form biofilms, which consist of large quantities of bacteria clustered together in a polysaccharide “slime”, that tightly attaches to the mucosal surface. This kind of colonization allows bacteria to survive in a protected environment preserving them from dehydratation, immune response, and antibiotics [9,10].
K. kingae anchors to the epithelia thanks to type 4 pili, which are proteinaceous fimbriae necessary for efficient adherence to respiratory mucosa and synovia [11].
Moreover, RTX toxin expression exerts a wide-spectrum cytotoxic effect on macrophages, leukocytes, synoviocytes, and respiratory epithelial cells. This toxin plays a key role in infection spreading favouring epithelial disruption and bloodstream dissemination [12,13]. Of note, type a and b polysaccharide capsule predominate in invasive isolates [14]. A further virulence factor possessed by K. kingae is the secretion of OMV, which are small parts of the outer membrane encasing periplasm proteins that bulge away from the bacterium and then are released in the extracellular space. These OMV’s are hemolytic and leukotoxic in an in vitro model and internalized by synoviocytes inducing the synthesis of granulocyte-macrophage colony stimulating factor (GM-CSF) and interleukin 6 (IL-6), likely representing the in vivo immunitary response in joint infections [15].
K. kingae has been recognized as a leading cause of septic arthritis and osteomyelitis in children less than 4 years old, usually with no underlying medical conditions [3,4]. Other rare primary manifestations in pediatric population are: Pneumonia, endocarditis, soft tissue infection, endophtalmitis, orbital cellulitis, and meningitis [1,2,16,17,18,19,20].
Being part of the HACEK group (Haemophilus spp, Aggregatibacter actinomycetemcomitans, Cardiobacterium hominis, Eikenella corrodens, Kingella kingae), K. kingae can cause endocarditis, affecting more frequently children and young adults [21].
Adult patients usually have predisposing conditions in order to develop invasive K. kingae disease, such as malignancies, liver cirrhosis, diabetes, sickle cell anemia, and renal transplant [1,22,23,24,25].
However, to the best of our knowledge, K. kingae infection has never been reported in pregnancy and besides as a cause of PPROM and miscarriage. Moreover, the patient was affected by UCTD in evolution toward LES with severe neutropenia, ANA, and ANCA.
The 31-year-old mother presented to the hospital after having suffered shaking chills, fever (38 °C), stomatitis, sore throat, abdominal pain, and minimal vaginal bleeding for the previous three days. US revealed IUFD. Microbiological cultures on placental subamnionic swab and parenchymal tissue isolated K. kingae. The same agent grew on fetal swabs (ear, nose, and pharyngeal). Fetal tissue cultures (blood, lung and liver) resulted negative. Placental histological examination confirmed severe necrotizing chorioamnionitis and funisitis. Within the chorion, coccoid bacteria were also observed. Fetal histology showed few neutrophils within the alveoli, and gastro-intestinal lumen, respectively.
K. kingae was then considered the etiologic agent responsible for the miscarriage. While other members of the genus Kingella such as K. negevensis and K. denitrificans are known to cause bacterial vaginosis, chorioamnionitis, and pediatric vaginitis [26,27,28]; K. kingae infections of the urogenital tract are extremely rare [29].
However, AC due to K. kingae has never been described. The main microorganisms responsible for AC usually are group B Streptococcus, Fusobacterium nucleatum, Peptostreptococcus, Escherichia coli, Bacteroides species, Ureaplasma urealyticum, and Listeria monocytogenes [30,31]. As K. kingae is not part of the lower genital tract flora, in the case described, an ascending infection was unlikely. The bacterium probably reached the amniotic cavity through the hematogenous pathway from the oropharynx. In fact, the mother presented with sore throat and stomatitis. Although reported in children, K. kingae invasive disease has been associated with recent or concomitant virus infections like coxsackievirus, herpes simplex, varicella zoster, and rhinovirus in the oropharynx and upper respiratory tract [32,33,34,35]. Therefore, a concomitant viral infection in those locations may represent a cofactor in the pathophysiology of invasive K. kingae, probably favoring epithelial breaching and altering the local immune response [36].
In the case we described, it is impossible to differentiate a condition of maternal oropharyngeal carrier exacerbated by a concomitant viral infection or a K. kingae primary oropharyngeal infection turned out to be invasive. Notwithstanding, the mother was affected by UCTD in evolution toward LES with severe neutropenia. To date, K. kingae infection has never been described in this kind of peculiar setting. Only few cases have been observed in a granulocytopenic host [22], LES [37,38,39,40], rheumatoid arthritis [41], and acquired immunodeficiency syndrome (AIDS) [42,43,44,45,46].
Besides, recognition of K. kingae intrauterine infection allowed modifying maternal therapeutic plan, as G-CSF and cyclosporine were added to hydroxychloroquine.
In our specific case, placental cultures and fetal swabs revealed K. kingae infection, but the microorganism was not retrieved from fetal blood and tissues. This may be explained as a low bacterial load or a possible specimen type inhibition. In fact, it is known that recovery of K. kingae from bacteriological solid media may be difficult and nucleic acid amplification is advisable [1]. In our case, polymerase chain reaction (PCR) on the fetal tissues was not performed as infection was clearly demonstrated by neutrophils within the alveoli and in the lumen of gastrointestinal tract.
Usually, in the event of miscarriage due to chorioamnionitis, identification of the correct etiologic agent is of paramount importance as maternal medical treatment can be adjusted accordingly. Placental subamniotic swab and parenchymal cultures as well as fetal blood and tissues microbiological studies should always be carried out as recommended by perinatal autopsy protocols [47,48].
Author Contributions
M.P.B.; carried out the pathological diagnosis and written the manuscript—original draft preparation, review and editing, A.P.; provided the histological pictures and searched for the bibliograhy, G.D.D.; provided the draft preparation and writing, G.C. and G.P.; clinically managed the patient, G.R., G.B., M.B., C.Z., and E.C.; carried out the microbiological diagnosis. All authors have read and agreed to the published version of the manuscript.
Funding
This research received no external funding.
Institutional Review Board Statement
Our investigations were carried out following the rules of the Declaration of Helsinki of 1975, revised in 2013. According to Italian legislation, Ethical Approval for a single case is not required, as long as the data are kept anonymous and the investigations performed do not imply genetic results.
Informed Consent Statement
The current Italian legislation neither requires the family’s consent or ethical approval for a single case, as long as the data are strictly kept anonymous. As summoning the mother was not possible because it would interfere with the grieving process, patient’s consent was completely waived, according to the Italian Authority of Privacy and Data Protection (“Garante della Privacy”: GDPR nr 679/2016; 9/2016 and recent law addition number 424/ 19th of July 2018; http://www.garanteprivacy.it).
Data Availability Statement
The data presented in this study are available on request from the corresponding author.
Conflicts of Interest
The authors declare no conflict of interest.
Figure 1 Fetal lung: A few neutrophils within the alveoli (blue arrows; Hematoxylin Eosin (HE) staining 20×).
Figure 2 Amniochorial membranes: Severe chorioamnionitis with amnion necrosis (blue arrow; HE staining 10×).
Figure 3 Chorion: Abundant coccoid bacteria within the chorionic stroma (HE staining 40×).
Figure 4 Umbilical artery acute vasculitis: Neutrophils within the arterial wall (blue star) with extension to Warthon’s jelly (red star) (HE staining, 4×).
Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations. | Fatal | ReactionOutcome | CC BY | 33557386 | 20,145,774 | 2021-02-04 |
What was the outcome of reaction 'Renal tubular disorder'? | Kingella kingae Intrauterine Infection: An Unusual Cause of Chorioamnionitis and Miscarriage in a Patient with Undifferentiated Connective Tissue Disease.
Kingella kingae is a Gram-negative coccobacillus belonging to the Neisseriaceae family. In children less than 4 years old, K. kingae invasive infection can induce septic arthritis and osteomyelitis, and more rarely endocarditis, meningitis, ocular infections, and pneumonia. In adults, it may be a cause of endocarditis. To date, K. kingae acute chorioamnionitis (AC) leading to preterm rupture of membranes (PPROM) and miscarriage has never been reported. Herein, we describe a case of intrauterine fetal death (IUFD) at 22 weeks' gestation due to K. kingae infection occurred in a patient affected by undifferentiated connective tissue disease (UCTD) in lupus erythematosus systemic (LES) evolution with severe neutropenia. K. kingae was isolated in placental subamnionic swab and tissue cultures as well as fetal ear, nose, and pharyngeal swabs. Placental histological examination showed necrotizing AC and funisitis. In the fetus, neutrophils were observed within the alveoli and in the gastrointestinal lumen. Maternal medical treatment for UCTD was modified according to the K. kingae invasive infection. In the event of IUFD due to AC, microbiological cultures on placenta and fetal tissues should always be carried out in order to isolate the etiologic agent and target the correct medical treatment.
1. Introduction
Kingella kingae is a Gram-negative, facultatively anaerobic coccobacillus of the Neisseriaceae family. It is a slowly growing bacterium also a member of the HACEK group (Haemophilus spp., Aggregatibacter actinomycetemcomitans, Cardiobacterium hominis, Eikenella corrodens, and Kingella kingae) [1,2]. K. kingae is currently recognized as the most common etiology of septic arthritis and osteomyelitis in children between the ages of 6 and 48 months. More rarely, it can cause complicated endocarditis, meningitis, ocular infections, pericarditis, peritonitis, and pneumonia [3,4].
To the best of our knowledge, K. kingae infection has never been reported in pregnancy. Only a case of early onset sepsis (EOS) in a premature infant has been described [5]. Herein, we present an unusual case of preterm premature rupture of membranes (PPROM) at 22 weeks’ gestation with subsequent intrauterine fetal death (IUFD) due to severe acute chorioamnionitis (AC). Placental subamnionic swab and tissue microbiological cultures isolated K. kingae, including fetal ear, nose, and pharyngeal swabs. Moreover, the 31-year-old mother was affected by undifferentiated connective tissue disease (UCTD) in evolution toward lupus erythematosus systemic (LES); severe neutropenia, antinuclear antibodies (ANA), and low titer of anti-neutrophil cytoplasmic antibodies (ANCA) were also present.
2. Case Description
2.1. Mother Clinical Presentation and Treatment
A 31-year-old mother, gravida 2 para 1, presented at 22 weeks’ gestation to the Emergency Department of our Institution for miscarriage. The patient had been suffering from shaking chills, fever (38 °C), stomatitis, sore throat, abdominal pain, and minimal vaginal bleeding for the previous three days. Gynaecological examination revealed on speculum mild fresh blood in vagina and abdominal ultrasound (US) observed IUFD. She was admitted to the hospital, labour was induced and a stillborn female fetus was delivered. Placental microbiological samples and fetal swabs were sent to the Clinical Microbiology laboratory where cultures on different media were immediately performed.
Overall, the patient had a complex clinical history. She had suffered from monoarticular juvenile idiopathic arthritis, completely resolved at 15 years of age.
Six years before the current miscarriage, she had complained of bilateral gonalgia. Laboratory findings had shown severe neutropenia (250 neutrophils) and low titer of ANCA. Antinuclear antibodies (ANA) titer had been 1:160. Anti extractable nuclear antigens (ENA), anti-DNA antibodies, and antiphospholipid antibodies (lupus anticoagulant—LAC; anticardiolipin antibodies—aCL; anti-β2-glycoprotein-1—anti-β2GP-1) had been negative. Bone marrow biopsy had been reported within normal limits.
In the previous six years, although the patient had always been presenting with low neutrophils, she had never contracted opportunistic infections.
One year before the miscarriage, she had had her first pregnancy with a vaginally delivered male infant of 3200 g at 40 weeks + 6 days of gestational age. One month after delivery, she had severe mastitis, which required hospital admission and surgical treatment. After that, she presented with two episodes of bilateral knee arthritis, and then she was put on hydroxychloroquine 200 mg twice a day (tablets).
Regarding the current miscarriage, at hospital admission, maternal laboratory findings were as follows: WBC 2.6 x 1.000/μL and C-reactive protein (CRP) 13.45 mg/dL. During the first day after IUFD, CRP worsened to 18.02 mg/dL, then progressively decreased from 16.46 (2 days), 2.7 mg/dL (3 days), 1.43 mg/dL (5 days) to 0.11 mg/dL (10 days). Blood cultures performed at admission resulted negative.
Maternal medical treatment, started soon after IUFD, consisted of 2 days of meropenem, subsequently switched to piperacillin/tazobactam for 6 days. She fully recovered and was discharged after 10 days.
After hematologic and rheumatologic consult, due to low neutrophil count and recent intrauterine infection, Granulocyte-Colony Stimulating Factor (G-CSF) and cyclosporine (200 mg a day) were added to hydroxychloroquine.
2.2. Fetal Autopsy and Microbiological Results
Postmortem examination revealed a nonmacerated female fetus weighing 420 g and measuring 29 cm in crown-heel length. The other measurements were as follows: Crown-rump length, 19.5 cm; foot length, 3.7 cm; head, chest and abdominal circumference, 18, 16, and 15 cm, respectively. Overall, anthropometric measurements were consistent with 22 weeks’ gestation [6]. External examination showed a normal fetus with mild eyelid and nuchal oedema. On internal examination, intestinal rotation was incomplete (malrotation) with short midgut mesenteric attachment and mobile intestine. No volvulus was observed. Microscopic analysis revealed the presence of intra-alveolar, gastric and intestinal neutrophils (Figure 1); oedema, microhemorrhages and acute tubular necrosis (NTA) of the renal parenchyma were also present.
The placenta was received complete, weighed 137 g, and measured 10 × 10 × 2 cm. The membranes were yellowish and opaque. Microscopically, there was necrotizing AC (Figure 2) corresponding to a maternal inflammatory response stage 3/3 and grade 2/2 [7]. Coccoid bacteria were noted at high magnification within the chorion (Figure 3). Funisitis was also observed with neutrophilic infiltrate of the umbilical vein, and the two arteries with extension to Wharton’s jelly (Figure 4). These findings were consistent with fetal inflammatory response stage 2/3 and grade 2/2 [7]. In addition, in the placental parenchyma some recent infarcts were detected, and in the decidua few spiral arteries presented initial thrombosis.
Autoptical samples were cultured on Columbia blood agar (CBA), McConkey agar (MCA), mannitol salt agar (MSA) and Sabouraud agar (SAB; all these media were incubated at 36 °C, ambient air), chocolate agar (CA, incubated at 36 °C, 5% CO2), and Schaedler agar (SA, incubated at 36 °C, anaerobic atmosphere). After 48 hours from the fetus’s pharyngeal, nose, and ear swabs, small colonies grew on CBA and CA (better on the latter). No growth was observed on MCA. These smooth colonies were catalase negative and oxidase positive. They were identified as K. kingae using the MALDI-ToF technology (Bruker Daltonics, Germany), Biotyper OC software version 3.1. Microbiological cultures on fetal blood and tissues (lung and liver) showed no growth after 72 hours and were discarded as negative. Instead, K. kingae also grew on subamniotic swab and placental tissue cultures. If present, the microorganism grew as a pure culture in all the samples. Antimicrobial susceptibility testing was not performed.
3. Materials and Methods
We searched for (Kingella kingae AND (chorioamnionitis OR genital OR amniotic OR amnios OR placenta OR placental OR funisitis OR fetus OR fetal OR pregnancy OR pregnant OR (membrane AND rupture) OR uterus OR uterine OR intrauterine)) in Pubmed (all fields, 2 results), Scopus (Title/Abstract/Keyword, 9 results) and Web of Science (Topic/Title, 2 results). No limitations were set. The bibliographic research ended on 25 December 2020. Globally, a total of 10 articles resulted from our search. Titles and Abstract of all the articles were screened. All articles were excluded as non-relevant.
4. Discussion
K. kingae is a Gram-negative coccobacillus belonging to the Neisseriaceae family. It is a normal component of the oropharyngeal flora of children less than 4 years old. However, the bacterium, after having colonized and breached the epithelial surface, may disseminate in the bloodstream causing, especially in children, arthritis, osteomyelitis, and endocarditis. This latter complication may also occur in adults [1,8].
Mechanisms of virulence include biofilm formation, pili, RTX toxin production, polysaccharide capsule, and secretion of outer membrane vesicles (OMV).
K. kingae is able to form biofilms, which consist of large quantities of bacteria clustered together in a polysaccharide “slime”, that tightly attaches to the mucosal surface. This kind of colonization allows bacteria to survive in a protected environment preserving them from dehydratation, immune response, and antibiotics [9,10].
K. kingae anchors to the epithelia thanks to type 4 pili, which are proteinaceous fimbriae necessary for efficient adherence to respiratory mucosa and synovia [11].
Moreover, RTX toxin expression exerts a wide-spectrum cytotoxic effect on macrophages, leukocytes, synoviocytes, and respiratory epithelial cells. This toxin plays a key role in infection spreading favouring epithelial disruption and bloodstream dissemination [12,13]. Of note, type a and b polysaccharide capsule predominate in invasive isolates [14]. A further virulence factor possessed by K. kingae is the secretion of OMV, which are small parts of the outer membrane encasing periplasm proteins that bulge away from the bacterium and then are released in the extracellular space. These OMV’s are hemolytic and leukotoxic in an in vitro model and internalized by synoviocytes inducing the synthesis of granulocyte-macrophage colony stimulating factor (GM-CSF) and interleukin 6 (IL-6), likely representing the in vivo immunitary response in joint infections [15].
K. kingae has been recognized as a leading cause of septic arthritis and osteomyelitis in children less than 4 years old, usually with no underlying medical conditions [3,4]. Other rare primary manifestations in pediatric population are: Pneumonia, endocarditis, soft tissue infection, endophtalmitis, orbital cellulitis, and meningitis [1,2,16,17,18,19,20].
Being part of the HACEK group (Haemophilus spp, Aggregatibacter actinomycetemcomitans, Cardiobacterium hominis, Eikenella corrodens, Kingella kingae), K. kingae can cause endocarditis, affecting more frequently children and young adults [21].
Adult patients usually have predisposing conditions in order to develop invasive K. kingae disease, such as malignancies, liver cirrhosis, diabetes, sickle cell anemia, and renal transplant [1,22,23,24,25].
However, to the best of our knowledge, K. kingae infection has never been reported in pregnancy and besides as a cause of PPROM and miscarriage. Moreover, the patient was affected by UCTD in evolution toward LES with severe neutropenia, ANA, and ANCA.
The 31-year-old mother presented to the hospital after having suffered shaking chills, fever (38 °C), stomatitis, sore throat, abdominal pain, and minimal vaginal bleeding for the previous three days. US revealed IUFD. Microbiological cultures on placental subamnionic swab and parenchymal tissue isolated K. kingae. The same agent grew on fetal swabs (ear, nose, and pharyngeal). Fetal tissue cultures (blood, lung and liver) resulted negative. Placental histological examination confirmed severe necrotizing chorioamnionitis and funisitis. Within the chorion, coccoid bacteria were also observed. Fetal histology showed few neutrophils within the alveoli, and gastro-intestinal lumen, respectively.
K. kingae was then considered the etiologic agent responsible for the miscarriage. While other members of the genus Kingella such as K. negevensis and K. denitrificans are known to cause bacterial vaginosis, chorioamnionitis, and pediatric vaginitis [26,27,28]; K. kingae infections of the urogenital tract are extremely rare [29].
However, AC due to K. kingae has never been described. The main microorganisms responsible for AC usually are group B Streptococcus, Fusobacterium nucleatum, Peptostreptococcus, Escherichia coli, Bacteroides species, Ureaplasma urealyticum, and Listeria monocytogenes [30,31]. As K. kingae is not part of the lower genital tract flora, in the case described, an ascending infection was unlikely. The bacterium probably reached the amniotic cavity through the hematogenous pathway from the oropharynx. In fact, the mother presented with sore throat and stomatitis. Although reported in children, K. kingae invasive disease has been associated with recent or concomitant virus infections like coxsackievirus, herpes simplex, varicella zoster, and rhinovirus in the oropharynx and upper respiratory tract [32,33,34,35]. Therefore, a concomitant viral infection in those locations may represent a cofactor in the pathophysiology of invasive K. kingae, probably favoring epithelial breaching and altering the local immune response [36].
In the case we described, it is impossible to differentiate a condition of maternal oropharyngeal carrier exacerbated by a concomitant viral infection or a K. kingae primary oropharyngeal infection turned out to be invasive. Notwithstanding, the mother was affected by UCTD in evolution toward LES with severe neutropenia. To date, K. kingae infection has never been described in this kind of peculiar setting. Only few cases have been observed in a granulocytopenic host [22], LES [37,38,39,40], rheumatoid arthritis [41], and acquired immunodeficiency syndrome (AIDS) [42,43,44,45,46].
Besides, recognition of K. kingae intrauterine infection allowed modifying maternal therapeutic plan, as G-CSF and cyclosporine were added to hydroxychloroquine.
In our specific case, placental cultures and fetal swabs revealed K. kingae infection, but the microorganism was not retrieved from fetal blood and tissues. This may be explained as a low bacterial load or a possible specimen type inhibition. In fact, it is known that recovery of K. kingae from bacteriological solid media may be difficult and nucleic acid amplification is advisable [1]. In our case, polymerase chain reaction (PCR) on the fetal tissues was not performed as infection was clearly demonstrated by neutrophils within the alveoli and in the lumen of gastrointestinal tract.
Usually, in the event of miscarriage due to chorioamnionitis, identification of the correct etiologic agent is of paramount importance as maternal medical treatment can be adjusted accordingly. Placental subamniotic swab and parenchymal cultures as well as fetal blood and tissues microbiological studies should always be carried out as recommended by perinatal autopsy protocols [47,48].
Author Contributions
M.P.B.; carried out the pathological diagnosis and written the manuscript—original draft preparation, review and editing, A.P.; provided the histological pictures and searched for the bibliograhy, G.D.D.; provided the draft preparation and writing, G.C. and G.P.; clinically managed the patient, G.R., G.B., M.B., C.Z., and E.C.; carried out the microbiological diagnosis. All authors have read and agreed to the published version of the manuscript.
Funding
This research received no external funding.
Institutional Review Board Statement
Our investigations were carried out following the rules of the Declaration of Helsinki of 1975, revised in 2013. According to Italian legislation, Ethical Approval for a single case is not required, as long as the data are kept anonymous and the investigations performed do not imply genetic results.
Informed Consent Statement
The current Italian legislation neither requires the family’s consent or ethical approval for a single case, as long as the data are strictly kept anonymous. As summoning the mother was not possible because it would interfere with the grieving process, patient’s consent was completely waived, according to the Italian Authority of Privacy and Data Protection (“Garante della Privacy”: GDPR nr 679/2016; 9/2016 and recent law addition number 424/ 19th of July 2018; http://www.garanteprivacy.it).
Data Availability Statement
The data presented in this study are available on request from the corresponding author.
Conflicts of Interest
The authors declare no conflict of interest.
Figure 1 Fetal lung: A few neutrophils within the alveoli (blue arrows; Hematoxylin Eosin (HE) staining 20×).
Figure 2 Amniochorial membranes: Severe chorioamnionitis with amnion necrosis (blue arrow; HE staining 10×).
Figure 3 Chorion: Abundant coccoid bacteria within the chorionic stroma (HE staining 40×).
Figure 4 Umbilical artery acute vasculitis: Neutrophils within the arterial wall (blue star) with extension to Warthon’s jelly (red star) (HE staining, 4×).
Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations. | Fatal | ReactionOutcome | CC BY | 33557386 | 20,145,774 | 2021-02-04 |
What was the outcome of reaction 'Renal tubular necrosis'? | Kingella kingae Intrauterine Infection: An Unusual Cause of Chorioamnionitis and Miscarriage in a Patient with Undifferentiated Connective Tissue Disease.
Kingella kingae is a Gram-negative coccobacillus belonging to the Neisseriaceae family. In children less than 4 years old, K. kingae invasive infection can induce septic arthritis and osteomyelitis, and more rarely endocarditis, meningitis, ocular infections, and pneumonia. In adults, it may be a cause of endocarditis. To date, K. kingae acute chorioamnionitis (AC) leading to preterm rupture of membranes (PPROM) and miscarriage has never been reported. Herein, we describe a case of intrauterine fetal death (IUFD) at 22 weeks' gestation due to K. kingae infection occurred in a patient affected by undifferentiated connective tissue disease (UCTD) in lupus erythematosus systemic (LES) evolution with severe neutropenia. K. kingae was isolated in placental subamnionic swab and tissue cultures as well as fetal ear, nose, and pharyngeal swabs. Placental histological examination showed necrotizing AC and funisitis. In the fetus, neutrophils were observed within the alveoli and in the gastrointestinal lumen. Maternal medical treatment for UCTD was modified according to the K. kingae invasive infection. In the event of IUFD due to AC, microbiological cultures on placenta and fetal tissues should always be carried out in order to isolate the etiologic agent and target the correct medical treatment.
1. Introduction
Kingella kingae is a Gram-negative, facultatively anaerobic coccobacillus of the Neisseriaceae family. It is a slowly growing bacterium also a member of the HACEK group (Haemophilus spp., Aggregatibacter actinomycetemcomitans, Cardiobacterium hominis, Eikenella corrodens, and Kingella kingae) [1,2]. K. kingae is currently recognized as the most common etiology of septic arthritis and osteomyelitis in children between the ages of 6 and 48 months. More rarely, it can cause complicated endocarditis, meningitis, ocular infections, pericarditis, peritonitis, and pneumonia [3,4].
To the best of our knowledge, K. kingae infection has never been reported in pregnancy. Only a case of early onset sepsis (EOS) in a premature infant has been described [5]. Herein, we present an unusual case of preterm premature rupture of membranes (PPROM) at 22 weeks’ gestation with subsequent intrauterine fetal death (IUFD) due to severe acute chorioamnionitis (AC). Placental subamnionic swab and tissue microbiological cultures isolated K. kingae, including fetal ear, nose, and pharyngeal swabs. Moreover, the 31-year-old mother was affected by undifferentiated connective tissue disease (UCTD) in evolution toward lupus erythematosus systemic (LES); severe neutropenia, antinuclear antibodies (ANA), and low titer of anti-neutrophil cytoplasmic antibodies (ANCA) were also present.
2. Case Description
2.1. Mother Clinical Presentation and Treatment
A 31-year-old mother, gravida 2 para 1, presented at 22 weeks’ gestation to the Emergency Department of our Institution for miscarriage. The patient had been suffering from shaking chills, fever (38 °C), stomatitis, sore throat, abdominal pain, and minimal vaginal bleeding for the previous three days. Gynaecological examination revealed on speculum mild fresh blood in vagina and abdominal ultrasound (US) observed IUFD. She was admitted to the hospital, labour was induced and a stillborn female fetus was delivered. Placental microbiological samples and fetal swabs were sent to the Clinical Microbiology laboratory where cultures on different media were immediately performed.
Overall, the patient had a complex clinical history. She had suffered from monoarticular juvenile idiopathic arthritis, completely resolved at 15 years of age.
Six years before the current miscarriage, she had complained of bilateral gonalgia. Laboratory findings had shown severe neutropenia (250 neutrophils) and low titer of ANCA. Antinuclear antibodies (ANA) titer had been 1:160. Anti extractable nuclear antigens (ENA), anti-DNA antibodies, and antiphospholipid antibodies (lupus anticoagulant—LAC; anticardiolipin antibodies—aCL; anti-β2-glycoprotein-1—anti-β2GP-1) had been negative. Bone marrow biopsy had been reported within normal limits.
In the previous six years, although the patient had always been presenting with low neutrophils, she had never contracted opportunistic infections.
One year before the miscarriage, she had had her first pregnancy with a vaginally delivered male infant of 3200 g at 40 weeks + 6 days of gestational age. One month after delivery, she had severe mastitis, which required hospital admission and surgical treatment. After that, she presented with two episodes of bilateral knee arthritis, and then she was put on hydroxychloroquine 200 mg twice a day (tablets).
Regarding the current miscarriage, at hospital admission, maternal laboratory findings were as follows: WBC 2.6 x 1.000/μL and C-reactive protein (CRP) 13.45 mg/dL. During the first day after IUFD, CRP worsened to 18.02 mg/dL, then progressively decreased from 16.46 (2 days), 2.7 mg/dL (3 days), 1.43 mg/dL (5 days) to 0.11 mg/dL (10 days). Blood cultures performed at admission resulted negative.
Maternal medical treatment, started soon after IUFD, consisted of 2 days of meropenem, subsequently switched to piperacillin/tazobactam for 6 days. She fully recovered and was discharged after 10 days.
After hematologic and rheumatologic consult, due to low neutrophil count and recent intrauterine infection, Granulocyte-Colony Stimulating Factor (G-CSF) and cyclosporine (200 mg a day) were added to hydroxychloroquine.
2.2. Fetal Autopsy and Microbiological Results
Postmortem examination revealed a nonmacerated female fetus weighing 420 g and measuring 29 cm in crown-heel length. The other measurements were as follows: Crown-rump length, 19.5 cm; foot length, 3.7 cm; head, chest and abdominal circumference, 18, 16, and 15 cm, respectively. Overall, anthropometric measurements were consistent with 22 weeks’ gestation [6]. External examination showed a normal fetus with mild eyelid and nuchal oedema. On internal examination, intestinal rotation was incomplete (malrotation) with short midgut mesenteric attachment and mobile intestine. No volvulus was observed. Microscopic analysis revealed the presence of intra-alveolar, gastric and intestinal neutrophils (Figure 1); oedema, microhemorrhages and acute tubular necrosis (NTA) of the renal parenchyma were also present.
The placenta was received complete, weighed 137 g, and measured 10 × 10 × 2 cm. The membranes were yellowish and opaque. Microscopically, there was necrotizing AC (Figure 2) corresponding to a maternal inflammatory response stage 3/3 and grade 2/2 [7]. Coccoid bacteria were noted at high magnification within the chorion (Figure 3). Funisitis was also observed with neutrophilic infiltrate of the umbilical vein, and the two arteries with extension to Wharton’s jelly (Figure 4). These findings were consistent with fetal inflammatory response stage 2/3 and grade 2/2 [7]. In addition, in the placental parenchyma some recent infarcts were detected, and in the decidua few spiral arteries presented initial thrombosis.
Autoptical samples were cultured on Columbia blood agar (CBA), McConkey agar (MCA), mannitol salt agar (MSA) and Sabouraud agar (SAB; all these media were incubated at 36 °C, ambient air), chocolate agar (CA, incubated at 36 °C, 5% CO2), and Schaedler agar (SA, incubated at 36 °C, anaerobic atmosphere). After 48 hours from the fetus’s pharyngeal, nose, and ear swabs, small colonies grew on CBA and CA (better on the latter). No growth was observed on MCA. These smooth colonies were catalase negative and oxidase positive. They were identified as K. kingae using the MALDI-ToF technology (Bruker Daltonics, Germany), Biotyper OC software version 3.1. Microbiological cultures on fetal blood and tissues (lung and liver) showed no growth after 72 hours and were discarded as negative. Instead, K. kingae also grew on subamniotic swab and placental tissue cultures. If present, the microorganism grew as a pure culture in all the samples. Antimicrobial susceptibility testing was not performed.
3. Materials and Methods
We searched for (Kingella kingae AND (chorioamnionitis OR genital OR amniotic OR amnios OR placenta OR placental OR funisitis OR fetus OR fetal OR pregnancy OR pregnant OR (membrane AND rupture) OR uterus OR uterine OR intrauterine)) in Pubmed (all fields, 2 results), Scopus (Title/Abstract/Keyword, 9 results) and Web of Science (Topic/Title, 2 results). No limitations were set. The bibliographic research ended on 25 December 2020. Globally, a total of 10 articles resulted from our search. Titles and Abstract of all the articles were screened. All articles were excluded as non-relevant.
4. Discussion
K. kingae is a Gram-negative coccobacillus belonging to the Neisseriaceae family. It is a normal component of the oropharyngeal flora of children less than 4 years old. However, the bacterium, after having colonized and breached the epithelial surface, may disseminate in the bloodstream causing, especially in children, arthritis, osteomyelitis, and endocarditis. This latter complication may also occur in adults [1,8].
Mechanisms of virulence include biofilm formation, pili, RTX toxin production, polysaccharide capsule, and secretion of outer membrane vesicles (OMV).
K. kingae is able to form biofilms, which consist of large quantities of bacteria clustered together in a polysaccharide “slime”, that tightly attaches to the mucosal surface. This kind of colonization allows bacteria to survive in a protected environment preserving them from dehydratation, immune response, and antibiotics [9,10].
K. kingae anchors to the epithelia thanks to type 4 pili, which are proteinaceous fimbriae necessary for efficient adherence to respiratory mucosa and synovia [11].
Moreover, RTX toxin expression exerts a wide-spectrum cytotoxic effect on macrophages, leukocytes, synoviocytes, and respiratory epithelial cells. This toxin plays a key role in infection spreading favouring epithelial disruption and bloodstream dissemination [12,13]. Of note, type a and b polysaccharide capsule predominate in invasive isolates [14]. A further virulence factor possessed by K. kingae is the secretion of OMV, which are small parts of the outer membrane encasing periplasm proteins that bulge away from the bacterium and then are released in the extracellular space. These OMV’s are hemolytic and leukotoxic in an in vitro model and internalized by synoviocytes inducing the synthesis of granulocyte-macrophage colony stimulating factor (GM-CSF) and interleukin 6 (IL-6), likely representing the in vivo immunitary response in joint infections [15].
K. kingae has been recognized as a leading cause of septic arthritis and osteomyelitis in children less than 4 years old, usually with no underlying medical conditions [3,4]. Other rare primary manifestations in pediatric population are: Pneumonia, endocarditis, soft tissue infection, endophtalmitis, orbital cellulitis, and meningitis [1,2,16,17,18,19,20].
Being part of the HACEK group (Haemophilus spp, Aggregatibacter actinomycetemcomitans, Cardiobacterium hominis, Eikenella corrodens, Kingella kingae), K. kingae can cause endocarditis, affecting more frequently children and young adults [21].
Adult patients usually have predisposing conditions in order to develop invasive K. kingae disease, such as malignancies, liver cirrhosis, diabetes, sickle cell anemia, and renal transplant [1,22,23,24,25].
However, to the best of our knowledge, K. kingae infection has never been reported in pregnancy and besides as a cause of PPROM and miscarriage. Moreover, the patient was affected by UCTD in evolution toward LES with severe neutropenia, ANA, and ANCA.
The 31-year-old mother presented to the hospital after having suffered shaking chills, fever (38 °C), stomatitis, sore throat, abdominal pain, and minimal vaginal bleeding for the previous three days. US revealed IUFD. Microbiological cultures on placental subamnionic swab and parenchymal tissue isolated K. kingae. The same agent grew on fetal swabs (ear, nose, and pharyngeal). Fetal tissue cultures (blood, lung and liver) resulted negative. Placental histological examination confirmed severe necrotizing chorioamnionitis and funisitis. Within the chorion, coccoid bacteria were also observed. Fetal histology showed few neutrophils within the alveoli, and gastro-intestinal lumen, respectively.
K. kingae was then considered the etiologic agent responsible for the miscarriage. While other members of the genus Kingella such as K. negevensis and K. denitrificans are known to cause bacterial vaginosis, chorioamnionitis, and pediatric vaginitis [26,27,28]; K. kingae infections of the urogenital tract are extremely rare [29].
However, AC due to K. kingae has never been described. The main microorganisms responsible for AC usually are group B Streptococcus, Fusobacterium nucleatum, Peptostreptococcus, Escherichia coli, Bacteroides species, Ureaplasma urealyticum, and Listeria monocytogenes [30,31]. As K. kingae is not part of the lower genital tract flora, in the case described, an ascending infection was unlikely. The bacterium probably reached the amniotic cavity through the hematogenous pathway from the oropharynx. In fact, the mother presented with sore throat and stomatitis. Although reported in children, K. kingae invasive disease has been associated with recent or concomitant virus infections like coxsackievirus, herpes simplex, varicella zoster, and rhinovirus in the oropharynx and upper respiratory tract [32,33,34,35]. Therefore, a concomitant viral infection in those locations may represent a cofactor in the pathophysiology of invasive K. kingae, probably favoring epithelial breaching and altering the local immune response [36].
In the case we described, it is impossible to differentiate a condition of maternal oropharyngeal carrier exacerbated by a concomitant viral infection or a K. kingae primary oropharyngeal infection turned out to be invasive. Notwithstanding, the mother was affected by UCTD in evolution toward LES with severe neutropenia. To date, K. kingae infection has never been described in this kind of peculiar setting. Only few cases have been observed in a granulocytopenic host [22], LES [37,38,39,40], rheumatoid arthritis [41], and acquired immunodeficiency syndrome (AIDS) [42,43,44,45,46].
Besides, recognition of K. kingae intrauterine infection allowed modifying maternal therapeutic plan, as G-CSF and cyclosporine were added to hydroxychloroquine.
In our specific case, placental cultures and fetal swabs revealed K. kingae infection, but the microorganism was not retrieved from fetal blood and tissues. This may be explained as a low bacterial load or a possible specimen type inhibition. In fact, it is known that recovery of K. kingae from bacteriological solid media may be difficult and nucleic acid amplification is advisable [1]. In our case, polymerase chain reaction (PCR) on the fetal tissues was not performed as infection was clearly demonstrated by neutrophils within the alveoli and in the lumen of gastrointestinal tract.
Usually, in the event of miscarriage due to chorioamnionitis, identification of the correct etiologic agent is of paramount importance as maternal medical treatment can be adjusted accordingly. Placental subamniotic swab and parenchymal cultures as well as fetal blood and tissues microbiological studies should always be carried out as recommended by perinatal autopsy protocols [47,48].
Author Contributions
M.P.B.; carried out the pathological diagnosis and written the manuscript—original draft preparation, review and editing, A.P.; provided the histological pictures and searched for the bibliograhy, G.D.D.; provided the draft preparation and writing, G.C. and G.P.; clinically managed the patient, G.R., G.B., M.B., C.Z., and E.C.; carried out the microbiological diagnosis. All authors have read and agreed to the published version of the manuscript.
Funding
This research received no external funding.
Institutional Review Board Statement
Our investigations were carried out following the rules of the Declaration of Helsinki of 1975, revised in 2013. According to Italian legislation, Ethical Approval for a single case is not required, as long as the data are kept anonymous and the investigations performed do not imply genetic results.
Informed Consent Statement
The current Italian legislation neither requires the family’s consent or ethical approval for a single case, as long as the data are strictly kept anonymous. As summoning the mother was not possible because it would interfere with the grieving process, patient’s consent was completely waived, according to the Italian Authority of Privacy and Data Protection (“Garante della Privacy”: GDPR nr 679/2016; 9/2016 and recent law addition number 424/ 19th of July 2018; http://www.garanteprivacy.it).
Data Availability Statement
The data presented in this study are available on request from the corresponding author.
Conflicts of Interest
The authors declare no conflict of interest.
Figure 1 Fetal lung: A few neutrophils within the alveoli (blue arrows; Hematoxylin Eosin (HE) staining 20×).
Figure 2 Amniochorial membranes: Severe chorioamnionitis with amnion necrosis (blue arrow; HE staining 10×).
Figure 3 Chorion: Abundant coccoid bacteria within the chorionic stroma (HE staining 40×).
Figure 4 Umbilical artery acute vasculitis: Neutrophils within the arterial wall (blue star) with extension to Warthon’s jelly (red star) (HE staining, 4×).
Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations. | Fatal | ReactionOutcome | CC BY | 33557386 | 20,145,774 | 2021-02-04 |
What was the outcome of reaction 'Stillbirth'? | Kingella kingae Intrauterine Infection: An Unusual Cause of Chorioamnionitis and Miscarriage in a Patient with Undifferentiated Connective Tissue Disease.
Kingella kingae is a Gram-negative coccobacillus belonging to the Neisseriaceae family. In children less than 4 years old, K. kingae invasive infection can induce septic arthritis and osteomyelitis, and more rarely endocarditis, meningitis, ocular infections, and pneumonia. In adults, it may be a cause of endocarditis. To date, K. kingae acute chorioamnionitis (AC) leading to preterm rupture of membranes (PPROM) and miscarriage has never been reported. Herein, we describe a case of intrauterine fetal death (IUFD) at 22 weeks' gestation due to K. kingae infection occurred in a patient affected by undifferentiated connective tissue disease (UCTD) in lupus erythematosus systemic (LES) evolution with severe neutropenia. K. kingae was isolated in placental subamnionic swab and tissue cultures as well as fetal ear, nose, and pharyngeal swabs. Placental histological examination showed necrotizing AC and funisitis. In the fetus, neutrophils were observed within the alveoli and in the gastrointestinal lumen. Maternal medical treatment for UCTD was modified according to the K. kingae invasive infection. In the event of IUFD due to AC, microbiological cultures on placenta and fetal tissues should always be carried out in order to isolate the etiologic agent and target the correct medical treatment.
1. Introduction
Kingella kingae is a Gram-negative, facultatively anaerobic coccobacillus of the Neisseriaceae family. It is a slowly growing bacterium also a member of the HACEK group (Haemophilus spp., Aggregatibacter actinomycetemcomitans, Cardiobacterium hominis, Eikenella corrodens, and Kingella kingae) [1,2]. K. kingae is currently recognized as the most common etiology of septic arthritis and osteomyelitis in children between the ages of 6 and 48 months. More rarely, it can cause complicated endocarditis, meningitis, ocular infections, pericarditis, peritonitis, and pneumonia [3,4].
To the best of our knowledge, K. kingae infection has never been reported in pregnancy. Only a case of early onset sepsis (EOS) in a premature infant has been described [5]. Herein, we present an unusual case of preterm premature rupture of membranes (PPROM) at 22 weeks’ gestation with subsequent intrauterine fetal death (IUFD) due to severe acute chorioamnionitis (AC). Placental subamnionic swab and tissue microbiological cultures isolated K. kingae, including fetal ear, nose, and pharyngeal swabs. Moreover, the 31-year-old mother was affected by undifferentiated connective tissue disease (UCTD) in evolution toward lupus erythematosus systemic (LES); severe neutropenia, antinuclear antibodies (ANA), and low titer of anti-neutrophil cytoplasmic antibodies (ANCA) were also present.
2. Case Description
2.1. Mother Clinical Presentation and Treatment
A 31-year-old mother, gravida 2 para 1, presented at 22 weeks’ gestation to the Emergency Department of our Institution for miscarriage. The patient had been suffering from shaking chills, fever (38 °C), stomatitis, sore throat, abdominal pain, and minimal vaginal bleeding for the previous three days. Gynaecological examination revealed on speculum mild fresh blood in vagina and abdominal ultrasound (US) observed IUFD. She was admitted to the hospital, labour was induced and a stillborn female fetus was delivered. Placental microbiological samples and fetal swabs were sent to the Clinical Microbiology laboratory where cultures on different media were immediately performed.
Overall, the patient had a complex clinical history. She had suffered from monoarticular juvenile idiopathic arthritis, completely resolved at 15 years of age.
Six years before the current miscarriage, she had complained of bilateral gonalgia. Laboratory findings had shown severe neutropenia (250 neutrophils) and low titer of ANCA. Antinuclear antibodies (ANA) titer had been 1:160. Anti extractable nuclear antigens (ENA), anti-DNA antibodies, and antiphospholipid antibodies (lupus anticoagulant—LAC; anticardiolipin antibodies—aCL; anti-β2-glycoprotein-1—anti-β2GP-1) had been negative. Bone marrow biopsy had been reported within normal limits.
In the previous six years, although the patient had always been presenting with low neutrophils, she had never contracted opportunistic infections.
One year before the miscarriage, she had had her first pregnancy with a vaginally delivered male infant of 3200 g at 40 weeks + 6 days of gestational age. One month after delivery, she had severe mastitis, which required hospital admission and surgical treatment. After that, she presented with two episodes of bilateral knee arthritis, and then she was put on hydroxychloroquine 200 mg twice a day (tablets).
Regarding the current miscarriage, at hospital admission, maternal laboratory findings were as follows: WBC 2.6 x 1.000/μL and C-reactive protein (CRP) 13.45 mg/dL. During the first day after IUFD, CRP worsened to 18.02 mg/dL, then progressively decreased from 16.46 (2 days), 2.7 mg/dL (3 days), 1.43 mg/dL (5 days) to 0.11 mg/dL (10 days). Blood cultures performed at admission resulted negative.
Maternal medical treatment, started soon after IUFD, consisted of 2 days of meropenem, subsequently switched to piperacillin/tazobactam for 6 days. She fully recovered and was discharged after 10 days.
After hematologic and rheumatologic consult, due to low neutrophil count and recent intrauterine infection, Granulocyte-Colony Stimulating Factor (G-CSF) and cyclosporine (200 mg a day) were added to hydroxychloroquine.
2.2. Fetal Autopsy and Microbiological Results
Postmortem examination revealed a nonmacerated female fetus weighing 420 g and measuring 29 cm in crown-heel length. The other measurements were as follows: Crown-rump length, 19.5 cm; foot length, 3.7 cm; head, chest and abdominal circumference, 18, 16, and 15 cm, respectively. Overall, anthropometric measurements were consistent with 22 weeks’ gestation [6]. External examination showed a normal fetus with mild eyelid and nuchal oedema. On internal examination, intestinal rotation was incomplete (malrotation) with short midgut mesenteric attachment and mobile intestine. No volvulus was observed. Microscopic analysis revealed the presence of intra-alveolar, gastric and intestinal neutrophils (Figure 1); oedema, microhemorrhages and acute tubular necrosis (NTA) of the renal parenchyma were also present.
The placenta was received complete, weighed 137 g, and measured 10 × 10 × 2 cm. The membranes were yellowish and opaque. Microscopically, there was necrotizing AC (Figure 2) corresponding to a maternal inflammatory response stage 3/3 and grade 2/2 [7]. Coccoid bacteria were noted at high magnification within the chorion (Figure 3). Funisitis was also observed with neutrophilic infiltrate of the umbilical vein, and the two arteries with extension to Wharton’s jelly (Figure 4). These findings were consistent with fetal inflammatory response stage 2/3 and grade 2/2 [7]. In addition, in the placental parenchyma some recent infarcts were detected, and in the decidua few spiral arteries presented initial thrombosis.
Autoptical samples were cultured on Columbia blood agar (CBA), McConkey agar (MCA), mannitol salt agar (MSA) and Sabouraud agar (SAB; all these media were incubated at 36 °C, ambient air), chocolate agar (CA, incubated at 36 °C, 5% CO2), and Schaedler agar (SA, incubated at 36 °C, anaerobic atmosphere). After 48 hours from the fetus’s pharyngeal, nose, and ear swabs, small colonies grew on CBA and CA (better on the latter). No growth was observed on MCA. These smooth colonies were catalase negative and oxidase positive. They were identified as K. kingae using the MALDI-ToF technology (Bruker Daltonics, Germany), Biotyper OC software version 3.1. Microbiological cultures on fetal blood and tissues (lung and liver) showed no growth after 72 hours and were discarded as negative. Instead, K. kingae also grew on subamniotic swab and placental tissue cultures. If present, the microorganism grew as a pure culture in all the samples. Antimicrobial susceptibility testing was not performed.
3. Materials and Methods
We searched for (Kingella kingae AND (chorioamnionitis OR genital OR amniotic OR amnios OR placenta OR placental OR funisitis OR fetus OR fetal OR pregnancy OR pregnant OR (membrane AND rupture) OR uterus OR uterine OR intrauterine)) in Pubmed (all fields, 2 results), Scopus (Title/Abstract/Keyword, 9 results) and Web of Science (Topic/Title, 2 results). No limitations were set. The bibliographic research ended on 25 December 2020. Globally, a total of 10 articles resulted from our search. Titles and Abstract of all the articles were screened. All articles were excluded as non-relevant.
4. Discussion
K. kingae is a Gram-negative coccobacillus belonging to the Neisseriaceae family. It is a normal component of the oropharyngeal flora of children less than 4 years old. However, the bacterium, after having colonized and breached the epithelial surface, may disseminate in the bloodstream causing, especially in children, arthritis, osteomyelitis, and endocarditis. This latter complication may also occur in adults [1,8].
Mechanisms of virulence include biofilm formation, pili, RTX toxin production, polysaccharide capsule, and secretion of outer membrane vesicles (OMV).
K. kingae is able to form biofilms, which consist of large quantities of bacteria clustered together in a polysaccharide “slime”, that tightly attaches to the mucosal surface. This kind of colonization allows bacteria to survive in a protected environment preserving them from dehydratation, immune response, and antibiotics [9,10].
K. kingae anchors to the epithelia thanks to type 4 pili, which are proteinaceous fimbriae necessary for efficient adherence to respiratory mucosa and synovia [11].
Moreover, RTX toxin expression exerts a wide-spectrum cytotoxic effect on macrophages, leukocytes, synoviocytes, and respiratory epithelial cells. This toxin plays a key role in infection spreading favouring epithelial disruption and bloodstream dissemination [12,13]. Of note, type a and b polysaccharide capsule predominate in invasive isolates [14]. A further virulence factor possessed by K. kingae is the secretion of OMV, which are small parts of the outer membrane encasing periplasm proteins that bulge away from the bacterium and then are released in the extracellular space. These OMV’s are hemolytic and leukotoxic in an in vitro model and internalized by synoviocytes inducing the synthesis of granulocyte-macrophage colony stimulating factor (GM-CSF) and interleukin 6 (IL-6), likely representing the in vivo immunitary response in joint infections [15].
K. kingae has been recognized as a leading cause of septic arthritis and osteomyelitis in children less than 4 years old, usually with no underlying medical conditions [3,4]. Other rare primary manifestations in pediatric population are: Pneumonia, endocarditis, soft tissue infection, endophtalmitis, orbital cellulitis, and meningitis [1,2,16,17,18,19,20].
Being part of the HACEK group (Haemophilus spp, Aggregatibacter actinomycetemcomitans, Cardiobacterium hominis, Eikenella corrodens, Kingella kingae), K. kingae can cause endocarditis, affecting more frequently children and young adults [21].
Adult patients usually have predisposing conditions in order to develop invasive K. kingae disease, such as malignancies, liver cirrhosis, diabetes, sickle cell anemia, and renal transplant [1,22,23,24,25].
However, to the best of our knowledge, K. kingae infection has never been reported in pregnancy and besides as a cause of PPROM and miscarriage. Moreover, the patient was affected by UCTD in evolution toward LES with severe neutropenia, ANA, and ANCA.
The 31-year-old mother presented to the hospital after having suffered shaking chills, fever (38 °C), stomatitis, sore throat, abdominal pain, and minimal vaginal bleeding for the previous three days. US revealed IUFD. Microbiological cultures on placental subamnionic swab and parenchymal tissue isolated K. kingae. The same agent grew on fetal swabs (ear, nose, and pharyngeal). Fetal tissue cultures (blood, lung and liver) resulted negative. Placental histological examination confirmed severe necrotizing chorioamnionitis and funisitis. Within the chorion, coccoid bacteria were also observed. Fetal histology showed few neutrophils within the alveoli, and gastro-intestinal lumen, respectively.
K. kingae was then considered the etiologic agent responsible for the miscarriage. While other members of the genus Kingella such as K. negevensis and K. denitrificans are known to cause bacterial vaginosis, chorioamnionitis, and pediatric vaginitis [26,27,28]; K. kingae infections of the urogenital tract are extremely rare [29].
However, AC due to K. kingae has never been described. The main microorganisms responsible for AC usually are group B Streptococcus, Fusobacterium nucleatum, Peptostreptococcus, Escherichia coli, Bacteroides species, Ureaplasma urealyticum, and Listeria monocytogenes [30,31]. As K. kingae is not part of the lower genital tract flora, in the case described, an ascending infection was unlikely. The bacterium probably reached the amniotic cavity through the hematogenous pathway from the oropharynx. In fact, the mother presented with sore throat and stomatitis. Although reported in children, K. kingae invasive disease has been associated with recent or concomitant virus infections like coxsackievirus, herpes simplex, varicella zoster, and rhinovirus in the oropharynx and upper respiratory tract [32,33,34,35]. Therefore, a concomitant viral infection in those locations may represent a cofactor in the pathophysiology of invasive K. kingae, probably favoring epithelial breaching and altering the local immune response [36].
In the case we described, it is impossible to differentiate a condition of maternal oropharyngeal carrier exacerbated by a concomitant viral infection or a K. kingae primary oropharyngeal infection turned out to be invasive. Notwithstanding, the mother was affected by UCTD in evolution toward LES with severe neutropenia. To date, K. kingae infection has never been described in this kind of peculiar setting. Only few cases have been observed in a granulocytopenic host [22], LES [37,38,39,40], rheumatoid arthritis [41], and acquired immunodeficiency syndrome (AIDS) [42,43,44,45,46].
Besides, recognition of K. kingae intrauterine infection allowed modifying maternal therapeutic plan, as G-CSF and cyclosporine were added to hydroxychloroquine.
In our specific case, placental cultures and fetal swabs revealed K. kingae infection, but the microorganism was not retrieved from fetal blood and tissues. This may be explained as a low bacterial load or a possible specimen type inhibition. In fact, it is known that recovery of K. kingae from bacteriological solid media may be difficult and nucleic acid amplification is advisable [1]. In our case, polymerase chain reaction (PCR) on the fetal tissues was not performed as infection was clearly demonstrated by neutrophils within the alveoli and in the lumen of gastrointestinal tract.
Usually, in the event of miscarriage due to chorioamnionitis, identification of the correct etiologic agent is of paramount importance as maternal medical treatment can be adjusted accordingly. Placental subamniotic swab and parenchymal cultures as well as fetal blood and tissues microbiological studies should always be carried out as recommended by perinatal autopsy protocols [47,48].
Author Contributions
M.P.B.; carried out the pathological diagnosis and written the manuscript—original draft preparation, review and editing, A.P.; provided the histological pictures and searched for the bibliograhy, G.D.D.; provided the draft preparation and writing, G.C. and G.P.; clinically managed the patient, G.R., G.B., M.B., C.Z., and E.C.; carried out the microbiological diagnosis. All authors have read and agreed to the published version of the manuscript.
Funding
This research received no external funding.
Institutional Review Board Statement
Our investigations were carried out following the rules of the Declaration of Helsinki of 1975, revised in 2013. According to Italian legislation, Ethical Approval for a single case is not required, as long as the data are kept anonymous and the investigations performed do not imply genetic results.
Informed Consent Statement
The current Italian legislation neither requires the family’s consent or ethical approval for a single case, as long as the data are strictly kept anonymous. As summoning the mother was not possible because it would interfere with the grieving process, patient’s consent was completely waived, according to the Italian Authority of Privacy and Data Protection (“Garante della Privacy”: GDPR nr 679/2016; 9/2016 and recent law addition number 424/ 19th of July 2018; http://www.garanteprivacy.it).
Data Availability Statement
The data presented in this study are available on request from the corresponding author.
Conflicts of Interest
The authors declare no conflict of interest.
Figure 1 Fetal lung: A few neutrophils within the alveoli (blue arrows; Hematoxylin Eosin (HE) staining 20×).
Figure 2 Amniochorial membranes: Severe chorioamnionitis with amnion necrosis (blue arrow; HE staining 10×).
Figure 3 Chorion: Abundant coccoid bacteria within the chorionic stroma (HE staining 40×).
Figure 4 Umbilical artery acute vasculitis: Neutrophils within the arterial wall (blue star) with extension to Warthon’s jelly (red star) (HE staining, 4×).
Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations. | Fatal | ReactionOutcome | CC BY | 33557386 | 20,145,774 | 2021-02-04 |
Give an alphabetized list of all active substances of drugs taken by the patient who experienced 'Labelled drug-drug interaction medication error'. | Surgical treatment of carotid artery stent infection: a case report.
The most effective treatment for graft infection is still debated, and the success rate of current treatments is low. We herein report the results of surgical treatment and follow-up of a case of infection acquired during carotid stenting with the aim of exploring the most effective treatments for graft infection. We retrospectively analyzed a patient who was admitted in September 2019. This patient underwent debridement, autologous saphenous vein replacement of the common carotid to internal carotid artery, external carotid artery suturing, and continuous negative-pressure wound therapy for carotid stent infection. Ten days after carotid artery revascularization, the growth of granulation tissue in the incision was good, and we decided to suture the neck incision. Five days after removing the stitches, grade A healing was noted. Furthermore, the carotid artery and autologous vein grafts were unobstructed as shown by carotid artery computed tomography angiography reexamination. The patient was monitored for 8 months with no new neurological symptoms and good healing of the incision. Effective treatment of vascular graft infection includes debridement and removal of the infected graft, autologous vein graft revascularization, and negative-pressure wound therapy combined with antibiotic therapy.
Introduction
The application of vascular grafts has been revolutionary for the treatment of peripheral
vascular and aortic diseases, and grafts have become indispensable in vascular surgery.
However, with the extensive application of vascular grafts, graft infections have become a
major problem for vascular surgeons. Graft infection is characterized by arterial wall
destruction, thrombosis, septic embolism, pseudoaneurysm formation, arterial rupture, and hemorrhage.1 Carotid stent infection is much rarer. Son et al.2 reported that only 2 of 77 cases of graft infection were associated with carotid
stenting. No standardized treatment has been established for vascular graft infection.
Treatment of carotid artery graft infection is very dangerous, and the patient is always at
risk of perioperative large-area cerebral infarction. We herein report the successful
diagnosis and surgical treatment of a case of carotid artery stent infection at China-Japan
Union Hospital Jilin University.
Case report
A 51-year-old man with neck trauma underwent debridement, implantation of a carotid artery
covered stent (8 × 60 mm, Fluency Plus; C. R. Bard, Murray Hill, NJ, USA), and thrombectomy
of the middle cerebral artery at a local hospital in October 2018 (Figure 1). After emergency admission, three-dimensional
angiography of the carotid artery was performed. A dissecting aneurysm was present at the
end of the left common carotid artery and the beginning of the left internal carotid artery.
The blood flow toward the brain was significantly decreased, but the rate at which it was
decreased was unknown. Compression of the left common carotid artery for angiography of the
right internal carotid artery and left vertebral artery revealed poor compensation of the
anterior and posterior communicating arteries. General anesthesia was administered and
debridement was conducted to remove the foreign bodies. A wood splinter was located between
the carotid artery and the internal jugular vein. The dissecting aneurysm ruptured and
started bleeding during the process of tissue separation. A common carotid artery stent was
therefore implanted into the femoral artery. A cerebral protection device was not used. The
patient took aspirin (100 mg) and clopidogrel (75 mg) orally after the operation. Thrombosis
of the left middle cerebral artery was found in the second intracranial angiography
examination and was considered to have been caused by exfoliation of the thrombus during the
dissection. Thrombectomy of the middle cerebral artery was therefore performed. The lumen of
the middle cerebral artery was unobstructed as shown by angiography. After the
above-described operation, debridement of the wound was continued, and the wood splinter was
removed. Postoperatively, brain magnetic resonance imaging indicated previous hemorrhage and
the formation of a softening lesion in the left basal ganglia. In February 2019, the
incision was debrided and re-sutured because of infection (Figure 2). However, the incision did not heal
completely after this operation. This was an extremely dangerous situation because of the
risk of carotid blowout; the carotid arterial flow was protected only by a thin intimal
layer within the stent and was accompanied by infection.
Figure 1. Day of neck trauma. The first debridement, carotid stenting, and thrombectomy of the
middle cerebral artery were performed on this day.
Figure 2. Second debridement. The covered stent was partially exposed.
In September 2019, the patient was admitted to the China-Japan Union Hospital of Jilin
University because the incision had not healed completely after 7 months. Specialized
physical examinations revealed a sinus tract with pus overflowing on the left side of the
neck accompanied by patchy redness and tenderness around the previous incision. Bilateral
carotid pulses were palpable, and the right and left upper limb muscle strength was Lovett
muscle strength grade IV and V, respectively. Biochemical examination revealed an
erythrocyte sedimentation rate of 28 mm/hour and C-reactive protein concentration of 35.4
mg/L. Culture of the secretions revealed methicillin-resistant Staphylococcus
aureus (MRSA) infection. The MRSA was sensitive to moxifloxacin and levofloxacin.
Through the purulent sinus, we could vaguely see the carotid artery stent and obtained the
pus from the deep tissue. We believed that the results of the MRSA culture were clinically
significant. Ultrasound examination showed unobstructed blood flow in the carotid stents.
Computed tomography angiography (CTA) indicated that the blood circulation in the carotid
artery stent was smooth with intimal hyperplasia, the internal carotid artery was
unobstructed, and the external carotid artery was completely occluded (Figure 3). The patient was young, had no underlying
disease, had experienced a long disease course, and strongly wished for surgical treatment.
We decided upon the surgical plan after a discussion with several professors.
Figure 3. Computed tomography angiography findings. The carotid artery stent and internal carotid
artery were patent, the external carotid artery was completely occluded, and intimal
hyperplasia was evident in the stent.
Moxifloxacin (250 mL: 0.4 g, 1/day) was given intravenously and low-molecular-weight
heparin (4100 IU) was given subcutaneously in accordance with the patient’s drug sensitivity
results after hospitalization. Moxifloxacin (250 mL: 0.4 g) was intravenously administered
30 minutes before the operation. We monitored the brain activity with intraoperative
electroencephalography without assessing the tolerance of the internal carotid artery
occlusion before surgery. The supine position was adopted, the shoulders were raised, and
the head was tilted back to the uninjured side. The length of the incision along the
anterior edge of the sternocleidomastoid muscle and the original incision was about 15 cm.
The inflammatory reaction within the incision and the tissue adhesion were severe. The
inflammatory reaction around the anchorage area of the stent was also severe. The stent
completely covered the opening of the external carotid artery. The proximal end of the
common carotid artery was carefully dissected, and blocking tape was added. The internal and
external carotid arteries were dissected, although they were difficult to distinguish
because of severe inflammation and adhesion. The appropriate length of the saphenous vein
was then obtained. After attaining sufficient blood supply to the brain, the distal internal
and external carotid arteries were blocked off and the infected stent was removed. The
external carotid artery was completely occluded. The internal carotid artery was anastomosed
in an end-to-end manner with the saphenous vein. After restoring the blood supply of the
internal carotid artery for 5 minutes, the common carotid artery was anastomosed in an
end-to-side manner with the great saphenous vein, and the stump of the common carotid artery
was sutured (Figure 4). We then
intermittently sutured the surrounding tissue and loosely wrapped the transplanted great
saphenous vein and the anastomosis at both ends. We did not cover it with muscle. Finally,
we covered the wound with a negative-pressure device, which was not in direct contact with
the bypass. The operation lasted 2.5 hours, and the intraoperative blood loss was 600 mL.
The patient was administered 3 units of type A-positive blood and 200 mL of ordinary frozen
plasma. No neurological complications occurred after extubation.
Figure 4. First operation. The infected stent was removed and the carotid artery was
reconstructed.
On the day after the operation, the patient was given an intravenous injection of
dexamethasone (5 mg), and mannitol (250 mL: 50 g) was given intravenously at a volume of 125
mL every 12 hours for 4 days. Moxifloxacin (250 mL: 0.4g) was given intravenously once a day
for 10 days, low-molecular-weight heparin (4100 IU) was given subcutaneously once a day for
10 days, and levofloxacin sodium chloride injection (250 mL: 0.5 g) was used to rinse the
negative-pressure suction device once a day. The drainage fluid was not turbid. The
granulation tissue grew well after 10 days of carotid artery reconstruction; therefore, we
closed the incision (Figure 5). CTA
re-examination showed that the autogenous vein was unblocked. After discharge, the incision
was followed up for 1 month and showed grade A healing (Figure 6). Telephone follow-up was conducted regularly
for 1 month postoperatively. At the time of this writing, the patient was in good condition
without obvious neurological symptoms.
Figure 5. Second operation. Good granulation tissue growth was present, and the incision was
sutured.
Figure 6. Computed tomography angiography findings. The autogenous vein was unblocked, and the
incision achieved grade A healing. The patient was followed up for 1 month after
discharge.
The patient provided oral authorization for participation in this case study and
publication of the details of his case. We have de-identified all patient details. The
requirement for ethics approval was waived because this article does not contain information
that can be used to identify the patient and because he agreed to publication.
Discussion
About 80% of the pathogenic microorganisms involved in vascular graft infections are
Staphylococcus aureus and coagulase-negative
Staphylococcus. The risk factors for vascular graft infection include
patient-related factors (periodontal disease, nasal Staphylococcus aureus
colonization, postoperative bacteremia and stent characteristics, diabetes or postoperative
hyperglycemia, obesity, renal failure, liver disease, malnutrition, and immunosuppression)
as well as operation-related factors (intraoperative violation of sterility, a graft in the
groin, prolonged operation time, repeated vascular surgery, and lack of perioperative
antibiotic administration).3–5 The cause of the stent infection in this
case was considered to be that the open neck injury was a contaminated wound and that the
stent was partially exposed after two operations (Figure 2).
Vascular graft infection can be divided into Szilagyi grade I, II, and III. Szilagyi grade
I infection is limited to the skin, Szilagyi grade II infection is limited to the skin and
subcutaneous tissue, and Szilagyi grade III infection involves the graft.6 These different levels of infection involve different treatments. Generally, the
treatments can be divided into antibiotic and surgical treatments. The overall treatment
goal is to eradicate the infection and maintain the blood supply. Szilagyi grade I and II
infections are easier to control, and conservative treatment can be considered. For Szilagyi
grade II infection, extra attention should be invested to assess whether the infection has
progressed to grade III. No clear guidelines have been established for antibiotic treatment,
and intravenous administration of antibiotics for 4 to 6 weeks is generally considered
necessary. Our patient was considered to have Szilagyi grade III infection. Surgical
treatment combined with antibiotics was effective. The patient was given intravenous
antibiotics for 3 weeks in hospital. Considering that the patient’s infection was eliminated
and the autologous saphenous vein had strong antimicrobial protection, no oral antibiotics
were given after discharge.
Surgical intervention is required for a clearly diagnosed grade III infection when sepsis,
anastomotic rupture, aortoenteric fistula, and MRSA infection occurs. Conservative
treatments are less likely to succeed for graft infection. It was previously recommended
that anatomic bypass reconstruction be performed in the uninfected area. The disadvantages
of this are a low patency rate, high disability rate, and risk of anastomotic rupture. The
methods of in situ circulation reconstruction include partial graft removal
and reconstruction with cryopreserved homografts, fresh arterial allografts, autologous
veins, or antibiotic- or silver-bonded prosthetic grafts.7,8 The reinfection rate of biological materials is currently considered to
be low, and autogenous veins are considered the best choice to avoid reinfection.9
Negative-pressure wound therapy is reportedly an effective auxiliary treatment. Continuous
negative-pressure wound therapy can reduce the bacterial content in the wound, accelerate
blood flow, and promote the growth of granulation tissue.10 However, negative-pressure wound therapy is associated with a risk of anastomotic
bleeding; thus, low negative pressure can be considered.11
Patients with limb graft infection are at risk of amputation, whereas patients with carotid
artery graft infection are at high risk of cerebral infarction and intracranial infection.
This can be disastrous to their health and their family’s wellbeing. If the anchorage zone
and the anastomosis of the stent break, massive bleeding within a short period of time can
result in a huge hematoma, which may compress the trachea and cause suffocation. In patients
with grade I or II infections, the graft can be retained, and local debridement and muscle
flap coverage can be used together with antibiotic treatment. If the infection involves the
graft (grade III), removing all grafts and reconstructing the arteries may be necessary. The
material used to reconstruct the vasculature is usually autologous veins, and the saphenous
vein is most frequently used. The infection cure rate is very high, and the risk of
reinfection is only 0% to 10%.4
We achieved a definitive diagnosis of stent infection by combining the results of the
culture of the pus secretions, CTA, and ultrasound. The following points were considered.
First, the patient had no underlying disease and could tolerate surgery. Second, the patient
had undergone two previous neck operations, and the infection was severe because of exposure
of the stent to the environment through the sinus tract. Third, long-term stent infections
cannot be cured through conservative treatments. Finally, the patient had experienced a long
disease course and had a strong desire to eradicate the infection. Therefore, surgical
treatment was the best method.
In general, infection of carotid artery stents and vascular grafts is relatively rare. Such
infections increase patients’ disability rate and endanger their lives. Perioperative
sterility is important to prevent infection. If infection does occur, early identification
and treatment can prevent fatal consequences. For Szilagyi grade III infections, removal of
the infected graft and autologous venous reconstruction combined with low negative-pressure
wound therapy and sensitive antibiotic therapy are effective treatment methods. In addition,
individualized treatment plans should be formulated depending upon the grade of the vascular
graft infection.
Acknowledgements
We are very grateful to the vascular surgery team of the China-Japan Union Hospital of
Jilin University. We also thank Professor Dajun Sun, Director of Vascular Surgery of the
China-Japan Union Hospital of Jilin University, and Professor Yue Zhao.
Declaration of conflicting interest: The authors declare that there is no conflict of interest.
Funding: This research received no specific grant from any funding agency in the public,
commercial, or not-for-profit sectors.
ORCID iD: Xiwen Liu https://orcid.org/0000-0002-5220-8132 | ASPIRIN, CLOPIDOGREL BISULFATE, MOXIFLOXACIN, UNSPECIFIED INGREDIENT | DrugsGivenReaction | CC BY-NC | 33557657 | 19,674,675 | 2021-02 |
Give an alphabetized list of all active substances of drugs taken by the patient who experienced 'Off label use'. | Surgical treatment of carotid artery stent infection: a case report.
The most effective treatment for graft infection is still debated, and the success rate of current treatments is low. We herein report the results of surgical treatment and follow-up of a case of infection acquired during carotid stenting with the aim of exploring the most effective treatments for graft infection. We retrospectively analyzed a patient who was admitted in September 2019. This patient underwent debridement, autologous saphenous vein replacement of the common carotid to internal carotid artery, external carotid artery suturing, and continuous negative-pressure wound therapy for carotid stent infection. Ten days after carotid artery revascularization, the growth of granulation tissue in the incision was good, and we decided to suture the neck incision. Five days after removing the stitches, grade A healing was noted. Furthermore, the carotid artery and autologous vein grafts were unobstructed as shown by carotid artery computed tomography angiography reexamination. The patient was monitored for 8 months with no new neurological symptoms and good healing of the incision. Effective treatment of vascular graft infection includes debridement and removal of the infected graft, autologous vein graft revascularization, and negative-pressure wound therapy combined with antibiotic therapy.
Introduction
The application of vascular grafts has been revolutionary for the treatment of peripheral
vascular and aortic diseases, and grafts have become indispensable in vascular surgery.
However, with the extensive application of vascular grafts, graft infections have become a
major problem for vascular surgeons. Graft infection is characterized by arterial wall
destruction, thrombosis, septic embolism, pseudoaneurysm formation, arterial rupture, and hemorrhage.1 Carotid stent infection is much rarer. Son et al.2 reported that only 2 of 77 cases of graft infection were associated with carotid
stenting. No standardized treatment has been established for vascular graft infection.
Treatment of carotid artery graft infection is very dangerous, and the patient is always at
risk of perioperative large-area cerebral infarction. We herein report the successful
diagnosis and surgical treatment of a case of carotid artery stent infection at China-Japan
Union Hospital Jilin University.
Case report
A 51-year-old man with neck trauma underwent debridement, implantation of a carotid artery
covered stent (8 × 60 mm, Fluency Plus; C. R. Bard, Murray Hill, NJ, USA), and thrombectomy
of the middle cerebral artery at a local hospital in October 2018 (Figure 1). After emergency admission, three-dimensional
angiography of the carotid artery was performed. A dissecting aneurysm was present at the
end of the left common carotid artery and the beginning of the left internal carotid artery.
The blood flow toward the brain was significantly decreased, but the rate at which it was
decreased was unknown. Compression of the left common carotid artery for angiography of the
right internal carotid artery and left vertebral artery revealed poor compensation of the
anterior and posterior communicating arteries. General anesthesia was administered and
debridement was conducted to remove the foreign bodies. A wood splinter was located between
the carotid artery and the internal jugular vein. The dissecting aneurysm ruptured and
started bleeding during the process of tissue separation. A common carotid artery stent was
therefore implanted into the femoral artery. A cerebral protection device was not used. The
patient took aspirin (100 mg) and clopidogrel (75 mg) orally after the operation. Thrombosis
of the left middle cerebral artery was found in the second intracranial angiography
examination and was considered to have been caused by exfoliation of the thrombus during the
dissection. Thrombectomy of the middle cerebral artery was therefore performed. The lumen of
the middle cerebral artery was unobstructed as shown by angiography. After the
above-described operation, debridement of the wound was continued, and the wood splinter was
removed. Postoperatively, brain magnetic resonance imaging indicated previous hemorrhage and
the formation of a softening lesion in the left basal ganglia. In February 2019, the
incision was debrided and re-sutured because of infection (Figure 2). However, the incision did not heal
completely after this operation. This was an extremely dangerous situation because of the
risk of carotid blowout; the carotid arterial flow was protected only by a thin intimal
layer within the stent and was accompanied by infection.
Figure 1. Day of neck trauma. The first debridement, carotid stenting, and thrombectomy of the
middle cerebral artery were performed on this day.
Figure 2. Second debridement. The covered stent was partially exposed.
In September 2019, the patient was admitted to the China-Japan Union Hospital of Jilin
University because the incision had not healed completely after 7 months. Specialized
physical examinations revealed a sinus tract with pus overflowing on the left side of the
neck accompanied by patchy redness and tenderness around the previous incision. Bilateral
carotid pulses were palpable, and the right and left upper limb muscle strength was Lovett
muscle strength grade IV and V, respectively. Biochemical examination revealed an
erythrocyte sedimentation rate of 28 mm/hour and C-reactive protein concentration of 35.4
mg/L. Culture of the secretions revealed methicillin-resistant Staphylococcus
aureus (MRSA) infection. The MRSA was sensitive to moxifloxacin and levofloxacin.
Through the purulent sinus, we could vaguely see the carotid artery stent and obtained the
pus from the deep tissue. We believed that the results of the MRSA culture were clinically
significant. Ultrasound examination showed unobstructed blood flow in the carotid stents.
Computed tomography angiography (CTA) indicated that the blood circulation in the carotid
artery stent was smooth with intimal hyperplasia, the internal carotid artery was
unobstructed, and the external carotid artery was completely occluded (Figure 3). The patient was young, had no underlying
disease, had experienced a long disease course, and strongly wished for surgical treatment.
We decided upon the surgical plan after a discussion with several professors.
Figure 3. Computed tomography angiography findings. The carotid artery stent and internal carotid
artery were patent, the external carotid artery was completely occluded, and intimal
hyperplasia was evident in the stent.
Moxifloxacin (250 mL: 0.4 g, 1/day) was given intravenously and low-molecular-weight
heparin (4100 IU) was given subcutaneously in accordance with the patient’s drug sensitivity
results after hospitalization. Moxifloxacin (250 mL: 0.4 g) was intravenously administered
30 minutes before the operation. We monitored the brain activity with intraoperative
electroencephalography without assessing the tolerance of the internal carotid artery
occlusion before surgery. The supine position was adopted, the shoulders were raised, and
the head was tilted back to the uninjured side. The length of the incision along the
anterior edge of the sternocleidomastoid muscle and the original incision was about 15 cm.
The inflammatory reaction within the incision and the tissue adhesion were severe. The
inflammatory reaction around the anchorage area of the stent was also severe. The stent
completely covered the opening of the external carotid artery. The proximal end of the
common carotid artery was carefully dissected, and blocking tape was added. The internal and
external carotid arteries were dissected, although they were difficult to distinguish
because of severe inflammation and adhesion. The appropriate length of the saphenous vein
was then obtained. After attaining sufficient blood supply to the brain, the distal internal
and external carotid arteries were blocked off and the infected stent was removed. The
external carotid artery was completely occluded. The internal carotid artery was anastomosed
in an end-to-end manner with the saphenous vein. After restoring the blood supply of the
internal carotid artery for 5 minutes, the common carotid artery was anastomosed in an
end-to-side manner with the great saphenous vein, and the stump of the common carotid artery
was sutured (Figure 4). We then
intermittently sutured the surrounding tissue and loosely wrapped the transplanted great
saphenous vein and the anastomosis at both ends. We did not cover it with muscle. Finally,
we covered the wound with a negative-pressure device, which was not in direct contact with
the bypass. The operation lasted 2.5 hours, and the intraoperative blood loss was 600 mL.
The patient was administered 3 units of type A-positive blood and 200 mL of ordinary frozen
plasma. No neurological complications occurred after extubation.
Figure 4. First operation. The infected stent was removed and the carotid artery was
reconstructed.
On the day after the operation, the patient was given an intravenous injection of
dexamethasone (5 mg), and mannitol (250 mL: 50 g) was given intravenously at a volume of 125
mL every 12 hours for 4 days. Moxifloxacin (250 mL: 0.4g) was given intravenously once a day
for 10 days, low-molecular-weight heparin (4100 IU) was given subcutaneously once a day for
10 days, and levofloxacin sodium chloride injection (250 mL: 0.5 g) was used to rinse the
negative-pressure suction device once a day. The drainage fluid was not turbid. The
granulation tissue grew well after 10 days of carotid artery reconstruction; therefore, we
closed the incision (Figure 5). CTA
re-examination showed that the autogenous vein was unblocked. After discharge, the incision
was followed up for 1 month and showed grade A healing (Figure 6). Telephone follow-up was conducted regularly
for 1 month postoperatively. At the time of this writing, the patient was in good condition
without obvious neurological symptoms.
Figure 5. Second operation. Good granulation tissue growth was present, and the incision was
sutured.
Figure 6. Computed tomography angiography findings. The autogenous vein was unblocked, and the
incision achieved grade A healing. The patient was followed up for 1 month after
discharge.
The patient provided oral authorization for participation in this case study and
publication of the details of his case. We have de-identified all patient details. The
requirement for ethics approval was waived because this article does not contain information
that can be used to identify the patient and because he agreed to publication.
Discussion
About 80% of the pathogenic microorganisms involved in vascular graft infections are
Staphylococcus aureus and coagulase-negative
Staphylococcus. The risk factors for vascular graft infection include
patient-related factors (periodontal disease, nasal Staphylococcus aureus
colonization, postoperative bacteremia and stent characteristics, diabetes or postoperative
hyperglycemia, obesity, renal failure, liver disease, malnutrition, and immunosuppression)
as well as operation-related factors (intraoperative violation of sterility, a graft in the
groin, prolonged operation time, repeated vascular surgery, and lack of perioperative
antibiotic administration).3–5 The cause of the stent infection in this
case was considered to be that the open neck injury was a contaminated wound and that the
stent was partially exposed after two operations (Figure 2).
Vascular graft infection can be divided into Szilagyi grade I, II, and III. Szilagyi grade
I infection is limited to the skin, Szilagyi grade II infection is limited to the skin and
subcutaneous tissue, and Szilagyi grade III infection involves the graft.6 These different levels of infection involve different treatments. Generally, the
treatments can be divided into antibiotic and surgical treatments. The overall treatment
goal is to eradicate the infection and maintain the blood supply. Szilagyi grade I and II
infections are easier to control, and conservative treatment can be considered. For Szilagyi
grade II infection, extra attention should be invested to assess whether the infection has
progressed to grade III. No clear guidelines have been established for antibiotic treatment,
and intravenous administration of antibiotics for 4 to 6 weeks is generally considered
necessary. Our patient was considered to have Szilagyi grade III infection. Surgical
treatment combined with antibiotics was effective. The patient was given intravenous
antibiotics for 3 weeks in hospital. Considering that the patient’s infection was eliminated
and the autologous saphenous vein had strong antimicrobial protection, no oral antibiotics
were given after discharge.
Surgical intervention is required for a clearly diagnosed grade III infection when sepsis,
anastomotic rupture, aortoenteric fistula, and MRSA infection occurs. Conservative
treatments are less likely to succeed for graft infection. It was previously recommended
that anatomic bypass reconstruction be performed in the uninfected area. The disadvantages
of this are a low patency rate, high disability rate, and risk of anastomotic rupture. The
methods of in situ circulation reconstruction include partial graft removal
and reconstruction with cryopreserved homografts, fresh arterial allografts, autologous
veins, or antibiotic- or silver-bonded prosthetic grafts.7,8 The reinfection rate of biological materials is currently considered to
be low, and autogenous veins are considered the best choice to avoid reinfection.9
Negative-pressure wound therapy is reportedly an effective auxiliary treatment. Continuous
negative-pressure wound therapy can reduce the bacterial content in the wound, accelerate
blood flow, and promote the growth of granulation tissue.10 However, negative-pressure wound therapy is associated with a risk of anastomotic
bleeding; thus, low negative pressure can be considered.11
Patients with limb graft infection are at risk of amputation, whereas patients with carotid
artery graft infection are at high risk of cerebral infarction and intracranial infection.
This can be disastrous to their health and their family’s wellbeing. If the anchorage zone
and the anastomosis of the stent break, massive bleeding within a short period of time can
result in a huge hematoma, which may compress the trachea and cause suffocation. In patients
with grade I or II infections, the graft can be retained, and local debridement and muscle
flap coverage can be used together with antibiotic treatment. If the infection involves the
graft (grade III), removing all grafts and reconstructing the arteries may be necessary. The
material used to reconstruct the vasculature is usually autologous veins, and the saphenous
vein is most frequently used. The infection cure rate is very high, and the risk of
reinfection is only 0% to 10%.4
We achieved a definitive diagnosis of stent infection by combining the results of the
culture of the pus secretions, CTA, and ultrasound. The following points were considered.
First, the patient had no underlying disease and could tolerate surgery. Second, the patient
had undergone two previous neck operations, and the infection was severe because of exposure
of the stent to the environment through the sinus tract. Third, long-term stent infections
cannot be cured through conservative treatments. Finally, the patient had experienced a long
disease course and had a strong desire to eradicate the infection. Therefore, surgical
treatment was the best method.
In general, infection of carotid artery stents and vascular grafts is relatively rare. Such
infections increase patients’ disability rate and endanger their lives. Perioperative
sterility is important to prevent infection. If infection does occur, early identification
and treatment can prevent fatal consequences. For Szilagyi grade III infections, removal of
the infected graft and autologous venous reconstruction combined with low negative-pressure
wound therapy and sensitive antibiotic therapy are effective treatment methods. In addition,
individualized treatment plans should be formulated depending upon the grade of the vascular
graft infection.
Acknowledgements
We are very grateful to the vascular surgery team of the China-Japan Union Hospital of
Jilin University. We also thank Professor Dajun Sun, Director of Vascular Surgery of the
China-Japan Union Hospital of Jilin University, and Professor Yue Zhao.
Declaration of conflicting interest: The authors declare that there is no conflict of interest.
Funding: This research received no specific grant from any funding agency in the public,
commercial, or not-for-profit sectors.
ORCID iD: Xiwen Liu https://orcid.org/0000-0002-5220-8132 | ASPIRIN, CLOPIDOGREL BISULFATE, MOXIFLOXACIN, UNSPECIFIED INGREDIENT | DrugsGivenReaction | CC BY-NC | 33557657 | 19,674,675 | 2021-02 |
Give an alphabetized list of all active substances of drugs taken by the patient who experienced 'Procedural haemorrhage'. | Surgical treatment of carotid artery stent infection: a case report.
The most effective treatment for graft infection is still debated, and the success rate of current treatments is low. We herein report the results of surgical treatment and follow-up of a case of infection acquired during carotid stenting with the aim of exploring the most effective treatments for graft infection. We retrospectively analyzed a patient who was admitted in September 2019. This patient underwent debridement, autologous saphenous vein replacement of the common carotid to internal carotid artery, external carotid artery suturing, and continuous negative-pressure wound therapy for carotid stent infection. Ten days after carotid artery revascularization, the growth of granulation tissue in the incision was good, and we decided to suture the neck incision. Five days after removing the stitches, grade A healing was noted. Furthermore, the carotid artery and autologous vein grafts were unobstructed as shown by carotid artery computed tomography angiography reexamination. The patient was monitored for 8 months with no new neurological symptoms and good healing of the incision. Effective treatment of vascular graft infection includes debridement and removal of the infected graft, autologous vein graft revascularization, and negative-pressure wound therapy combined with antibiotic therapy.
Introduction
The application of vascular grafts has been revolutionary for the treatment of peripheral
vascular and aortic diseases, and grafts have become indispensable in vascular surgery.
However, with the extensive application of vascular grafts, graft infections have become a
major problem for vascular surgeons. Graft infection is characterized by arterial wall
destruction, thrombosis, septic embolism, pseudoaneurysm formation, arterial rupture, and hemorrhage.1 Carotid stent infection is much rarer. Son et al.2 reported that only 2 of 77 cases of graft infection were associated with carotid
stenting. No standardized treatment has been established for vascular graft infection.
Treatment of carotid artery graft infection is very dangerous, and the patient is always at
risk of perioperative large-area cerebral infarction. We herein report the successful
diagnosis and surgical treatment of a case of carotid artery stent infection at China-Japan
Union Hospital Jilin University.
Case report
A 51-year-old man with neck trauma underwent debridement, implantation of a carotid artery
covered stent (8 × 60 mm, Fluency Plus; C. R. Bard, Murray Hill, NJ, USA), and thrombectomy
of the middle cerebral artery at a local hospital in October 2018 (Figure 1). After emergency admission, three-dimensional
angiography of the carotid artery was performed. A dissecting aneurysm was present at the
end of the left common carotid artery and the beginning of the left internal carotid artery.
The blood flow toward the brain was significantly decreased, but the rate at which it was
decreased was unknown. Compression of the left common carotid artery for angiography of the
right internal carotid artery and left vertebral artery revealed poor compensation of the
anterior and posterior communicating arteries. General anesthesia was administered and
debridement was conducted to remove the foreign bodies. A wood splinter was located between
the carotid artery and the internal jugular vein. The dissecting aneurysm ruptured and
started bleeding during the process of tissue separation. A common carotid artery stent was
therefore implanted into the femoral artery. A cerebral protection device was not used. The
patient took aspirin (100 mg) and clopidogrel (75 mg) orally after the operation. Thrombosis
of the left middle cerebral artery was found in the second intracranial angiography
examination and was considered to have been caused by exfoliation of the thrombus during the
dissection. Thrombectomy of the middle cerebral artery was therefore performed. The lumen of
the middle cerebral artery was unobstructed as shown by angiography. After the
above-described operation, debridement of the wound was continued, and the wood splinter was
removed. Postoperatively, brain magnetic resonance imaging indicated previous hemorrhage and
the formation of a softening lesion in the left basal ganglia. In February 2019, the
incision was debrided and re-sutured because of infection (Figure 2). However, the incision did not heal
completely after this operation. This was an extremely dangerous situation because of the
risk of carotid blowout; the carotid arterial flow was protected only by a thin intimal
layer within the stent and was accompanied by infection.
Figure 1. Day of neck trauma. The first debridement, carotid stenting, and thrombectomy of the
middle cerebral artery were performed on this day.
Figure 2. Second debridement. The covered stent was partially exposed.
In September 2019, the patient was admitted to the China-Japan Union Hospital of Jilin
University because the incision had not healed completely after 7 months. Specialized
physical examinations revealed a sinus tract with pus overflowing on the left side of the
neck accompanied by patchy redness and tenderness around the previous incision. Bilateral
carotid pulses were palpable, and the right and left upper limb muscle strength was Lovett
muscle strength grade IV and V, respectively. Biochemical examination revealed an
erythrocyte sedimentation rate of 28 mm/hour and C-reactive protein concentration of 35.4
mg/L. Culture of the secretions revealed methicillin-resistant Staphylococcus
aureus (MRSA) infection. The MRSA was sensitive to moxifloxacin and levofloxacin.
Through the purulent sinus, we could vaguely see the carotid artery stent and obtained the
pus from the deep tissue. We believed that the results of the MRSA culture were clinically
significant. Ultrasound examination showed unobstructed blood flow in the carotid stents.
Computed tomography angiography (CTA) indicated that the blood circulation in the carotid
artery stent was smooth with intimal hyperplasia, the internal carotid artery was
unobstructed, and the external carotid artery was completely occluded (Figure 3). The patient was young, had no underlying
disease, had experienced a long disease course, and strongly wished for surgical treatment.
We decided upon the surgical plan after a discussion with several professors.
Figure 3. Computed tomography angiography findings. The carotid artery stent and internal carotid
artery were patent, the external carotid artery was completely occluded, and intimal
hyperplasia was evident in the stent.
Moxifloxacin (250 mL: 0.4 g, 1/day) was given intravenously and low-molecular-weight
heparin (4100 IU) was given subcutaneously in accordance with the patient’s drug sensitivity
results after hospitalization. Moxifloxacin (250 mL: 0.4 g) was intravenously administered
30 minutes before the operation. We monitored the brain activity with intraoperative
electroencephalography without assessing the tolerance of the internal carotid artery
occlusion before surgery. The supine position was adopted, the shoulders were raised, and
the head was tilted back to the uninjured side. The length of the incision along the
anterior edge of the sternocleidomastoid muscle and the original incision was about 15 cm.
The inflammatory reaction within the incision and the tissue adhesion were severe. The
inflammatory reaction around the anchorage area of the stent was also severe. The stent
completely covered the opening of the external carotid artery. The proximal end of the
common carotid artery was carefully dissected, and blocking tape was added. The internal and
external carotid arteries were dissected, although they were difficult to distinguish
because of severe inflammation and adhesion. The appropriate length of the saphenous vein
was then obtained. After attaining sufficient blood supply to the brain, the distal internal
and external carotid arteries were blocked off and the infected stent was removed. The
external carotid artery was completely occluded. The internal carotid artery was anastomosed
in an end-to-end manner with the saphenous vein. After restoring the blood supply of the
internal carotid artery for 5 minutes, the common carotid artery was anastomosed in an
end-to-side manner with the great saphenous vein, and the stump of the common carotid artery
was sutured (Figure 4). We then
intermittently sutured the surrounding tissue and loosely wrapped the transplanted great
saphenous vein and the anastomosis at both ends. We did not cover it with muscle. Finally,
we covered the wound with a negative-pressure device, which was not in direct contact with
the bypass. The operation lasted 2.5 hours, and the intraoperative blood loss was 600 mL.
The patient was administered 3 units of type A-positive blood and 200 mL of ordinary frozen
plasma. No neurological complications occurred after extubation.
Figure 4. First operation. The infected stent was removed and the carotid artery was
reconstructed.
On the day after the operation, the patient was given an intravenous injection of
dexamethasone (5 mg), and mannitol (250 mL: 50 g) was given intravenously at a volume of 125
mL every 12 hours for 4 days. Moxifloxacin (250 mL: 0.4g) was given intravenously once a day
for 10 days, low-molecular-weight heparin (4100 IU) was given subcutaneously once a day for
10 days, and levofloxacin sodium chloride injection (250 mL: 0.5 g) was used to rinse the
negative-pressure suction device once a day. The drainage fluid was not turbid. The
granulation tissue grew well after 10 days of carotid artery reconstruction; therefore, we
closed the incision (Figure 5). CTA
re-examination showed that the autogenous vein was unblocked. After discharge, the incision
was followed up for 1 month and showed grade A healing (Figure 6). Telephone follow-up was conducted regularly
for 1 month postoperatively. At the time of this writing, the patient was in good condition
without obvious neurological symptoms.
Figure 5. Second operation. Good granulation tissue growth was present, and the incision was
sutured.
Figure 6. Computed tomography angiography findings. The autogenous vein was unblocked, and the
incision achieved grade A healing. The patient was followed up for 1 month after
discharge.
The patient provided oral authorization for participation in this case study and
publication of the details of his case. We have de-identified all patient details. The
requirement for ethics approval was waived because this article does not contain information
that can be used to identify the patient and because he agreed to publication.
Discussion
About 80% of the pathogenic microorganisms involved in vascular graft infections are
Staphylococcus aureus and coagulase-negative
Staphylococcus. The risk factors for vascular graft infection include
patient-related factors (periodontal disease, nasal Staphylococcus aureus
colonization, postoperative bacteremia and stent characteristics, diabetes or postoperative
hyperglycemia, obesity, renal failure, liver disease, malnutrition, and immunosuppression)
as well as operation-related factors (intraoperative violation of sterility, a graft in the
groin, prolonged operation time, repeated vascular surgery, and lack of perioperative
antibiotic administration).3–5 The cause of the stent infection in this
case was considered to be that the open neck injury was a contaminated wound and that the
stent was partially exposed after two operations (Figure 2).
Vascular graft infection can be divided into Szilagyi grade I, II, and III. Szilagyi grade
I infection is limited to the skin, Szilagyi grade II infection is limited to the skin and
subcutaneous tissue, and Szilagyi grade III infection involves the graft.6 These different levels of infection involve different treatments. Generally, the
treatments can be divided into antibiotic and surgical treatments. The overall treatment
goal is to eradicate the infection and maintain the blood supply. Szilagyi grade I and II
infections are easier to control, and conservative treatment can be considered. For Szilagyi
grade II infection, extra attention should be invested to assess whether the infection has
progressed to grade III. No clear guidelines have been established for antibiotic treatment,
and intravenous administration of antibiotics for 4 to 6 weeks is generally considered
necessary. Our patient was considered to have Szilagyi grade III infection. Surgical
treatment combined with antibiotics was effective. The patient was given intravenous
antibiotics for 3 weeks in hospital. Considering that the patient’s infection was eliminated
and the autologous saphenous vein had strong antimicrobial protection, no oral antibiotics
were given after discharge.
Surgical intervention is required for a clearly diagnosed grade III infection when sepsis,
anastomotic rupture, aortoenteric fistula, and MRSA infection occurs. Conservative
treatments are less likely to succeed for graft infection. It was previously recommended
that anatomic bypass reconstruction be performed in the uninfected area. The disadvantages
of this are a low patency rate, high disability rate, and risk of anastomotic rupture. The
methods of in situ circulation reconstruction include partial graft removal
and reconstruction with cryopreserved homografts, fresh arterial allografts, autologous
veins, or antibiotic- or silver-bonded prosthetic grafts.7,8 The reinfection rate of biological materials is currently considered to
be low, and autogenous veins are considered the best choice to avoid reinfection.9
Negative-pressure wound therapy is reportedly an effective auxiliary treatment. Continuous
negative-pressure wound therapy can reduce the bacterial content in the wound, accelerate
blood flow, and promote the growth of granulation tissue.10 However, negative-pressure wound therapy is associated with a risk of anastomotic
bleeding; thus, low negative pressure can be considered.11
Patients with limb graft infection are at risk of amputation, whereas patients with carotid
artery graft infection are at high risk of cerebral infarction and intracranial infection.
This can be disastrous to their health and their family’s wellbeing. If the anchorage zone
and the anastomosis of the stent break, massive bleeding within a short period of time can
result in a huge hematoma, which may compress the trachea and cause suffocation. In patients
with grade I or II infections, the graft can be retained, and local debridement and muscle
flap coverage can be used together with antibiotic treatment. If the infection involves the
graft (grade III), removing all grafts and reconstructing the arteries may be necessary. The
material used to reconstruct the vasculature is usually autologous veins, and the saphenous
vein is most frequently used. The infection cure rate is very high, and the risk of
reinfection is only 0% to 10%.4
We achieved a definitive diagnosis of stent infection by combining the results of the
culture of the pus secretions, CTA, and ultrasound. The following points were considered.
First, the patient had no underlying disease and could tolerate surgery. Second, the patient
had undergone two previous neck operations, and the infection was severe because of exposure
of the stent to the environment through the sinus tract. Third, long-term stent infections
cannot be cured through conservative treatments. Finally, the patient had experienced a long
disease course and had a strong desire to eradicate the infection. Therefore, surgical
treatment was the best method.
In general, infection of carotid artery stents and vascular grafts is relatively rare. Such
infections increase patients’ disability rate and endanger their lives. Perioperative
sterility is important to prevent infection. If infection does occur, early identification
and treatment can prevent fatal consequences. For Szilagyi grade III infections, removal of
the infected graft and autologous venous reconstruction combined with low negative-pressure
wound therapy and sensitive antibiotic therapy are effective treatment methods. In addition,
individualized treatment plans should be formulated depending upon the grade of the vascular
graft infection.
Acknowledgements
We are very grateful to the vascular surgery team of the China-Japan Union Hospital of
Jilin University. We also thank Professor Dajun Sun, Director of Vascular Surgery of the
China-Japan Union Hospital of Jilin University, and Professor Yue Zhao.
Declaration of conflicting interest: The authors declare that there is no conflict of interest.
Funding: This research received no specific grant from any funding agency in the public,
commercial, or not-for-profit sectors.
ORCID iD: Xiwen Liu https://orcid.org/0000-0002-5220-8132 | ASPIRIN, CLOPIDOGREL BISULFATE, MOXIFLOXACIN, UNSPECIFIED INGREDIENT | DrugsGivenReaction | CC BY-NC | 33557657 | 19,674,675 | 2021-02 |
What was the administration route of drug 'ASPIRIN'? | Surgical treatment of carotid artery stent infection: a case report.
The most effective treatment for graft infection is still debated, and the success rate of current treatments is low. We herein report the results of surgical treatment and follow-up of a case of infection acquired during carotid stenting with the aim of exploring the most effective treatments for graft infection. We retrospectively analyzed a patient who was admitted in September 2019. This patient underwent debridement, autologous saphenous vein replacement of the common carotid to internal carotid artery, external carotid artery suturing, and continuous negative-pressure wound therapy for carotid stent infection. Ten days after carotid artery revascularization, the growth of granulation tissue in the incision was good, and we decided to suture the neck incision. Five days after removing the stitches, grade A healing was noted. Furthermore, the carotid artery and autologous vein grafts were unobstructed as shown by carotid artery computed tomography angiography reexamination. The patient was monitored for 8 months with no new neurological symptoms and good healing of the incision. Effective treatment of vascular graft infection includes debridement and removal of the infected graft, autologous vein graft revascularization, and negative-pressure wound therapy combined with antibiotic therapy.
Introduction
The application of vascular grafts has been revolutionary for the treatment of peripheral
vascular and aortic diseases, and grafts have become indispensable in vascular surgery.
However, with the extensive application of vascular grafts, graft infections have become a
major problem for vascular surgeons. Graft infection is characterized by arterial wall
destruction, thrombosis, septic embolism, pseudoaneurysm formation, arterial rupture, and hemorrhage.1 Carotid stent infection is much rarer. Son et al.2 reported that only 2 of 77 cases of graft infection were associated with carotid
stenting. No standardized treatment has been established for vascular graft infection.
Treatment of carotid artery graft infection is very dangerous, and the patient is always at
risk of perioperative large-area cerebral infarction. We herein report the successful
diagnosis and surgical treatment of a case of carotid artery stent infection at China-Japan
Union Hospital Jilin University.
Case report
A 51-year-old man with neck trauma underwent debridement, implantation of a carotid artery
covered stent (8 × 60 mm, Fluency Plus; C. R. Bard, Murray Hill, NJ, USA), and thrombectomy
of the middle cerebral artery at a local hospital in October 2018 (Figure 1). After emergency admission, three-dimensional
angiography of the carotid artery was performed. A dissecting aneurysm was present at the
end of the left common carotid artery and the beginning of the left internal carotid artery.
The blood flow toward the brain was significantly decreased, but the rate at which it was
decreased was unknown. Compression of the left common carotid artery for angiography of the
right internal carotid artery and left vertebral artery revealed poor compensation of the
anterior and posterior communicating arteries. General anesthesia was administered and
debridement was conducted to remove the foreign bodies. A wood splinter was located between
the carotid artery and the internal jugular vein. The dissecting aneurysm ruptured and
started bleeding during the process of tissue separation. A common carotid artery stent was
therefore implanted into the femoral artery. A cerebral protection device was not used. The
patient took aspirin (100 mg) and clopidogrel (75 mg) orally after the operation. Thrombosis
of the left middle cerebral artery was found in the second intracranial angiography
examination and was considered to have been caused by exfoliation of the thrombus during the
dissection. Thrombectomy of the middle cerebral artery was therefore performed. The lumen of
the middle cerebral artery was unobstructed as shown by angiography. After the
above-described operation, debridement of the wound was continued, and the wood splinter was
removed. Postoperatively, brain magnetic resonance imaging indicated previous hemorrhage and
the formation of a softening lesion in the left basal ganglia. In February 2019, the
incision was debrided and re-sutured because of infection (Figure 2). However, the incision did not heal
completely after this operation. This was an extremely dangerous situation because of the
risk of carotid blowout; the carotid arterial flow was protected only by a thin intimal
layer within the stent and was accompanied by infection.
Figure 1. Day of neck trauma. The first debridement, carotid stenting, and thrombectomy of the
middle cerebral artery were performed on this day.
Figure 2. Second debridement. The covered stent was partially exposed.
In September 2019, the patient was admitted to the China-Japan Union Hospital of Jilin
University because the incision had not healed completely after 7 months. Specialized
physical examinations revealed a sinus tract with pus overflowing on the left side of the
neck accompanied by patchy redness and tenderness around the previous incision. Bilateral
carotid pulses were palpable, and the right and left upper limb muscle strength was Lovett
muscle strength grade IV and V, respectively. Biochemical examination revealed an
erythrocyte sedimentation rate of 28 mm/hour and C-reactive protein concentration of 35.4
mg/L. Culture of the secretions revealed methicillin-resistant Staphylococcus
aureus (MRSA) infection. The MRSA was sensitive to moxifloxacin and levofloxacin.
Through the purulent sinus, we could vaguely see the carotid artery stent and obtained the
pus from the deep tissue. We believed that the results of the MRSA culture were clinically
significant. Ultrasound examination showed unobstructed blood flow in the carotid stents.
Computed tomography angiography (CTA) indicated that the blood circulation in the carotid
artery stent was smooth with intimal hyperplasia, the internal carotid artery was
unobstructed, and the external carotid artery was completely occluded (Figure 3). The patient was young, had no underlying
disease, had experienced a long disease course, and strongly wished for surgical treatment.
We decided upon the surgical plan after a discussion with several professors.
Figure 3. Computed tomography angiography findings. The carotid artery stent and internal carotid
artery were patent, the external carotid artery was completely occluded, and intimal
hyperplasia was evident in the stent.
Moxifloxacin (250 mL: 0.4 g, 1/day) was given intravenously and low-molecular-weight
heparin (4100 IU) was given subcutaneously in accordance with the patient’s drug sensitivity
results after hospitalization. Moxifloxacin (250 mL: 0.4 g) was intravenously administered
30 minutes before the operation. We monitored the brain activity with intraoperative
electroencephalography without assessing the tolerance of the internal carotid artery
occlusion before surgery. The supine position was adopted, the shoulders were raised, and
the head was tilted back to the uninjured side. The length of the incision along the
anterior edge of the sternocleidomastoid muscle and the original incision was about 15 cm.
The inflammatory reaction within the incision and the tissue adhesion were severe. The
inflammatory reaction around the anchorage area of the stent was also severe. The stent
completely covered the opening of the external carotid artery. The proximal end of the
common carotid artery was carefully dissected, and blocking tape was added. The internal and
external carotid arteries were dissected, although they were difficult to distinguish
because of severe inflammation and adhesion. The appropriate length of the saphenous vein
was then obtained. After attaining sufficient blood supply to the brain, the distal internal
and external carotid arteries were blocked off and the infected stent was removed. The
external carotid artery was completely occluded. The internal carotid artery was anastomosed
in an end-to-end manner with the saphenous vein. After restoring the blood supply of the
internal carotid artery for 5 minutes, the common carotid artery was anastomosed in an
end-to-side manner with the great saphenous vein, and the stump of the common carotid artery
was sutured (Figure 4). We then
intermittently sutured the surrounding tissue and loosely wrapped the transplanted great
saphenous vein and the anastomosis at both ends. We did not cover it with muscle. Finally,
we covered the wound with a negative-pressure device, which was not in direct contact with
the bypass. The operation lasted 2.5 hours, and the intraoperative blood loss was 600 mL.
The patient was administered 3 units of type A-positive blood and 200 mL of ordinary frozen
plasma. No neurological complications occurred after extubation.
Figure 4. First operation. The infected stent was removed and the carotid artery was
reconstructed.
On the day after the operation, the patient was given an intravenous injection of
dexamethasone (5 mg), and mannitol (250 mL: 50 g) was given intravenously at a volume of 125
mL every 12 hours for 4 days. Moxifloxacin (250 mL: 0.4g) was given intravenously once a day
for 10 days, low-molecular-weight heparin (4100 IU) was given subcutaneously once a day for
10 days, and levofloxacin sodium chloride injection (250 mL: 0.5 g) was used to rinse the
negative-pressure suction device once a day. The drainage fluid was not turbid. The
granulation tissue grew well after 10 days of carotid artery reconstruction; therefore, we
closed the incision (Figure 5). CTA
re-examination showed that the autogenous vein was unblocked. After discharge, the incision
was followed up for 1 month and showed grade A healing (Figure 6). Telephone follow-up was conducted regularly
for 1 month postoperatively. At the time of this writing, the patient was in good condition
without obvious neurological symptoms.
Figure 5. Second operation. Good granulation tissue growth was present, and the incision was
sutured.
Figure 6. Computed tomography angiography findings. The autogenous vein was unblocked, and the
incision achieved grade A healing. The patient was followed up for 1 month after
discharge.
The patient provided oral authorization for participation in this case study and
publication of the details of his case. We have de-identified all patient details. The
requirement for ethics approval was waived because this article does not contain information
that can be used to identify the patient and because he agreed to publication.
Discussion
About 80% of the pathogenic microorganisms involved in vascular graft infections are
Staphylococcus aureus and coagulase-negative
Staphylococcus. The risk factors for vascular graft infection include
patient-related factors (periodontal disease, nasal Staphylococcus aureus
colonization, postoperative bacteremia and stent characteristics, diabetes or postoperative
hyperglycemia, obesity, renal failure, liver disease, malnutrition, and immunosuppression)
as well as operation-related factors (intraoperative violation of sterility, a graft in the
groin, prolonged operation time, repeated vascular surgery, and lack of perioperative
antibiotic administration).3–5 The cause of the stent infection in this
case was considered to be that the open neck injury was a contaminated wound and that the
stent was partially exposed after two operations (Figure 2).
Vascular graft infection can be divided into Szilagyi grade I, II, and III. Szilagyi grade
I infection is limited to the skin, Szilagyi grade II infection is limited to the skin and
subcutaneous tissue, and Szilagyi grade III infection involves the graft.6 These different levels of infection involve different treatments. Generally, the
treatments can be divided into antibiotic and surgical treatments. The overall treatment
goal is to eradicate the infection and maintain the blood supply. Szilagyi grade I and II
infections are easier to control, and conservative treatment can be considered. For Szilagyi
grade II infection, extra attention should be invested to assess whether the infection has
progressed to grade III. No clear guidelines have been established for antibiotic treatment,
and intravenous administration of antibiotics for 4 to 6 weeks is generally considered
necessary. Our patient was considered to have Szilagyi grade III infection. Surgical
treatment combined with antibiotics was effective. The patient was given intravenous
antibiotics for 3 weeks in hospital. Considering that the patient’s infection was eliminated
and the autologous saphenous vein had strong antimicrobial protection, no oral antibiotics
were given after discharge.
Surgical intervention is required for a clearly diagnosed grade III infection when sepsis,
anastomotic rupture, aortoenteric fistula, and MRSA infection occurs. Conservative
treatments are less likely to succeed for graft infection. It was previously recommended
that anatomic bypass reconstruction be performed in the uninfected area. The disadvantages
of this are a low patency rate, high disability rate, and risk of anastomotic rupture. The
methods of in situ circulation reconstruction include partial graft removal
and reconstruction with cryopreserved homografts, fresh arterial allografts, autologous
veins, or antibiotic- or silver-bonded prosthetic grafts.7,8 The reinfection rate of biological materials is currently considered to
be low, and autogenous veins are considered the best choice to avoid reinfection.9
Negative-pressure wound therapy is reportedly an effective auxiliary treatment. Continuous
negative-pressure wound therapy can reduce the bacterial content in the wound, accelerate
blood flow, and promote the growth of granulation tissue.10 However, negative-pressure wound therapy is associated with a risk of anastomotic
bleeding; thus, low negative pressure can be considered.11
Patients with limb graft infection are at risk of amputation, whereas patients with carotid
artery graft infection are at high risk of cerebral infarction and intracranial infection.
This can be disastrous to their health and their family’s wellbeing. If the anchorage zone
and the anastomosis of the stent break, massive bleeding within a short period of time can
result in a huge hematoma, which may compress the trachea and cause suffocation. In patients
with grade I or II infections, the graft can be retained, and local debridement and muscle
flap coverage can be used together with antibiotic treatment. If the infection involves the
graft (grade III), removing all grafts and reconstructing the arteries may be necessary. The
material used to reconstruct the vasculature is usually autologous veins, and the saphenous
vein is most frequently used. The infection cure rate is very high, and the risk of
reinfection is only 0% to 10%.4
We achieved a definitive diagnosis of stent infection by combining the results of the
culture of the pus secretions, CTA, and ultrasound. The following points were considered.
First, the patient had no underlying disease and could tolerate surgery. Second, the patient
had undergone two previous neck operations, and the infection was severe because of exposure
of the stent to the environment through the sinus tract. Third, long-term stent infections
cannot be cured through conservative treatments. Finally, the patient had experienced a long
disease course and had a strong desire to eradicate the infection. Therefore, surgical
treatment was the best method.
In general, infection of carotid artery stents and vascular grafts is relatively rare. Such
infections increase patients’ disability rate and endanger their lives. Perioperative
sterility is important to prevent infection. If infection does occur, early identification
and treatment can prevent fatal consequences. For Szilagyi grade III infections, removal of
the infected graft and autologous venous reconstruction combined with low negative-pressure
wound therapy and sensitive antibiotic therapy are effective treatment methods. In addition,
individualized treatment plans should be formulated depending upon the grade of the vascular
graft infection.
Acknowledgements
We are very grateful to the vascular surgery team of the China-Japan Union Hospital of
Jilin University. We also thank Professor Dajun Sun, Director of Vascular Surgery of the
China-Japan Union Hospital of Jilin University, and Professor Yue Zhao.
Declaration of conflicting interest: The authors declare that there is no conflict of interest.
Funding: This research received no specific grant from any funding agency in the public,
commercial, or not-for-profit sectors.
ORCID iD: Xiwen Liu https://orcid.org/0000-0002-5220-8132 | Oral | DrugAdministrationRoute | CC BY-NC | 33557657 | 19,674,675 | 2021-02 |
What was the administration route of drug 'CLOPIDOGREL BISULFATE'? | Surgical treatment of carotid artery stent infection: a case report.
The most effective treatment for graft infection is still debated, and the success rate of current treatments is low. We herein report the results of surgical treatment and follow-up of a case of infection acquired during carotid stenting with the aim of exploring the most effective treatments for graft infection. We retrospectively analyzed a patient who was admitted in September 2019. This patient underwent debridement, autologous saphenous vein replacement of the common carotid to internal carotid artery, external carotid artery suturing, and continuous negative-pressure wound therapy for carotid stent infection. Ten days after carotid artery revascularization, the growth of granulation tissue in the incision was good, and we decided to suture the neck incision. Five days after removing the stitches, grade A healing was noted. Furthermore, the carotid artery and autologous vein grafts were unobstructed as shown by carotid artery computed tomography angiography reexamination. The patient was monitored for 8 months with no new neurological symptoms and good healing of the incision. Effective treatment of vascular graft infection includes debridement and removal of the infected graft, autologous vein graft revascularization, and negative-pressure wound therapy combined with antibiotic therapy.
Introduction
The application of vascular grafts has been revolutionary for the treatment of peripheral
vascular and aortic diseases, and grafts have become indispensable in vascular surgery.
However, with the extensive application of vascular grafts, graft infections have become a
major problem for vascular surgeons. Graft infection is characterized by arterial wall
destruction, thrombosis, septic embolism, pseudoaneurysm formation, arterial rupture, and hemorrhage.1 Carotid stent infection is much rarer. Son et al.2 reported that only 2 of 77 cases of graft infection were associated with carotid
stenting. No standardized treatment has been established for vascular graft infection.
Treatment of carotid artery graft infection is very dangerous, and the patient is always at
risk of perioperative large-area cerebral infarction. We herein report the successful
diagnosis and surgical treatment of a case of carotid artery stent infection at China-Japan
Union Hospital Jilin University.
Case report
A 51-year-old man with neck trauma underwent debridement, implantation of a carotid artery
covered stent (8 × 60 mm, Fluency Plus; C. R. Bard, Murray Hill, NJ, USA), and thrombectomy
of the middle cerebral artery at a local hospital in October 2018 (Figure 1). After emergency admission, three-dimensional
angiography of the carotid artery was performed. A dissecting aneurysm was present at the
end of the left common carotid artery and the beginning of the left internal carotid artery.
The blood flow toward the brain was significantly decreased, but the rate at which it was
decreased was unknown. Compression of the left common carotid artery for angiography of the
right internal carotid artery and left vertebral artery revealed poor compensation of the
anterior and posterior communicating arteries. General anesthesia was administered and
debridement was conducted to remove the foreign bodies. A wood splinter was located between
the carotid artery and the internal jugular vein. The dissecting aneurysm ruptured and
started bleeding during the process of tissue separation. A common carotid artery stent was
therefore implanted into the femoral artery. A cerebral protection device was not used. The
patient took aspirin (100 mg) and clopidogrel (75 mg) orally after the operation. Thrombosis
of the left middle cerebral artery was found in the second intracranial angiography
examination and was considered to have been caused by exfoliation of the thrombus during the
dissection. Thrombectomy of the middle cerebral artery was therefore performed. The lumen of
the middle cerebral artery was unobstructed as shown by angiography. After the
above-described operation, debridement of the wound was continued, and the wood splinter was
removed. Postoperatively, brain magnetic resonance imaging indicated previous hemorrhage and
the formation of a softening lesion in the left basal ganglia. In February 2019, the
incision was debrided and re-sutured because of infection (Figure 2). However, the incision did not heal
completely after this operation. This was an extremely dangerous situation because of the
risk of carotid blowout; the carotid arterial flow was protected only by a thin intimal
layer within the stent and was accompanied by infection.
Figure 1. Day of neck trauma. The first debridement, carotid stenting, and thrombectomy of the
middle cerebral artery were performed on this day.
Figure 2. Second debridement. The covered stent was partially exposed.
In September 2019, the patient was admitted to the China-Japan Union Hospital of Jilin
University because the incision had not healed completely after 7 months. Specialized
physical examinations revealed a sinus tract with pus overflowing on the left side of the
neck accompanied by patchy redness and tenderness around the previous incision. Bilateral
carotid pulses were palpable, and the right and left upper limb muscle strength was Lovett
muscle strength grade IV and V, respectively. Biochemical examination revealed an
erythrocyte sedimentation rate of 28 mm/hour and C-reactive protein concentration of 35.4
mg/L. Culture of the secretions revealed methicillin-resistant Staphylococcus
aureus (MRSA) infection. The MRSA was sensitive to moxifloxacin and levofloxacin.
Through the purulent sinus, we could vaguely see the carotid artery stent and obtained the
pus from the deep tissue. We believed that the results of the MRSA culture were clinically
significant. Ultrasound examination showed unobstructed blood flow in the carotid stents.
Computed tomography angiography (CTA) indicated that the blood circulation in the carotid
artery stent was smooth with intimal hyperplasia, the internal carotid artery was
unobstructed, and the external carotid artery was completely occluded (Figure 3). The patient was young, had no underlying
disease, had experienced a long disease course, and strongly wished for surgical treatment.
We decided upon the surgical plan after a discussion with several professors.
Figure 3. Computed tomography angiography findings. The carotid artery stent and internal carotid
artery were patent, the external carotid artery was completely occluded, and intimal
hyperplasia was evident in the stent.
Moxifloxacin (250 mL: 0.4 g, 1/day) was given intravenously and low-molecular-weight
heparin (4100 IU) was given subcutaneously in accordance with the patient’s drug sensitivity
results after hospitalization. Moxifloxacin (250 mL: 0.4 g) was intravenously administered
30 minutes before the operation. We monitored the brain activity with intraoperative
electroencephalography without assessing the tolerance of the internal carotid artery
occlusion before surgery. The supine position was adopted, the shoulders were raised, and
the head was tilted back to the uninjured side. The length of the incision along the
anterior edge of the sternocleidomastoid muscle and the original incision was about 15 cm.
The inflammatory reaction within the incision and the tissue adhesion were severe. The
inflammatory reaction around the anchorage area of the stent was also severe. The stent
completely covered the opening of the external carotid artery. The proximal end of the
common carotid artery was carefully dissected, and blocking tape was added. The internal and
external carotid arteries were dissected, although they were difficult to distinguish
because of severe inflammation and adhesion. The appropriate length of the saphenous vein
was then obtained. After attaining sufficient blood supply to the brain, the distal internal
and external carotid arteries were blocked off and the infected stent was removed. The
external carotid artery was completely occluded. The internal carotid artery was anastomosed
in an end-to-end manner with the saphenous vein. After restoring the blood supply of the
internal carotid artery for 5 minutes, the common carotid artery was anastomosed in an
end-to-side manner with the great saphenous vein, and the stump of the common carotid artery
was sutured (Figure 4). We then
intermittently sutured the surrounding tissue and loosely wrapped the transplanted great
saphenous vein and the anastomosis at both ends. We did not cover it with muscle. Finally,
we covered the wound with a negative-pressure device, which was not in direct contact with
the bypass. The operation lasted 2.5 hours, and the intraoperative blood loss was 600 mL.
The patient was administered 3 units of type A-positive blood and 200 mL of ordinary frozen
plasma. No neurological complications occurred after extubation.
Figure 4. First operation. The infected stent was removed and the carotid artery was
reconstructed.
On the day after the operation, the patient was given an intravenous injection of
dexamethasone (5 mg), and mannitol (250 mL: 50 g) was given intravenously at a volume of 125
mL every 12 hours for 4 days. Moxifloxacin (250 mL: 0.4g) was given intravenously once a day
for 10 days, low-molecular-weight heparin (4100 IU) was given subcutaneously once a day for
10 days, and levofloxacin sodium chloride injection (250 mL: 0.5 g) was used to rinse the
negative-pressure suction device once a day. The drainage fluid was not turbid. The
granulation tissue grew well after 10 days of carotid artery reconstruction; therefore, we
closed the incision (Figure 5). CTA
re-examination showed that the autogenous vein was unblocked. After discharge, the incision
was followed up for 1 month and showed grade A healing (Figure 6). Telephone follow-up was conducted regularly
for 1 month postoperatively. At the time of this writing, the patient was in good condition
without obvious neurological symptoms.
Figure 5. Second operation. Good granulation tissue growth was present, and the incision was
sutured.
Figure 6. Computed tomography angiography findings. The autogenous vein was unblocked, and the
incision achieved grade A healing. The patient was followed up for 1 month after
discharge.
The patient provided oral authorization for participation in this case study and
publication of the details of his case. We have de-identified all patient details. The
requirement for ethics approval was waived because this article does not contain information
that can be used to identify the patient and because he agreed to publication.
Discussion
About 80% of the pathogenic microorganisms involved in vascular graft infections are
Staphylococcus aureus and coagulase-negative
Staphylococcus. The risk factors for vascular graft infection include
patient-related factors (periodontal disease, nasal Staphylococcus aureus
colonization, postoperative bacteremia and stent characteristics, diabetes or postoperative
hyperglycemia, obesity, renal failure, liver disease, malnutrition, and immunosuppression)
as well as operation-related factors (intraoperative violation of sterility, a graft in the
groin, prolonged operation time, repeated vascular surgery, and lack of perioperative
antibiotic administration).3–5 The cause of the stent infection in this
case was considered to be that the open neck injury was a contaminated wound and that the
stent was partially exposed after two operations (Figure 2).
Vascular graft infection can be divided into Szilagyi grade I, II, and III. Szilagyi grade
I infection is limited to the skin, Szilagyi grade II infection is limited to the skin and
subcutaneous tissue, and Szilagyi grade III infection involves the graft.6 These different levels of infection involve different treatments. Generally, the
treatments can be divided into antibiotic and surgical treatments. The overall treatment
goal is to eradicate the infection and maintain the blood supply. Szilagyi grade I and II
infections are easier to control, and conservative treatment can be considered. For Szilagyi
grade II infection, extra attention should be invested to assess whether the infection has
progressed to grade III. No clear guidelines have been established for antibiotic treatment,
and intravenous administration of antibiotics for 4 to 6 weeks is generally considered
necessary. Our patient was considered to have Szilagyi grade III infection. Surgical
treatment combined with antibiotics was effective. The patient was given intravenous
antibiotics for 3 weeks in hospital. Considering that the patient’s infection was eliminated
and the autologous saphenous vein had strong antimicrobial protection, no oral antibiotics
were given after discharge.
Surgical intervention is required for a clearly diagnosed grade III infection when sepsis,
anastomotic rupture, aortoenteric fistula, and MRSA infection occurs. Conservative
treatments are less likely to succeed for graft infection. It was previously recommended
that anatomic bypass reconstruction be performed in the uninfected area. The disadvantages
of this are a low patency rate, high disability rate, and risk of anastomotic rupture. The
methods of in situ circulation reconstruction include partial graft removal
and reconstruction with cryopreserved homografts, fresh arterial allografts, autologous
veins, or antibiotic- or silver-bonded prosthetic grafts.7,8 The reinfection rate of biological materials is currently considered to
be low, and autogenous veins are considered the best choice to avoid reinfection.9
Negative-pressure wound therapy is reportedly an effective auxiliary treatment. Continuous
negative-pressure wound therapy can reduce the bacterial content in the wound, accelerate
blood flow, and promote the growth of granulation tissue.10 However, negative-pressure wound therapy is associated with a risk of anastomotic
bleeding; thus, low negative pressure can be considered.11
Patients with limb graft infection are at risk of amputation, whereas patients with carotid
artery graft infection are at high risk of cerebral infarction and intracranial infection.
This can be disastrous to their health and their family’s wellbeing. If the anchorage zone
and the anastomosis of the stent break, massive bleeding within a short period of time can
result in a huge hematoma, which may compress the trachea and cause suffocation. In patients
with grade I or II infections, the graft can be retained, and local debridement and muscle
flap coverage can be used together with antibiotic treatment. If the infection involves the
graft (grade III), removing all grafts and reconstructing the arteries may be necessary. The
material used to reconstruct the vasculature is usually autologous veins, and the saphenous
vein is most frequently used. The infection cure rate is very high, and the risk of
reinfection is only 0% to 10%.4
We achieved a definitive diagnosis of stent infection by combining the results of the
culture of the pus secretions, CTA, and ultrasound. The following points were considered.
First, the patient had no underlying disease and could tolerate surgery. Second, the patient
had undergone two previous neck operations, and the infection was severe because of exposure
of the stent to the environment through the sinus tract. Third, long-term stent infections
cannot be cured through conservative treatments. Finally, the patient had experienced a long
disease course and had a strong desire to eradicate the infection. Therefore, surgical
treatment was the best method.
In general, infection of carotid artery stents and vascular grafts is relatively rare. Such
infections increase patients’ disability rate and endanger their lives. Perioperative
sterility is important to prevent infection. If infection does occur, early identification
and treatment can prevent fatal consequences. For Szilagyi grade III infections, removal of
the infected graft and autologous venous reconstruction combined with low negative-pressure
wound therapy and sensitive antibiotic therapy are effective treatment methods. In addition,
individualized treatment plans should be formulated depending upon the grade of the vascular
graft infection.
Acknowledgements
We are very grateful to the vascular surgery team of the China-Japan Union Hospital of
Jilin University. We also thank Professor Dajun Sun, Director of Vascular Surgery of the
China-Japan Union Hospital of Jilin University, and Professor Yue Zhao.
Declaration of conflicting interest: The authors declare that there is no conflict of interest.
Funding: This research received no specific grant from any funding agency in the public,
commercial, or not-for-profit sectors.
ORCID iD: Xiwen Liu https://orcid.org/0000-0002-5220-8132 | Oral | DrugAdministrationRoute | CC BY-NC | 33557657 | 19,674,675 | 2021-02 |
What was the administration route of drug 'MOXIFLOXACIN'? | Surgical treatment of carotid artery stent infection: a case report.
The most effective treatment for graft infection is still debated, and the success rate of current treatments is low. We herein report the results of surgical treatment and follow-up of a case of infection acquired during carotid stenting with the aim of exploring the most effective treatments for graft infection. We retrospectively analyzed a patient who was admitted in September 2019. This patient underwent debridement, autologous saphenous vein replacement of the common carotid to internal carotid artery, external carotid artery suturing, and continuous negative-pressure wound therapy for carotid stent infection. Ten days after carotid artery revascularization, the growth of granulation tissue in the incision was good, and we decided to suture the neck incision. Five days after removing the stitches, grade A healing was noted. Furthermore, the carotid artery and autologous vein grafts were unobstructed as shown by carotid artery computed tomography angiography reexamination. The patient was monitored for 8 months with no new neurological symptoms and good healing of the incision. Effective treatment of vascular graft infection includes debridement and removal of the infected graft, autologous vein graft revascularization, and negative-pressure wound therapy combined with antibiotic therapy.
Introduction
The application of vascular grafts has been revolutionary for the treatment of peripheral
vascular and aortic diseases, and grafts have become indispensable in vascular surgery.
However, with the extensive application of vascular grafts, graft infections have become a
major problem for vascular surgeons. Graft infection is characterized by arterial wall
destruction, thrombosis, septic embolism, pseudoaneurysm formation, arterial rupture, and hemorrhage.1 Carotid stent infection is much rarer. Son et al.2 reported that only 2 of 77 cases of graft infection were associated with carotid
stenting. No standardized treatment has been established for vascular graft infection.
Treatment of carotid artery graft infection is very dangerous, and the patient is always at
risk of perioperative large-area cerebral infarction. We herein report the successful
diagnosis and surgical treatment of a case of carotid artery stent infection at China-Japan
Union Hospital Jilin University.
Case report
A 51-year-old man with neck trauma underwent debridement, implantation of a carotid artery
covered stent (8 × 60 mm, Fluency Plus; C. R. Bard, Murray Hill, NJ, USA), and thrombectomy
of the middle cerebral artery at a local hospital in October 2018 (Figure 1). After emergency admission, three-dimensional
angiography of the carotid artery was performed. A dissecting aneurysm was present at the
end of the left common carotid artery and the beginning of the left internal carotid artery.
The blood flow toward the brain was significantly decreased, but the rate at which it was
decreased was unknown. Compression of the left common carotid artery for angiography of the
right internal carotid artery and left vertebral artery revealed poor compensation of the
anterior and posterior communicating arteries. General anesthesia was administered and
debridement was conducted to remove the foreign bodies. A wood splinter was located between
the carotid artery and the internal jugular vein. The dissecting aneurysm ruptured and
started bleeding during the process of tissue separation. A common carotid artery stent was
therefore implanted into the femoral artery. A cerebral protection device was not used. The
patient took aspirin (100 mg) and clopidogrel (75 mg) orally after the operation. Thrombosis
of the left middle cerebral artery was found in the second intracranial angiography
examination and was considered to have been caused by exfoliation of the thrombus during the
dissection. Thrombectomy of the middle cerebral artery was therefore performed. The lumen of
the middle cerebral artery was unobstructed as shown by angiography. After the
above-described operation, debridement of the wound was continued, and the wood splinter was
removed. Postoperatively, brain magnetic resonance imaging indicated previous hemorrhage and
the formation of a softening lesion in the left basal ganglia. In February 2019, the
incision was debrided and re-sutured because of infection (Figure 2). However, the incision did not heal
completely after this operation. This was an extremely dangerous situation because of the
risk of carotid blowout; the carotid arterial flow was protected only by a thin intimal
layer within the stent and was accompanied by infection.
Figure 1. Day of neck trauma. The first debridement, carotid stenting, and thrombectomy of the
middle cerebral artery were performed on this day.
Figure 2. Second debridement. The covered stent was partially exposed.
In September 2019, the patient was admitted to the China-Japan Union Hospital of Jilin
University because the incision had not healed completely after 7 months. Specialized
physical examinations revealed a sinus tract with pus overflowing on the left side of the
neck accompanied by patchy redness and tenderness around the previous incision. Bilateral
carotid pulses were palpable, and the right and left upper limb muscle strength was Lovett
muscle strength grade IV and V, respectively. Biochemical examination revealed an
erythrocyte sedimentation rate of 28 mm/hour and C-reactive protein concentration of 35.4
mg/L. Culture of the secretions revealed methicillin-resistant Staphylococcus
aureus (MRSA) infection. The MRSA was sensitive to moxifloxacin and levofloxacin.
Through the purulent sinus, we could vaguely see the carotid artery stent and obtained the
pus from the deep tissue. We believed that the results of the MRSA culture were clinically
significant. Ultrasound examination showed unobstructed blood flow in the carotid stents.
Computed tomography angiography (CTA) indicated that the blood circulation in the carotid
artery stent was smooth with intimal hyperplasia, the internal carotid artery was
unobstructed, and the external carotid artery was completely occluded (Figure 3). The patient was young, had no underlying
disease, had experienced a long disease course, and strongly wished for surgical treatment.
We decided upon the surgical plan after a discussion with several professors.
Figure 3. Computed tomography angiography findings. The carotid artery stent and internal carotid
artery were patent, the external carotid artery was completely occluded, and intimal
hyperplasia was evident in the stent.
Moxifloxacin (250 mL: 0.4 g, 1/day) was given intravenously and low-molecular-weight
heparin (4100 IU) was given subcutaneously in accordance with the patient’s drug sensitivity
results after hospitalization. Moxifloxacin (250 mL: 0.4 g) was intravenously administered
30 minutes before the operation. We monitored the brain activity with intraoperative
electroencephalography without assessing the tolerance of the internal carotid artery
occlusion before surgery. The supine position was adopted, the shoulders were raised, and
the head was tilted back to the uninjured side. The length of the incision along the
anterior edge of the sternocleidomastoid muscle and the original incision was about 15 cm.
The inflammatory reaction within the incision and the tissue adhesion were severe. The
inflammatory reaction around the anchorage area of the stent was also severe. The stent
completely covered the opening of the external carotid artery. The proximal end of the
common carotid artery was carefully dissected, and blocking tape was added. The internal and
external carotid arteries were dissected, although they were difficult to distinguish
because of severe inflammation and adhesion. The appropriate length of the saphenous vein
was then obtained. After attaining sufficient blood supply to the brain, the distal internal
and external carotid arteries were blocked off and the infected stent was removed. The
external carotid artery was completely occluded. The internal carotid artery was anastomosed
in an end-to-end manner with the saphenous vein. After restoring the blood supply of the
internal carotid artery for 5 minutes, the common carotid artery was anastomosed in an
end-to-side manner with the great saphenous vein, and the stump of the common carotid artery
was sutured (Figure 4). We then
intermittently sutured the surrounding tissue and loosely wrapped the transplanted great
saphenous vein and the anastomosis at both ends. We did not cover it with muscle. Finally,
we covered the wound with a negative-pressure device, which was not in direct contact with
the bypass. The operation lasted 2.5 hours, and the intraoperative blood loss was 600 mL.
The patient was administered 3 units of type A-positive blood and 200 mL of ordinary frozen
plasma. No neurological complications occurred after extubation.
Figure 4. First operation. The infected stent was removed and the carotid artery was
reconstructed.
On the day after the operation, the patient was given an intravenous injection of
dexamethasone (5 mg), and mannitol (250 mL: 50 g) was given intravenously at a volume of 125
mL every 12 hours for 4 days. Moxifloxacin (250 mL: 0.4g) was given intravenously once a day
for 10 days, low-molecular-weight heparin (4100 IU) was given subcutaneously once a day for
10 days, and levofloxacin sodium chloride injection (250 mL: 0.5 g) was used to rinse the
negative-pressure suction device once a day. The drainage fluid was not turbid. The
granulation tissue grew well after 10 days of carotid artery reconstruction; therefore, we
closed the incision (Figure 5). CTA
re-examination showed that the autogenous vein was unblocked. After discharge, the incision
was followed up for 1 month and showed grade A healing (Figure 6). Telephone follow-up was conducted regularly
for 1 month postoperatively. At the time of this writing, the patient was in good condition
without obvious neurological symptoms.
Figure 5. Second operation. Good granulation tissue growth was present, and the incision was
sutured.
Figure 6. Computed tomography angiography findings. The autogenous vein was unblocked, and the
incision achieved grade A healing. The patient was followed up for 1 month after
discharge.
The patient provided oral authorization for participation in this case study and
publication of the details of his case. We have de-identified all patient details. The
requirement for ethics approval was waived because this article does not contain information
that can be used to identify the patient and because he agreed to publication.
Discussion
About 80% of the pathogenic microorganisms involved in vascular graft infections are
Staphylococcus aureus and coagulase-negative
Staphylococcus. The risk factors for vascular graft infection include
patient-related factors (periodontal disease, nasal Staphylococcus aureus
colonization, postoperative bacteremia and stent characteristics, diabetes or postoperative
hyperglycemia, obesity, renal failure, liver disease, malnutrition, and immunosuppression)
as well as operation-related factors (intraoperative violation of sterility, a graft in the
groin, prolonged operation time, repeated vascular surgery, and lack of perioperative
antibiotic administration).3–5 The cause of the stent infection in this
case was considered to be that the open neck injury was a contaminated wound and that the
stent was partially exposed after two operations (Figure 2).
Vascular graft infection can be divided into Szilagyi grade I, II, and III. Szilagyi grade
I infection is limited to the skin, Szilagyi grade II infection is limited to the skin and
subcutaneous tissue, and Szilagyi grade III infection involves the graft.6 These different levels of infection involve different treatments. Generally, the
treatments can be divided into antibiotic and surgical treatments. The overall treatment
goal is to eradicate the infection and maintain the blood supply. Szilagyi grade I and II
infections are easier to control, and conservative treatment can be considered. For Szilagyi
grade II infection, extra attention should be invested to assess whether the infection has
progressed to grade III. No clear guidelines have been established for antibiotic treatment,
and intravenous administration of antibiotics for 4 to 6 weeks is generally considered
necessary. Our patient was considered to have Szilagyi grade III infection. Surgical
treatment combined with antibiotics was effective. The patient was given intravenous
antibiotics for 3 weeks in hospital. Considering that the patient’s infection was eliminated
and the autologous saphenous vein had strong antimicrobial protection, no oral antibiotics
were given after discharge.
Surgical intervention is required for a clearly diagnosed grade III infection when sepsis,
anastomotic rupture, aortoenteric fistula, and MRSA infection occurs. Conservative
treatments are less likely to succeed for graft infection. It was previously recommended
that anatomic bypass reconstruction be performed in the uninfected area. The disadvantages
of this are a low patency rate, high disability rate, and risk of anastomotic rupture. The
methods of in situ circulation reconstruction include partial graft removal
and reconstruction with cryopreserved homografts, fresh arterial allografts, autologous
veins, or antibiotic- or silver-bonded prosthetic grafts.7,8 The reinfection rate of biological materials is currently considered to
be low, and autogenous veins are considered the best choice to avoid reinfection.9
Negative-pressure wound therapy is reportedly an effective auxiliary treatment. Continuous
negative-pressure wound therapy can reduce the bacterial content in the wound, accelerate
blood flow, and promote the growth of granulation tissue.10 However, negative-pressure wound therapy is associated with a risk of anastomotic
bleeding; thus, low negative pressure can be considered.11
Patients with limb graft infection are at risk of amputation, whereas patients with carotid
artery graft infection are at high risk of cerebral infarction and intracranial infection.
This can be disastrous to their health and their family’s wellbeing. If the anchorage zone
and the anastomosis of the stent break, massive bleeding within a short period of time can
result in a huge hematoma, which may compress the trachea and cause suffocation. In patients
with grade I or II infections, the graft can be retained, and local debridement and muscle
flap coverage can be used together with antibiotic treatment. If the infection involves the
graft (grade III), removing all grafts and reconstructing the arteries may be necessary. The
material used to reconstruct the vasculature is usually autologous veins, and the saphenous
vein is most frequently used. The infection cure rate is very high, and the risk of
reinfection is only 0% to 10%.4
We achieved a definitive diagnosis of stent infection by combining the results of the
culture of the pus secretions, CTA, and ultrasound. The following points were considered.
First, the patient had no underlying disease and could tolerate surgery. Second, the patient
had undergone two previous neck operations, and the infection was severe because of exposure
of the stent to the environment through the sinus tract. Third, long-term stent infections
cannot be cured through conservative treatments. Finally, the patient had experienced a long
disease course and had a strong desire to eradicate the infection. Therefore, surgical
treatment was the best method.
In general, infection of carotid artery stents and vascular grafts is relatively rare. Such
infections increase patients’ disability rate and endanger their lives. Perioperative
sterility is important to prevent infection. If infection does occur, early identification
and treatment can prevent fatal consequences. For Szilagyi grade III infections, removal of
the infected graft and autologous venous reconstruction combined with low negative-pressure
wound therapy and sensitive antibiotic therapy are effective treatment methods. In addition,
individualized treatment plans should be formulated depending upon the grade of the vascular
graft infection.
Acknowledgements
We are very grateful to the vascular surgery team of the China-Japan Union Hospital of
Jilin University. We also thank Professor Dajun Sun, Director of Vascular Surgery of the
China-Japan Union Hospital of Jilin University, and Professor Yue Zhao.
Declaration of conflicting interest: The authors declare that there is no conflict of interest.
Funding: This research received no specific grant from any funding agency in the public,
commercial, or not-for-profit sectors.
ORCID iD: Xiwen Liu https://orcid.org/0000-0002-5220-8132 | Intravenous (not otherwise specified) | DrugAdministrationRoute | CC BY-NC | 33557657 | 19,674,675 | 2021-02 |
What was the administration route of drug 'UNSPECIFIED INGREDIENT'? | Surgical treatment of carotid artery stent infection: a case report.
The most effective treatment for graft infection is still debated, and the success rate of current treatments is low. We herein report the results of surgical treatment and follow-up of a case of infection acquired during carotid stenting with the aim of exploring the most effective treatments for graft infection. We retrospectively analyzed a patient who was admitted in September 2019. This patient underwent debridement, autologous saphenous vein replacement of the common carotid to internal carotid artery, external carotid artery suturing, and continuous negative-pressure wound therapy for carotid stent infection. Ten days after carotid artery revascularization, the growth of granulation tissue in the incision was good, and we decided to suture the neck incision. Five days after removing the stitches, grade A healing was noted. Furthermore, the carotid artery and autologous vein grafts were unobstructed as shown by carotid artery computed tomography angiography reexamination. The patient was monitored for 8 months with no new neurological symptoms and good healing of the incision. Effective treatment of vascular graft infection includes debridement and removal of the infected graft, autologous vein graft revascularization, and negative-pressure wound therapy combined with antibiotic therapy.
Introduction
The application of vascular grafts has been revolutionary for the treatment of peripheral
vascular and aortic diseases, and grafts have become indispensable in vascular surgery.
However, with the extensive application of vascular grafts, graft infections have become a
major problem for vascular surgeons. Graft infection is characterized by arterial wall
destruction, thrombosis, septic embolism, pseudoaneurysm formation, arterial rupture, and hemorrhage.1 Carotid stent infection is much rarer. Son et al.2 reported that only 2 of 77 cases of graft infection were associated with carotid
stenting. No standardized treatment has been established for vascular graft infection.
Treatment of carotid artery graft infection is very dangerous, and the patient is always at
risk of perioperative large-area cerebral infarction. We herein report the successful
diagnosis and surgical treatment of a case of carotid artery stent infection at China-Japan
Union Hospital Jilin University.
Case report
A 51-year-old man with neck trauma underwent debridement, implantation of a carotid artery
covered stent (8 × 60 mm, Fluency Plus; C. R. Bard, Murray Hill, NJ, USA), and thrombectomy
of the middle cerebral artery at a local hospital in October 2018 (Figure 1). After emergency admission, three-dimensional
angiography of the carotid artery was performed. A dissecting aneurysm was present at the
end of the left common carotid artery and the beginning of the left internal carotid artery.
The blood flow toward the brain was significantly decreased, but the rate at which it was
decreased was unknown. Compression of the left common carotid artery for angiography of the
right internal carotid artery and left vertebral artery revealed poor compensation of the
anterior and posterior communicating arteries. General anesthesia was administered and
debridement was conducted to remove the foreign bodies. A wood splinter was located between
the carotid artery and the internal jugular vein. The dissecting aneurysm ruptured and
started bleeding during the process of tissue separation. A common carotid artery stent was
therefore implanted into the femoral artery. A cerebral protection device was not used. The
patient took aspirin (100 mg) and clopidogrel (75 mg) orally after the operation. Thrombosis
of the left middle cerebral artery was found in the second intracranial angiography
examination and was considered to have been caused by exfoliation of the thrombus during the
dissection. Thrombectomy of the middle cerebral artery was therefore performed. The lumen of
the middle cerebral artery was unobstructed as shown by angiography. After the
above-described operation, debridement of the wound was continued, and the wood splinter was
removed. Postoperatively, brain magnetic resonance imaging indicated previous hemorrhage and
the formation of a softening lesion in the left basal ganglia. In February 2019, the
incision was debrided and re-sutured because of infection (Figure 2). However, the incision did not heal
completely after this operation. This was an extremely dangerous situation because of the
risk of carotid blowout; the carotid arterial flow was protected only by a thin intimal
layer within the stent and was accompanied by infection.
Figure 1. Day of neck trauma. The first debridement, carotid stenting, and thrombectomy of the
middle cerebral artery were performed on this day.
Figure 2. Second debridement. The covered stent was partially exposed.
In September 2019, the patient was admitted to the China-Japan Union Hospital of Jilin
University because the incision had not healed completely after 7 months. Specialized
physical examinations revealed a sinus tract with pus overflowing on the left side of the
neck accompanied by patchy redness and tenderness around the previous incision. Bilateral
carotid pulses were palpable, and the right and left upper limb muscle strength was Lovett
muscle strength grade IV and V, respectively. Biochemical examination revealed an
erythrocyte sedimentation rate of 28 mm/hour and C-reactive protein concentration of 35.4
mg/L. Culture of the secretions revealed methicillin-resistant Staphylococcus
aureus (MRSA) infection. The MRSA was sensitive to moxifloxacin and levofloxacin.
Through the purulent sinus, we could vaguely see the carotid artery stent and obtained the
pus from the deep tissue. We believed that the results of the MRSA culture were clinically
significant. Ultrasound examination showed unobstructed blood flow in the carotid stents.
Computed tomography angiography (CTA) indicated that the blood circulation in the carotid
artery stent was smooth with intimal hyperplasia, the internal carotid artery was
unobstructed, and the external carotid artery was completely occluded (Figure 3). The patient was young, had no underlying
disease, had experienced a long disease course, and strongly wished for surgical treatment.
We decided upon the surgical plan after a discussion with several professors.
Figure 3. Computed tomography angiography findings. The carotid artery stent and internal carotid
artery were patent, the external carotid artery was completely occluded, and intimal
hyperplasia was evident in the stent.
Moxifloxacin (250 mL: 0.4 g, 1/day) was given intravenously and low-molecular-weight
heparin (4100 IU) was given subcutaneously in accordance with the patient’s drug sensitivity
results after hospitalization. Moxifloxacin (250 mL: 0.4 g) was intravenously administered
30 minutes before the operation. We monitored the brain activity with intraoperative
electroencephalography without assessing the tolerance of the internal carotid artery
occlusion before surgery. The supine position was adopted, the shoulders were raised, and
the head was tilted back to the uninjured side. The length of the incision along the
anterior edge of the sternocleidomastoid muscle and the original incision was about 15 cm.
The inflammatory reaction within the incision and the tissue adhesion were severe. The
inflammatory reaction around the anchorage area of the stent was also severe. The stent
completely covered the opening of the external carotid artery. The proximal end of the
common carotid artery was carefully dissected, and blocking tape was added. The internal and
external carotid arteries were dissected, although they were difficult to distinguish
because of severe inflammation and adhesion. The appropriate length of the saphenous vein
was then obtained. After attaining sufficient blood supply to the brain, the distal internal
and external carotid arteries were blocked off and the infected stent was removed. The
external carotid artery was completely occluded. The internal carotid artery was anastomosed
in an end-to-end manner with the saphenous vein. After restoring the blood supply of the
internal carotid artery for 5 minutes, the common carotid artery was anastomosed in an
end-to-side manner with the great saphenous vein, and the stump of the common carotid artery
was sutured (Figure 4). We then
intermittently sutured the surrounding tissue and loosely wrapped the transplanted great
saphenous vein and the anastomosis at both ends. We did not cover it with muscle. Finally,
we covered the wound with a negative-pressure device, which was not in direct contact with
the bypass. The operation lasted 2.5 hours, and the intraoperative blood loss was 600 mL.
The patient was administered 3 units of type A-positive blood and 200 mL of ordinary frozen
plasma. No neurological complications occurred after extubation.
Figure 4. First operation. The infected stent was removed and the carotid artery was
reconstructed.
On the day after the operation, the patient was given an intravenous injection of
dexamethasone (5 mg), and mannitol (250 mL: 50 g) was given intravenously at a volume of 125
mL every 12 hours for 4 days. Moxifloxacin (250 mL: 0.4g) was given intravenously once a day
for 10 days, low-molecular-weight heparin (4100 IU) was given subcutaneously once a day for
10 days, and levofloxacin sodium chloride injection (250 mL: 0.5 g) was used to rinse the
negative-pressure suction device once a day. The drainage fluid was not turbid. The
granulation tissue grew well after 10 days of carotid artery reconstruction; therefore, we
closed the incision (Figure 5). CTA
re-examination showed that the autogenous vein was unblocked. After discharge, the incision
was followed up for 1 month and showed grade A healing (Figure 6). Telephone follow-up was conducted regularly
for 1 month postoperatively. At the time of this writing, the patient was in good condition
without obvious neurological symptoms.
Figure 5. Second operation. Good granulation tissue growth was present, and the incision was
sutured.
Figure 6. Computed tomography angiography findings. The autogenous vein was unblocked, and the
incision achieved grade A healing. The patient was followed up for 1 month after
discharge.
The patient provided oral authorization for participation in this case study and
publication of the details of his case. We have de-identified all patient details. The
requirement for ethics approval was waived because this article does not contain information
that can be used to identify the patient and because he agreed to publication.
Discussion
About 80% of the pathogenic microorganisms involved in vascular graft infections are
Staphylococcus aureus and coagulase-negative
Staphylococcus. The risk factors for vascular graft infection include
patient-related factors (periodontal disease, nasal Staphylococcus aureus
colonization, postoperative bacteremia and stent characteristics, diabetes or postoperative
hyperglycemia, obesity, renal failure, liver disease, malnutrition, and immunosuppression)
as well as operation-related factors (intraoperative violation of sterility, a graft in the
groin, prolonged operation time, repeated vascular surgery, and lack of perioperative
antibiotic administration).3–5 The cause of the stent infection in this
case was considered to be that the open neck injury was a contaminated wound and that the
stent was partially exposed after two operations (Figure 2).
Vascular graft infection can be divided into Szilagyi grade I, II, and III. Szilagyi grade
I infection is limited to the skin, Szilagyi grade II infection is limited to the skin and
subcutaneous tissue, and Szilagyi grade III infection involves the graft.6 These different levels of infection involve different treatments. Generally, the
treatments can be divided into antibiotic and surgical treatments. The overall treatment
goal is to eradicate the infection and maintain the blood supply. Szilagyi grade I and II
infections are easier to control, and conservative treatment can be considered. For Szilagyi
grade II infection, extra attention should be invested to assess whether the infection has
progressed to grade III. No clear guidelines have been established for antibiotic treatment,
and intravenous administration of antibiotics for 4 to 6 weeks is generally considered
necessary. Our patient was considered to have Szilagyi grade III infection. Surgical
treatment combined with antibiotics was effective. The patient was given intravenous
antibiotics for 3 weeks in hospital. Considering that the patient’s infection was eliminated
and the autologous saphenous vein had strong antimicrobial protection, no oral antibiotics
were given after discharge.
Surgical intervention is required for a clearly diagnosed grade III infection when sepsis,
anastomotic rupture, aortoenteric fistula, and MRSA infection occurs. Conservative
treatments are less likely to succeed for graft infection. It was previously recommended
that anatomic bypass reconstruction be performed in the uninfected area. The disadvantages
of this are a low patency rate, high disability rate, and risk of anastomotic rupture. The
methods of in situ circulation reconstruction include partial graft removal
and reconstruction with cryopreserved homografts, fresh arterial allografts, autologous
veins, or antibiotic- or silver-bonded prosthetic grafts.7,8 The reinfection rate of biological materials is currently considered to
be low, and autogenous veins are considered the best choice to avoid reinfection.9
Negative-pressure wound therapy is reportedly an effective auxiliary treatment. Continuous
negative-pressure wound therapy can reduce the bacterial content in the wound, accelerate
blood flow, and promote the growth of granulation tissue.10 However, negative-pressure wound therapy is associated with a risk of anastomotic
bleeding; thus, low negative pressure can be considered.11
Patients with limb graft infection are at risk of amputation, whereas patients with carotid
artery graft infection are at high risk of cerebral infarction and intracranial infection.
This can be disastrous to their health and their family’s wellbeing. If the anchorage zone
and the anastomosis of the stent break, massive bleeding within a short period of time can
result in a huge hematoma, which may compress the trachea and cause suffocation. In patients
with grade I or II infections, the graft can be retained, and local debridement and muscle
flap coverage can be used together with antibiotic treatment. If the infection involves the
graft (grade III), removing all grafts and reconstructing the arteries may be necessary. The
material used to reconstruct the vasculature is usually autologous veins, and the saphenous
vein is most frequently used. The infection cure rate is very high, and the risk of
reinfection is only 0% to 10%.4
We achieved a definitive diagnosis of stent infection by combining the results of the
culture of the pus secretions, CTA, and ultrasound. The following points were considered.
First, the patient had no underlying disease and could tolerate surgery. Second, the patient
had undergone two previous neck operations, and the infection was severe because of exposure
of the stent to the environment through the sinus tract. Third, long-term stent infections
cannot be cured through conservative treatments. Finally, the patient had experienced a long
disease course and had a strong desire to eradicate the infection. Therefore, surgical
treatment was the best method.
In general, infection of carotid artery stents and vascular grafts is relatively rare. Such
infections increase patients’ disability rate and endanger their lives. Perioperative
sterility is important to prevent infection. If infection does occur, early identification
and treatment can prevent fatal consequences. For Szilagyi grade III infections, removal of
the infected graft and autologous venous reconstruction combined with low negative-pressure
wound therapy and sensitive antibiotic therapy are effective treatment methods. In addition,
individualized treatment plans should be formulated depending upon the grade of the vascular
graft infection.
Acknowledgements
We are very grateful to the vascular surgery team of the China-Japan Union Hospital of
Jilin University. We also thank Professor Dajun Sun, Director of Vascular Surgery of the
China-Japan Union Hospital of Jilin University, and Professor Yue Zhao.
Declaration of conflicting interest: The authors declare that there is no conflict of interest.
Funding: This research received no specific grant from any funding agency in the public,
commercial, or not-for-profit sectors.
ORCID iD: Xiwen Liu https://orcid.org/0000-0002-5220-8132 | Subcutaneous | DrugAdministrationRoute | CC BY-NC | 33557657 | 19,674,675 | 2021-02 |
What was the dosage of drug 'ASPIRIN'? | Surgical treatment of carotid artery stent infection: a case report.
The most effective treatment for graft infection is still debated, and the success rate of current treatments is low. We herein report the results of surgical treatment and follow-up of a case of infection acquired during carotid stenting with the aim of exploring the most effective treatments for graft infection. We retrospectively analyzed a patient who was admitted in September 2019. This patient underwent debridement, autologous saphenous vein replacement of the common carotid to internal carotid artery, external carotid artery suturing, and continuous negative-pressure wound therapy for carotid stent infection. Ten days after carotid artery revascularization, the growth of granulation tissue in the incision was good, and we decided to suture the neck incision. Five days after removing the stitches, grade A healing was noted. Furthermore, the carotid artery and autologous vein grafts were unobstructed as shown by carotid artery computed tomography angiography reexamination. The patient was monitored for 8 months with no new neurological symptoms and good healing of the incision. Effective treatment of vascular graft infection includes debridement and removal of the infected graft, autologous vein graft revascularization, and negative-pressure wound therapy combined with antibiotic therapy.
Introduction
The application of vascular grafts has been revolutionary for the treatment of peripheral
vascular and aortic diseases, and grafts have become indispensable in vascular surgery.
However, with the extensive application of vascular grafts, graft infections have become a
major problem for vascular surgeons. Graft infection is characterized by arterial wall
destruction, thrombosis, septic embolism, pseudoaneurysm formation, arterial rupture, and hemorrhage.1 Carotid stent infection is much rarer. Son et al.2 reported that only 2 of 77 cases of graft infection were associated with carotid
stenting. No standardized treatment has been established for vascular graft infection.
Treatment of carotid artery graft infection is very dangerous, and the patient is always at
risk of perioperative large-area cerebral infarction. We herein report the successful
diagnosis and surgical treatment of a case of carotid artery stent infection at China-Japan
Union Hospital Jilin University.
Case report
A 51-year-old man with neck trauma underwent debridement, implantation of a carotid artery
covered stent (8 × 60 mm, Fluency Plus; C. R. Bard, Murray Hill, NJ, USA), and thrombectomy
of the middle cerebral artery at a local hospital in October 2018 (Figure 1). After emergency admission, three-dimensional
angiography of the carotid artery was performed. A dissecting aneurysm was present at the
end of the left common carotid artery and the beginning of the left internal carotid artery.
The blood flow toward the brain was significantly decreased, but the rate at which it was
decreased was unknown. Compression of the left common carotid artery for angiography of the
right internal carotid artery and left vertebral artery revealed poor compensation of the
anterior and posterior communicating arteries. General anesthesia was administered and
debridement was conducted to remove the foreign bodies. A wood splinter was located between
the carotid artery and the internal jugular vein. The dissecting aneurysm ruptured and
started bleeding during the process of tissue separation. A common carotid artery stent was
therefore implanted into the femoral artery. A cerebral protection device was not used. The
patient took aspirin (100 mg) and clopidogrel (75 mg) orally after the operation. Thrombosis
of the left middle cerebral artery was found in the second intracranial angiography
examination and was considered to have been caused by exfoliation of the thrombus during the
dissection. Thrombectomy of the middle cerebral artery was therefore performed. The lumen of
the middle cerebral artery was unobstructed as shown by angiography. After the
above-described operation, debridement of the wound was continued, and the wood splinter was
removed. Postoperatively, brain magnetic resonance imaging indicated previous hemorrhage and
the formation of a softening lesion in the left basal ganglia. In February 2019, the
incision was debrided and re-sutured because of infection (Figure 2). However, the incision did not heal
completely after this operation. This was an extremely dangerous situation because of the
risk of carotid blowout; the carotid arterial flow was protected only by a thin intimal
layer within the stent and was accompanied by infection.
Figure 1. Day of neck trauma. The first debridement, carotid stenting, and thrombectomy of the
middle cerebral artery were performed on this day.
Figure 2. Second debridement. The covered stent was partially exposed.
In September 2019, the patient was admitted to the China-Japan Union Hospital of Jilin
University because the incision had not healed completely after 7 months. Specialized
physical examinations revealed a sinus tract with pus overflowing on the left side of the
neck accompanied by patchy redness and tenderness around the previous incision. Bilateral
carotid pulses were palpable, and the right and left upper limb muscle strength was Lovett
muscle strength grade IV and V, respectively. Biochemical examination revealed an
erythrocyte sedimentation rate of 28 mm/hour and C-reactive protein concentration of 35.4
mg/L. Culture of the secretions revealed methicillin-resistant Staphylococcus
aureus (MRSA) infection. The MRSA was sensitive to moxifloxacin and levofloxacin.
Through the purulent sinus, we could vaguely see the carotid artery stent and obtained the
pus from the deep tissue. We believed that the results of the MRSA culture were clinically
significant. Ultrasound examination showed unobstructed blood flow in the carotid stents.
Computed tomography angiography (CTA) indicated that the blood circulation in the carotid
artery stent was smooth with intimal hyperplasia, the internal carotid artery was
unobstructed, and the external carotid artery was completely occluded (Figure 3). The patient was young, had no underlying
disease, had experienced a long disease course, and strongly wished for surgical treatment.
We decided upon the surgical plan after a discussion with several professors.
Figure 3. Computed tomography angiography findings. The carotid artery stent and internal carotid
artery were patent, the external carotid artery was completely occluded, and intimal
hyperplasia was evident in the stent.
Moxifloxacin (250 mL: 0.4 g, 1/day) was given intravenously and low-molecular-weight
heparin (4100 IU) was given subcutaneously in accordance with the patient’s drug sensitivity
results after hospitalization. Moxifloxacin (250 mL: 0.4 g) was intravenously administered
30 minutes before the operation. We monitored the brain activity with intraoperative
electroencephalography without assessing the tolerance of the internal carotid artery
occlusion before surgery. The supine position was adopted, the shoulders were raised, and
the head was tilted back to the uninjured side. The length of the incision along the
anterior edge of the sternocleidomastoid muscle and the original incision was about 15 cm.
The inflammatory reaction within the incision and the tissue adhesion were severe. The
inflammatory reaction around the anchorage area of the stent was also severe. The stent
completely covered the opening of the external carotid artery. The proximal end of the
common carotid artery was carefully dissected, and blocking tape was added. The internal and
external carotid arteries were dissected, although they were difficult to distinguish
because of severe inflammation and adhesion. The appropriate length of the saphenous vein
was then obtained. After attaining sufficient blood supply to the brain, the distal internal
and external carotid arteries were blocked off and the infected stent was removed. The
external carotid artery was completely occluded. The internal carotid artery was anastomosed
in an end-to-end manner with the saphenous vein. After restoring the blood supply of the
internal carotid artery for 5 minutes, the common carotid artery was anastomosed in an
end-to-side manner with the great saphenous vein, and the stump of the common carotid artery
was sutured (Figure 4). We then
intermittently sutured the surrounding tissue and loosely wrapped the transplanted great
saphenous vein and the anastomosis at both ends. We did not cover it with muscle. Finally,
we covered the wound with a negative-pressure device, which was not in direct contact with
the bypass. The operation lasted 2.5 hours, and the intraoperative blood loss was 600 mL.
The patient was administered 3 units of type A-positive blood and 200 mL of ordinary frozen
plasma. No neurological complications occurred after extubation.
Figure 4. First operation. The infected stent was removed and the carotid artery was
reconstructed.
On the day after the operation, the patient was given an intravenous injection of
dexamethasone (5 mg), and mannitol (250 mL: 50 g) was given intravenously at a volume of 125
mL every 12 hours for 4 days. Moxifloxacin (250 mL: 0.4g) was given intravenously once a day
for 10 days, low-molecular-weight heparin (4100 IU) was given subcutaneously once a day for
10 days, and levofloxacin sodium chloride injection (250 mL: 0.5 g) was used to rinse the
negative-pressure suction device once a day. The drainage fluid was not turbid. The
granulation tissue grew well after 10 days of carotid artery reconstruction; therefore, we
closed the incision (Figure 5). CTA
re-examination showed that the autogenous vein was unblocked. After discharge, the incision
was followed up for 1 month and showed grade A healing (Figure 6). Telephone follow-up was conducted regularly
for 1 month postoperatively. At the time of this writing, the patient was in good condition
without obvious neurological symptoms.
Figure 5. Second operation. Good granulation tissue growth was present, and the incision was
sutured.
Figure 6. Computed tomography angiography findings. The autogenous vein was unblocked, and the
incision achieved grade A healing. The patient was followed up for 1 month after
discharge.
The patient provided oral authorization for participation in this case study and
publication of the details of his case. We have de-identified all patient details. The
requirement for ethics approval was waived because this article does not contain information
that can be used to identify the patient and because he agreed to publication.
Discussion
About 80% of the pathogenic microorganisms involved in vascular graft infections are
Staphylococcus aureus and coagulase-negative
Staphylococcus. The risk factors for vascular graft infection include
patient-related factors (periodontal disease, nasal Staphylococcus aureus
colonization, postoperative bacteremia and stent characteristics, diabetes or postoperative
hyperglycemia, obesity, renal failure, liver disease, malnutrition, and immunosuppression)
as well as operation-related factors (intraoperative violation of sterility, a graft in the
groin, prolonged operation time, repeated vascular surgery, and lack of perioperative
antibiotic administration).3–5 The cause of the stent infection in this
case was considered to be that the open neck injury was a contaminated wound and that the
stent was partially exposed after two operations (Figure 2).
Vascular graft infection can be divided into Szilagyi grade I, II, and III. Szilagyi grade
I infection is limited to the skin, Szilagyi grade II infection is limited to the skin and
subcutaneous tissue, and Szilagyi grade III infection involves the graft.6 These different levels of infection involve different treatments. Generally, the
treatments can be divided into antibiotic and surgical treatments. The overall treatment
goal is to eradicate the infection and maintain the blood supply. Szilagyi grade I and II
infections are easier to control, and conservative treatment can be considered. For Szilagyi
grade II infection, extra attention should be invested to assess whether the infection has
progressed to grade III. No clear guidelines have been established for antibiotic treatment,
and intravenous administration of antibiotics for 4 to 6 weeks is generally considered
necessary. Our patient was considered to have Szilagyi grade III infection. Surgical
treatment combined with antibiotics was effective. The patient was given intravenous
antibiotics for 3 weeks in hospital. Considering that the patient’s infection was eliminated
and the autologous saphenous vein had strong antimicrobial protection, no oral antibiotics
were given after discharge.
Surgical intervention is required for a clearly diagnosed grade III infection when sepsis,
anastomotic rupture, aortoenteric fistula, and MRSA infection occurs. Conservative
treatments are less likely to succeed for graft infection. It was previously recommended
that anatomic bypass reconstruction be performed in the uninfected area. The disadvantages
of this are a low patency rate, high disability rate, and risk of anastomotic rupture. The
methods of in situ circulation reconstruction include partial graft removal
and reconstruction with cryopreserved homografts, fresh arterial allografts, autologous
veins, or antibiotic- or silver-bonded prosthetic grafts.7,8 The reinfection rate of biological materials is currently considered to
be low, and autogenous veins are considered the best choice to avoid reinfection.9
Negative-pressure wound therapy is reportedly an effective auxiliary treatment. Continuous
negative-pressure wound therapy can reduce the bacterial content in the wound, accelerate
blood flow, and promote the growth of granulation tissue.10 However, negative-pressure wound therapy is associated with a risk of anastomotic
bleeding; thus, low negative pressure can be considered.11
Patients with limb graft infection are at risk of amputation, whereas patients with carotid
artery graft infection are at high risk of cerebral infarction and intracranial infection.
This can be disastrous to their health and their family’s wellbeing. If the anchorage zone
and the anastomosis of the stent break, massive bleeding within a short period of time can
result in a huge hematoma, which may compress the trachea and cause suffocation. In patients
with grade I or II infections, the graft can be retained, and local debridement and muscle
flap coverage can be used together with antibiotic treatment. If the infection involves the
graft (grade III), removing all grafts and reconstructing the arteries may be necessary. The
material used to reconstruct the vasculature is usually autologous veins, and the saphenous
vein is most frequently used. The infection cure rate is very high, and the risk of
reinfection is only 0% to 10%.4
We achieved a definitive diagnosis of stent infection by combining the results of the
culture of the pus secretions, CTA, and ultrasound. The following points were considered.
First, the patient had no underlying disease and could tolerate surgery. Second, the patient
had undergone two previous neck operations, and the infection was severe because of exposure
of the stent to the environment through the sinus tract. Third, long-term stent infections
cannot be cured through conservative treatments. Finally, the patient had experienced a long
disease course and had a strong desire to eradicate the infection. Therefore, surgical
treatment was the best method.
In general, infection of carotid artery stents and vascular grafts is relatively rare. Such
infections increase patients’ disability rate and endanger their lives. Perioperative
sterility is important to prevent infection. If infection does occur, early identification
and treatment can prevent fatal consequences. For Szilagyi grade III infections, removal of
the infected graft and autologous venous reconstruction combined with low negative-pressure
wound therapy and sensitive antibiotic therapy are effective treatment methods. In addition,
individualized treatment plans should be formulated depending upon the grade of the vascular
graft infection.
Acknowledgements
We are very grateful to the vascular surgery team of the China-Japan Union Hospital of
Jilin University. We also thank Professor Dajun Sun, Director of Vascular Surgery of the
China-Japan Union Hospital of Jilin University, and Professor Yue Zhao.
Declaration of conflicting interest: The authors declare that there is no conflict of interest.
Funding: This research received no specific grant from any funding agency in the public,
commercial, or not-for-profit sectors.
ORCID iD: Xiwen Liu https://orcid.org/0000-0002-5220-8132 | 100 MG, QD | DrugDosageText | CC BY-NC | 33557657 | 19,674,675 | 2021-02 |
What was the dosage of drug 'CLOPIDOGREL BISULFATE'? | Surgical treatment of carotid artery stent infection: a case report.
The most effective treatment for graft infection is still debated, and the success rate of current treatments is low. We herein report the results of surgical treatment and follow-up of a case of infection acquired during carotid stenting with the aim of exploring the most effective treatments for graft infection. We retrospectively analyzed a patient who was admitted in September 2019. This patient underwent debridement, autologous saphenous vein replacement of the common carotid to internal carotid artery, external carotid artery suturing, and continuous negative-pressure wound therapy for carotid stent infection. Ten days after carotid artery revascularization, the growth of granulation tissue in the incision was good, and we decided to suture the neck incision. Five days after removing the stitches, grade A healing was noted. Furthermore, the carotid artery and autologous vein grafts were unobstructed as shown by carotid artery computed tomography angiography reexamination. The patient was monitored for 8 months with no new neurological symptoms and good healing of the incision. Effective treatment of vascular graft infection includes debridement and removal of the infected graft, autologous vein graft revascularization, and negative-pressure wound therapy combined with antibiotic therapy.
Introduction
The application of vascular grafts has been revolutionary for the treatment of peripheral
vascular and aortic diseases, and grafts have become indispensable in vascular surgery.
However, with the extensive application of vascular grafts, graft infections have become a
major problem for vascular surgeons. Graft infection is characterized by arterial wall
destruction, thrombosis, septic embolism, pseudoaneurysm formation, arterial rupture, and hemorrhage.1 Carotid stent infection is much rarer. Son et al.2 reported that only 2 of 77 cases of graft infection were associated with carotid
stenting. No standardized treatment has been established for vascular graft infection.
Treatment of carotid artery graft infection is very dangerous, and the patient is always at
risk of perioperative large-area cerebral infarction. We herein report the successful
diagnosis and surgical treatment of a case of carotid artery stent infection at China-Japan
Union Hospital Jilin University.
Case report
A 51-year-old man with neck trauma underwent debridement, implantation of a carotid artery
covered stent (8 × 60 mm, Fluency Plus; C. R. Bard, Murray Hill, NJ, USA), and thrombectomy
of the middle cerebral artery at a local hospital in October 2018 (Figure 1). After emergency admission, three-dimensional
angiography of the carotid artery was performed. A dissecting aneurysm was present at the
end of the left common carotid artery and the beginning of the left internal carotid artery.
The blood flow toward the brain was significantly decreased, but the rate at which it was
decreased was unknown. Compression of the left common carotid artery for angiography of the
right internal carotid artery and left vertebral artery revealed poor compensation of the
anterior and posterior communicating arteries. General anesthesia was administered and
debridement was conducted to remove the foreign bodies. A wood splinter was located between
the carotid artery and the internal jugular vein. The dissecting aneurysm ruptured and
started bleeding during the process of tissue separation. A common carotid artery stent was
therefore implanted into the femoral artery. A cerebral protection device was not used. The
patient took aspirin (100 mg) and clopidogrel (75 mg) orally after the operation. Thrombosis
of the left middle cerebral artery was found in the second intracranial angiography
examination and was considered to have been caused by exfoliation of the thrombus during the
dissection. Thrombectomy of the middle cerebral artery was therefore performed. The lumen of
the middle cerebral artery was unobstructed as shown by angiography. After the
above-described operation, debridement of the wound was continued, and the wood splinter was
removed. Postoperatively, brain magnetic resonance imaging indicated previous hemorrhage and
the formation of a softening lesion in the left basal ganglia. In February 2019, the
incision was debrided and re-sutured because of infection (Figure 2). However, the incision did not heal
completely after this operation. This was an extremely dangerous situation because of the
risk of carotid blowout; the carotid arterial flow was protected only by a thin intimal
layer within the stent and was accompanied by infection.
Figure 1. Day of neck trauma. The first debridement, carotid stenting, and thrombectomy of the
middle cerebral artery were performed on this day.
Figure 2. Second debridement. The covered stent was partially exposed.
In September 2019, the patient was admitted to the China-Japan Union Hospital of Jilin
University because the incision had not healed completely after 7 months. Specialized
physical examinations revealed a sinus tract with pus overflowing on the left side of the
neck accompanied by patchy redness and tenderness around the previous incision. Bilateral
carotid pulses were palpable, and the right and left upper limb muscle strength was Lovett
muscle strength grade IV and V, respectively. Biochemical examination revealed an
erythrocyte sedimentation rate of 28 mm/hour and C-reactive protein concentration of 35.4
mg/L. Culture of the secretions revealed methicillin-resistant Staphylococcus
aureus (MRSA) infection. The MRSA was sensitive to moxifloxacin and levofloxacin.
Through the purulent sinus, we could vaguely see the carotid artery stent and obtained the
pus from the deep tissue. We believed that the results of the MRSA culture were clinically
significant. Ultrasound examination showed unobstructed blood flow in the carotid stents.
Computed tomography angiography (CTA) indicated that the blood circulation in the carotid
artery stent was smooth with intimal hyperplasia, the internal carotid artery was
unobstructed, and the external carotid artery was completely occluded (Figure 3). The patient was young, had no underlying
disease, had experienced a long disease course, and strongly wished for surgical treatment.
We decided upon the surgical plan after a discussion with several professors.
Figure 3. Computed tomography angiography findings. The carotid artery stent and internal carotid
artery were patent, the external carotid artery was completely occluded, and intimal
hyperplasia was evident in the stent.
Moxifloxacin (250 mL: 0.4 g, 1/day) was given intravenously and low-molecular-weight
heparin (4100 IU) was given subcutaneously in accordance with the patient’s drug sensitivity
results after hospitalization. Moxifloxacin (250 mL: 0.4 g) was intravenously administered
30 minutes before the operation. We monitored the brain activity with intraoperative
electroencephalography without assessing the tolerance of the internal carotid artery
occlusion before surgery. The supine position was adopted, the shoulders were raised, and
the head was tilted back to the uninjured side. The length of the incision along the
anterior edge of the sternocleidomastoid muscle and the original incision was about 15 cm.
The inflammatory reaction within the incision and the tissue adhesion were severe. The
inflammatory reaction around the anchorage area of the stent was also severe. The stent
completely covered the opening of the external carotid artery. The proximal end of the
common carotid artery was carefully dissected, and blocking tape was added. The internal and
external carotid arteries were dissected, although they were difficult to distinguish
because of severe inflammation and adhesion. The appropriate length of the saphenous vein
was then obtained. After attaining sufficient blood supply to the brain, the distal internal
and external carotid arteries were blocked off and the infected stent was removed. The
external carotid artery was completely occluded. The internal carotid artery was anastomosed
in an end-to-end manner with the saphenous vein. After restoring the blood supply of the
internal carotid artery for 5 minutes, the common carotid artery was anastomosed in an
end-to-side manner with the great saphenous vein, and the stump of the common carotid artery
was sutured (Figure 4). We then
intermittently sutured the surrounding tissue and loosely wrapped the transplanted great
saphenous vein and the anastomosis at both ends. We did not cover it with muscle. Finally,
we covered the wound with a negative-pressure device, which was not in direct contact with
the bypass. The operation lasted 2.5 hours, and the intraoperative blood loss was 600 mL.
The patient was administered 3 units of type A-positive blood and 200 mL of ordinary frozen
plasma. No neurological complications occurred after extubation.
Figure 4. First operation. The infected stent was removed and the carotid artery was
reconstructed.
On the day after the operation, the patient was given an intravenous injection of
dexamethasone (5 mg), and mannitol (250 mL: 50 g) was given intravenously at a volume of 125
mL every 12 hours for 4 days. Moxifloxacin (250 mL: 0.4g) was given intravenously once a day
for 10 days, low-molecular-weight heparin (4100 IU) was given subcutaneously once a day for
10 days, and levofloxacin sodium chloride injection (250 mL: 0.5 g) was used to rinse the
negative-pressure suction device once a day. The drainage fluid was not turbid. The
granulation tissue grew well after 10 days of carotid artery reconstruction; therefore, we
closed the incision (Figure 5). CTA
re-examination showed that the autogenous vein was unblocked. After discharge, the incision
was followed up for 1 month and showed grade A healing (Figure 6). Telephone follow-up was conducted regularly
for 1 month postoperatively. At the time of this writing, the patient was in good condition
without obvious neurological symptoms.
Figure 5. Second operation. Good granulation tissue growth was present, and the incision was
sutured.
Figure 6. Computed tomography angiography findings. The autogenous vein was unblocked, and the
incision achieved grade A healing. The patient was followed up for 1 month after
discharge.
The patient provided oral authorization for participation in this case study and
publication of the details of his case. We have de-identified all patient details. The
requirement for ethics approval was waived because this article does not contain information
that can be used to identify the patient and because he agreed to publication.
Discussion
About 80% of the pathogenic microorganisms involved in vascular graft infections are
Staphylococcus aureus and coagulase-negative
Staphylococcus. The risk factors for vascular graft infection include
patient-related factors (periodontal disease, nasal Staphylococcus aureus
colonization, postoperative bacteremia and stent characteristics, diabetes or postoperative
hyperglycemia, obesity, renal failure, liver disease, malnutrition, and immunosuppression)
as well as operation-related factors (intraoperative violation of sterility, a graft in the
groin, prolonged operation time, repeated vascular surgery, and lack of perioperative
antibiotic administration).3–5 The cause of the stent infection in this
case was considered to be that the open neck injury was a contaminated wound and that the
stent was partially exposed after two operations (Figure 2).
Vascular graft infection can be divided into Szilagyi grade I, II, and III. Szilagyi grade
I infection is limited to the skin, Szilagyi grade II infection is limited to the skin and
subcutaneous tissue, and Szilagyi grade III infection involves the graft.6 These different levels of infection involve different treatments. Generally, the
treatments can be divided into antibiotic and surgical treatments. The overall treatment
goal is to eradicate the infection and maintain the blood supply. Szilagyi grade I and II
infections are easier to control, and conservative treatment can be considered. For Szilagyi
grade II infection, extra attention should be invested to assess whether the infection has
progressed to grade III. No clear guidelines have been established for antibiotic treatment,
and intravenous administration of antibiotics for 4 to 6 weeks is generally considered
necessary. Our patient was considered to have Szilagyi grade III infection. Surgical
treatment combined with antibiotics was effective. The patient was given intravenous
antibiotics for 3 weeks in hospital. Considering that the patient’s infection was eliminated
and the autologous saphenous vein had strong antimicrobial protection, no oral antibiotics
were given after discharge.
Surgical intervention is required for a clearly diagnosed grade III infection when sepsis,
anastomotic rupture, aortoenteric fistula, and MRSA infection occurs. Conservative
treatments are less likely to succeed for graft infection. It was previously recommended
that anatomic bypass reconstruction be performed in the uninfected area. The disadvantages
of this are a low patency rate, high disability rate, and risk of anastomotic rupture. The
methods of in situ circulation reconstruction include partial graft removal
and reconstruction with cryopreserved homografts, fresh arterial allografts, autologous
veins, or antibiotic- or silver-bonded prosthetic grafts.7,8 The reinfection rate of biological materials is currently considered to
be low, and autogenous veins are considered the best choice to avoid reinfection.9
Negative-pressure wound therapy is reportedly an effective auxiliary treatment. Continuous
negative-pressure wound therapy can reduce the bacterial content in the wound, accelerate
blood flow, and promote the growth of granulation tissue.10 However, negative-pressure wound therapy is associated with a risk of anastomotic
bleeding; thus, low negative pressure can be considered.11
Patients with limb graft infection are at risk of amputation, whereas patients with carotid
artery graft infection are at high risk of cerebral infarction and intracranial infection.
This can be disastrous to their health and their family’s wellbeing. If the anchorage zone
and the anastomosis of the stent break, massive bleeding within a short period of time can
result in a huge hematoma, which may compress the trachea and cause suffocation. In patients
with grade I or II infections, the graft can be retained, and local debridement and muscle
flap coverage can be used together with antibiotic treatment. If the infection involves the
graft (grade III), removing all grafts and reconstructing the arteries may be necessary. The
material used to reconstruct the vasculature is usually autologous veins, and the saphenous
vein is most frequently used. The infection cure rate is very high, and the risk of
reinfection is only 0% to 10%.4
We achieved a definitive diagnosis of stent infection by combining the results of the
culture of the pus secretions, CTA, and ultrasound. The following points were considered.
First, the patient had no underlying disease and could tolerate surgery. Second, the patient
had undergone two previous neck operations, and the infection was severe because of exposure
of the stent to the environment through the sinus tract. Third, long-term stent infections
cannot be cured through conservative treatments. Finally, the patient had experienced a long
disease course and had a strong desire to eradicate the infection. Therefore, surgical
treatment was the best method.
In general, infection of carotid artery stents and vascular grafts is relatively rare. Such
infections increase patients’ disability rate and endanger their lives. Perioperative
sterility is important to prevent infection. If infection does occur, early identification
and treatment can prevent fatal consequences. For Szilagyi grade III infections, removal of
the infected graft and autologous venous reconstruction combined with low negative-pressure
wound therapy and sensitive antibiotic therapy are effective treatment methods. In addition,
individualized treatment plans should be formulated depending upon the grade of the vascular
graft infection.
Acknowledgements
We are very grateful to the vascular surgery team of the China-Japan Union Hospital of
Jilin University. We also thank Professor Dajun Sun, Director of Vascular Surgery of the
China-Japan Union Hospital of Jilin University, and Professor Yue Zhao.
Declaration of conflicting interest: The authors declare that there is no conflict of interest.
Funding: This research received no specific grant from any funding agency in the public,
commercial, or not-for-profit sectors.
ORCID iD: Xiwen Liu https://orcid.org/0000-0002-5220-8132 | 75 MG, QD | DrugDosageText | CC BY-NC | 33557657 | 19,674,675 | 2021-02 |
What was the dosage of drug 'MOXIFLOXACIN'? | Surgical treatment of carotid artery stent infection: a case report.
The most effective treatment for graft infection is still debated, and the success rate of current treatments is low. We herein report the results of surgical treatment and follow-up of a case of infection acquired during carotid stenting with the aim of exploring the most effective treatments for graft infection. We retrospectively analyzed a patient who was admitted in September 2019. This patient underwent debridement, autologous saphenous vein replacement of the common carotid to internal carotid artery, external carotid artery suturing, and continuous negative-pressure wound therapy for carotid stent infection. Ten days after carotid artery revascularization, the growth of granulation tissue in the incision was good, and we decided to suture the neck incision. Five days after removing the stitches, grade A healing was noted. Furthermore, the carotid artery and autologous vein grafts were unobstructed as shown by carotid artery computed tomography angiography reexamination. The patient was monitored for 8 months with no new neurological symptoms and good healing of the incision. Effective treatment of vascular graft infection includes debridement and removal of the infected graft, autologous vein graft revascularization, and negative-pressure wound therapy combined with antibiotic therapy.
Introduction
The application of vascular grafts has been revolutionary for the treatment of peripheral
vascular and aortic diseases, and grafts have become indispensable in vascular surgery.
However, with the extensive application of vascular grafts, graft infections have become a
major problem for vascular surgeons. Graft infection is characterized by arterial wall
destruction, thrombosis, septic embolism, pseudoaneurysm formation, arterial rupture, and hemorrhage.1 Carotid stent infection is much rarer. Son et al.2 reported that only 2 of 77 cases of graft infection were associated with carotid
stenting. No standardized treatment has been established for vascular graft infection.
Treatment of carotid artery graft infection is very dangerous, and the patient is always at
risk of perioperative large-area cerebral infarction. We herein report the successful
diagnosis and surgical treatment of a case of carotid artery stent infection at China-Japan
Union Hospital Jilin University.
Case report
A 51-year-old man with neck trauma underwent debridement, implantation of a carotid artery
covered stent (8 × 60 mm, Fluency Plus; C. R. Bard, Murray Hill, NJ, USA), and thrombectomy
of the middle cerebral artery at a local hospital in October 2018 (Figure 1). After emergency admission, three-dimensional
angiography of the carotid artery was performed. A dissecting aneurysm was present at the
end of the left common carotid artery and the beginning of the left internal carotid artery.
The blood flow toward the brain was significantly decreased, but the rate at which it was
decreased was unknown. Compression of the left common carotid artery for angiography of the
right internal carotid artery and left vertebral artery revealed poor compensation of the
anterior and posterior communicating arteries. General anesthesia was administered and
debridement was conducted to remove the foreign bodies. A wood splinter was located between
the carotid artery and the internal jugular vein. The dissecting aneurysm ruptured and
started bleeding during the process of tissue separation. A common carotid artery stent was
therefore implanted into the femoral artery. A cerebral protection device was not used. The
patient took aspirin (100 mg) and clopidogrel (75 mg) orally after the operation. Thrombosis
of the left middle cerebral artery was found in the second intracranial angiography
examination and was considered to have been caused by exfoliation of the thrombus during the
dissection. Thrombectomy of the middle cerebral artery was therefore performed. The lumen of
the middle cerebral artery was unobstructed as shown by angiography. After the
above-described operation, debridement of the wound was continued, and the wood splinter was
removed. Postoperatively, brain magnetic resonance imaging indicated previous hemorrhage and
the formation of a softening lesion in the left basal ganglia. In February 2019, the
incision was debrided and re-sutured because of infection (Figure 2). However, the incision did not heal
completely after this operation. This was an extremely dangerous situation because of the
risk of carotid blowout; the carotid arterial flow was protected only by a thin intimal
layer within the stent and was accompanied by infection.
Figure 1. Day of neck trauma. The first debridement, carotid stenting, and thrombectomy of the
middle cerebral artery were performed on this day.
Figure 2. Second debridement. The covered stent was partially exposed.
In September 2019, the patient was admitted to the China-Japan Union Hospital of Jilin
University because the incision had not healed completely after 7 months. Specialized
physical examinations revealed a sinus tract with pus overflowing on the left side of the
neck accompanied by patchy redness and tenderness around the previous incision. Bilateral
carotid pulses were palpable, and the right and left upper limb muscle strength was Lovett
muscle strength grade IV and V, respectively. Biochemical examination revealed an
erythrocyte sedimentation rate of 28 mm/hour and C-reactive protein concentration of 35.4
mg/L. Culture of the secretions revealed methicillin-resistant Staphylococcus
aureus (MRSA) infection. The MRSA was sensitive to moxifloxacin and levofloxacin.
Through the purulent sinus, we could vaguely see the carotid artery stent and obtained the
pus from the deep tissue. We believed that the results of the MRSA culture were clinically
significant. Ultrasound examination showed unobstructed blood flow in the carotid stents.
Computed tomography angiography (CTA) indicated that the blood circulation in the carotid
artery stent was smooth with intimal hyperplasia, the internal carotid artery was
unobstructed, and the external carotid artery was completely occluded (Figure 3). The patient was young, had no underlying
disease, had experienced a long disease course, and strongly wished for surgical treatment.
We decided upon the surgical plan after a discussion with several professors.
Figure 3. Computed tomography angiography findings. The carotid artery stent and internal carotid
artery were patent, the external carotid artery was completely occluded, and intimal
hyperplasia was evident in the stent.
Moxifloxacin (250 mL: 0.4 g, 1/day) was given intravenously and low-molecular-weight
heparin (4100 IU) was given subcutaneously in accordance with the patient’s drug sensitivity
results after hospitalization. Moxifloxacin (250 mL: 0.4 g) was intravenously administered
30 minutes before the operation. We monitored the brain activity with intraoperative
electroencephalography without assessing the tolerance of the internal carotid artery
occlusion before surgery. The supine position was adopted, the shoulders were raised, and
the head was tilted back to the uninjured side. The length of the incision along the
anterior edge of the sternocleidomastoid muscle and the original incision was about 15 cm.
The inflammatory reaction within the incision and the tissue adhesion were severe. The
inflammatory reaction around the anchorage area of the stent was also severe. The stent
completely covered the opening of the external carotid artery. The proximal end of the
common carotid artery was carefully dissected, and blocking tape was added. The internal and
external carotid arteries were dissected, although they were difficult to distinguish
because of severe inflammation and adhesion. The appropriate length of the saphenous vein
was then obtained. After attaining sufficient blood supply to the brain, the distal internal
and external carotid arteries were blocked off and the infected stent was removed. The
external carotid artery was completely occluded. The internal carotid artery was anastomosed
in an end-to-end manner with the saphenous vein. After restoring the blood supply of the
internal carotid artery for 5 minutes, the common carotid artery was anastomosed in an
end-to-side manner with the great saphenous vein, and the stump of the common carotid artery
was sutured (Figure 4). We then
intermittently sutured the surrounding tissue and loosely wrapped the transplanted great
saphenous vein and the anastomosis at both ends. We did not cover it with muscle. Finally,
we covered the wound with a negative-pressure device, which was not in direct contact with
the bypass. The operation lasted 2.5 hours, and the intraoperative blood loss was 600 mL.
The patient was administered 3 units of type A-positive blood and 200 mL of ordinary frozen
plasma. No neurological complications occurred after extubation.
Figure 4. First operation. The infected stent was removed and the carotid artery was
reconstructed.
On the day after the operation, the patient was given an intravenous injection of
dexamethasone (5 mg), and mannitol (250 mL: 50 g) was given intravenously at a volume of 125
mL every 12 hours for 4 days. Moxifloxacin (250 mL: 0.4g) was given intravenously once a day
for 10 days, low-molecular-weight heparin (4100 IU) was given subcutaneously once a day for
10 days, and levofloxacin sodium chloride injection (250 mL: 0.5 g) was used to rinse the
negative-pressure suction device once a day. The drainage fluid was not turbid. The
granulation tissue grew well after 10 days of carotid artery reconstruction; therefore, we
closed the incision (Figure 5). CTA
re-examination showed that the autogenous vein was unblocked. After discharge, the incision
was followed up for 1 month and showed grade A healing (Figure 6). Telephone follow-up was conducted regularly
for 1 month postoperatively. At the time of this writing, the patient was in good condition
without obvious neurological symptoms.
Figure 5. Second operation. Good granulation tissue growth was present, and the incision was
sutured.
Figure 6. Computed tomography angiography findings. The autogenous vein was unblocked, and the
incision achieved grade A healing. The patient was followed up for 1 month after
discharge.
The patient provided oral authorization for participation in this case study and
publication of the details of his case. We have de-identified all patient details. The
requirement for ethics approval was waived because this article does not contain information
that can be used to identify the patient and because he agreed to publication.
Discussion
About 80% of the pathogenic microorganisms involved in vascular graft infections are
Staphylococcus aureus and coagulase-negative
Staphylococcus. The risk factors for vascular graft infection include
patient-related factors (periodontal disease, nasal Staphylococcus aureus
colonization, postoperative bacteremia and stent characteristics, diabetes or postoperative
hyperglycemia, obesity, renal failure, liver disease, malnutrition, and immunosuppression)
as well as operation-related factors (intraoperative violation of sterility, a graft in the
groin, prolonged operation time, repeated vascular surgery, and lack of perioperative
antibiotic administration).3–5 The cause of the stent infection in this
case was considered to be that the open neck injury was a contaminated wound and that the
stent was partially exposed after two operations (Figure 2).
Vascular graft infection can be divided into Szilagyi grade I, II, and III. Szilagyi grade
I infection is limited to the skin, Szilagyi grade II infection is limited to the skin and
subcutaneous tissue, and Szilagyi grade III infection involves the graft.6 These different levels of infection involve different treatments. Generally, the
treatments can be divided into antibiotic and surgical treatments. The overall treatment
goal is to eradicate the infection and maintain the blood supply. Szilagyi grade I and II
infections are easier to control, and conservative treatment can be considered. For Szilagyi
grade II infection, extra attention should be invested to assess whether the infection has
progressed to grade III. No clear guidelines have been established for antibiotic treatment,
and intravenous administration of antibiotics for 4 to 6 weeks is generally considered
necessary. Our patient was considered to have Szilagyi grade III infection. Surgical
treatment combined with antibiotics was effective. The patient was given intravenous
antibiotics for 3 weeks in hospital. Considering that the patient’s infection was eliminated
and the autologous saphenous vein had strong antimicrobial protection, no oral antibiotics
were given after discharge.
Surgical intervention is required for a clearly diagnosed grade III infection when sepsis,
anastomotic rupture, aortoenteric fistula, and MRSA infection occurs. Conservative
treatments are less likely to succeed for graft infection. It was previously recommended
that anatomic bypass reconstruction be performed in the uninfected area. The disadvantages
of this are a low patency rate, high disability rate, and risk of anastomotic rupture. The
methods of in situ circulation reconstruction include partial graft removal
and reconstruction with cryopreserved homografts, fresh arterial allografts, autologous
veins, or antibiotic- or silver-bonded prosthetic grafts.7,8 The reinfection rate of biological materials is currently considered to
be low, and autogenous veins are considered the best choice to avoid reinfection.9
Negative-pressure wound therapy is reportedly an effective auxiliary treatment. Continuous
negative-pressure wound therapy can reduce the bacterial content in the wound, accelerate
blood flow, and promote the growth of granulation tissue.10 However, negative-pressure wound therapy is associated with a risk of anastomotic
bleeding; thus, low negative pressure can be considered.11
Patients with limb graft infection are at risk of amputation, whereas patients with carotid
artery graft infection are at high risk of cerebral infarction and intracranial infection.
This can be disastrous to their health and their family’s wellbeing. If the anchorage zone
and the anastomosis of the stent break, massive bleeding within a short period of time can
result in a huge hematoma, which may compress the trachea and cause suffocation. In patients
with grade I or II infections, the graft can be retained, and local debridement and muscle
flap coverage can be used together with antibiotic treatment. If the infection involves the
graft (grade III), removing all grafts and reconstructing the arteries may be necessary. The
material used to reconstruct the vasculature is usually autologous veins, and the saphenous
vein is most frequently used. The infection cure rate is very high, and the risk of
reinfection is only 0% to 10%.4
We achieved a definitive diagnosis of stent infection by combining the results of the
culture of the pus secretions, CTA, and ultrasound. The following points were considered.
First, the patient had no underlying disease and could tolerate surgery. Second, the patient
had undergone two previous neck operations, and the infection was severe because of exposure
of the stent to the environment through the sinus tract. Third, long-term stent infections
cannot be cured through conservative treatments. Finally, the patient had experienced a long
disease course and had a strong desire to eradicate the infection. Therefore, surgical
treatment was the best method.
In general, infection of carotid artery stents and vascular grafts is relatively rare. Such
infections increase patients’ disability rate and endanger their lives. Perioperative
sterility is important to prevent infection. If infection does occur, early identification
and treatment can prevent fatal consequences. For Szilagyi grade III infections, removal of
the infected graft and autologous venous reconstruction combined with low negative-pressure
wound therapy and sensitive antibiotic therapy are effective treatment methods. In addition,
individualized treatment plans should be formulated depending upon the grade of the vascular
graft infection.
Acknowledgements
We are very grateful to the vascular surgery team of the China-Japan Union Hospital of
Jilin University. We also thank Professor Dajun Sun, Director of Vascular Surgery of the
China-Japan Union Hospital of Jilin University, and Professor Yue Zhao.
Declaration of conflicting interest: The authors declare that there is no conflict of interest.
Funding: This research received no specific grant from any funding agency in the public,
commercial, or not-for-profit sectors.
ORCID iD: Xiwen Liu https://orcid.org/0000-0002-5220-8132 | 250 ML, QD | DrugDosageText | CC BY-NC | 33557657 | 19,674,675 | 2021-02 |
Give an alphabetized list of all active substances of drugs taken by the patient who experienced 'Cerebral ventricle dilatation'. | Mycoplasma hominis meningitis in an extremely preterm newborn: a case report.
Mycoplasma Hominis is a micro-organism which is a part of the human genitourinary tract flora. Neonates are susceptible to acquire this pathogen either in utero or through vertical transmission. In rare cases, it may cause central nervous system infections with severe morbidity and mortality in preterm and term neonates.
We present a case of Mycoplasma Hominis meningitis in an extremely preterm neonate who presented with lethargy, tachycardia and seizures on day 7 of life. There was no history of maternal systemic or genitourinary infection during pregnancy and at the time of delivery. Empirical antibiotic therapy for neonatal meningitis was commenced after sending blood and cerebrospinal fluid cultures. Cerebrospinal fluid analysis showed pleocytosis with neutrophilic predominance, but no bacteria was identified on gram staining. Blood culture yielded no growth of any bacterial pathogen. However, growth of Mycoplasma Hominis was suspected in cerebrospinal fluid culture which was confirmed by 16S ribosomal ribonucleic acid (RNA) polymerase chain reaction analysis. Subsequently, antibiotics were changed to Moxifloxacin and Doxycycline which were given for a total duration of 6 weeks. Multiple cerebrospinal fluid cultures were performed during this treatment. No growth of any pathogen was identified on any of these cerebrospinal fluid cultures.
We report a rare case of Mycoplasma Hominis meningitis in an extremely preterm neonate which was successfully treated with a combination therapy of Moxifloxacin and Doxycycline. It is important to consider the possibility of Mycoplasma Hominis meningitis in neonates who present with clinical signs and pleocytosis in cerebrospinal fluid but negative gram staining and no growth on conventional culture media.
Background
Mycoplasma Hominis is a frequent habitant of the human genital tract [1]. Neonates are susceptible to acquire this microbe either in utero or through the colonized birth canal during the process of parturition [2]. However, invasive infections with this organism in preterm and term infants are noted to be rare [1, 3]. We describe an unusual case of neonatal meningitis due to Mycoplasma Hominis, confirmed in bacterial cultures and 16s ribosomal RNA Polymerase chain reaction (PCR) analysis. This case report demonstrates the importance of suspecting Mycoplasma Hominis as a cause of central nervous system (CNS) infection in neonates who present with clinical signs but no growth on conventional bacterial cultures and no improvement on empirical antibiotic treatment.
Case presentation
A male neonate was born at 25 + 6 weeks of gestation to 35 years old gravida 2, parity1 (G2P1) mother with antiphospholipid antibody syndrome. This was an in vitro fertilization (IVF) pregnancy. She was Rubella immune and negative for Hepatitis B surface antigen, Venereal disease research laboratory test (VDRL), Human immunodeficiency virus, Gonococci and Chlamydia. Her urine culture and vaginal swab for Group B Streptococci was also negative. Her anatomy scan at 18 weeks of gestation showed normal fetal anatomy and a short cervix for which she underwent cervical cerclage placement at 20 + 5 weeks gestation. There was no history of chorioamnionitis or prolonged rupture of membranes. She presented at 25 + 5 weeks with preterm labor and had a spontaneous vaginal delivery the next day. She had received two doses of Betamethasone and Magnesium sulphate prior to delivery. He initially required positive pressure ventilation followed by intubation and surfactant administration with an acceptable response. Umbilical arterial and venous catheters were placed and the neonate was transferred to neonatal intensive care unit (NICU) in a stable condition.
A blood culture was drawn at birth and empiric treatment with Ampicillin and Gentamicin was intiated. The antibiotics were discontinued after 36 hours as the blood culture showed no growth and he remained clinically stable. In addition, as per unit protocol, an endotracheal aspirate was sent for a Ureaplasma culture on admission. This grew a Mycoplasma species for which 3 days of intravenous Azithromycin was given.
A head ultrasound on day 4 of life showed bilateral intraventricular hemorrhage (grade 3) with mild ventriculomegaly and a hemorrhagic venous infarct in the right frontoparietal region. Umbilical arterial catheter was removed on day 4 of life whereas umbilical venous catheter was removed on day 6 of life. He remained stable till day 7 of life when he presented with an acute clinical deterioration presenting as lethargy and tachycardia; a septic work up including blood and cerebrospinal fluid (CSF) cultures was completed and Vancomycin and Cefotaxime were started as empiric antibiotics. His CSF analysis showed red blood cells (RBC) count of 4887 × 10E6/l, pleocytosis of white blood cells (WBC) 9620 × 10E6/l with neutrophilic predominance, hyperproteorachia - protein 8300 mg/l and hypoglycorachia - glucose 0.1 mmoles/liter. Gram staining in CSF was negative. Within hours he developed generalized clinical seizures which was treated with Lorazepam and Phenobarbital followed by a Levetiracetam load and maintenance dose. He had further episodes of clinical and subclinical seizures which resolved after further adjustment of levetiracetam doses.
His first CSF culture was suspected to grow Mycoplasma Hominis and was sent to the regional national diagnostic laboratory for confirmation. The CSF culture was repeated along with a sample for 16s ribosomal RNA PCR analyses. The 16s ribosomal RNA PCR analysis confirmed Mycoplasma hominis in both CSF samples. Antibiotics were then changed to Moxifloxacin and Doxycycline. The repeat CSF culture after 48 hours of Moxifloxacin and Doxycycline showed no growth. CSF analysis done seven days after starting this treatment showed RBC 5650 × 10E6/l, WBC 449 × 10E6/l, protein 3763 mg/l and glucose 0.2 mmoles/liter. Subsequent CSF findings repeated after another three days showed further improvement, RBC 7187 × 10E6/l, WBC 93 × 10E6/l, protein 3691 mg/l and glucose 0.5 mmoles/liter. No growth was seen on any of these CSF cultures. Serial head ultrasound scans were done which showed progressive ventriculomegaly, post hemorrhagic ventricular dilatation and cystic evolution of hemorrhagic/venous infarct in the right frontoparietal region. Although these findings could be attributed to extreme prematurity; there is a likelihood that infection with Mycoplasma Hominis may have played a role in its progression. There have been documented cases of Mycoplasma Hominis meningitis resulting in CNS complications including intraventricular and periventricular hemorrhage, hydrocephalus, and infarction [3]. Lumbar taps were repeated as therapeutic measure to reduce ventriculomegaly, but optimal volumes of CSF were not obtained. Because of the ventriculomegaly, he was evaluated for a possible shunt on day 31; this was deferred because of the stable ventriculomegaly.
Antibiotics were given for a total duration of six weeks after which he was discharged home with a normal neurological examination. He was referred to Neurodevelopmental clinic for follow-up.
Discussion and conclusion
Neonatal CNS infections with Mycoplasma Hominis, although rare, can cause severe morbidity and mortality in neonates [1]. In a case series of 29 neonates with Mycoplasma Hominis infection (age of presentation day1-32 of life), Hata and colleagues reported complications such as brain abscess, hydrocephalus, infarction, cerebritis and periventricular/intraventricular hemorrhage in 34 % cases, death in 28 % and sequelae mostly hemiparesis in another 28 % cases [3]. This may be attributed to a delay in diagnosis, ineffective antibiotic treatment, or suboptimal treatment regimens for neonatal CNS disease [3, 4]. Therefore, prompt diagnosis, early initiation and optimal duration of appropriate antibiotic therapy is necessary for a favorable prognosis.
The clinical presentation may include apnea, temperature instability, lethargy, vomiting, irritability poor tone, twitching or seizures [7]. Detection of Mycoplasma Hominis can be challenging since they lack peptidoglycan cell wall which renders them unidentifiable by gram staining [5]. In addition to this, they grow very slowly on routine culture media and require a specific blood agar medium for their detection [1, 6]. Due to this, there is a likelihood that Mycoplasma Hominis infections may remain undiagnosed or diagnosed late in infants presenting with clinical signs and symptoms [2]. Hence, it is important to consider the possibility of Mycoplasma Hominis infection in cases where the CSF shows pleocytosis and no growth of organism on routine culture media. A 16S ribosomal RNA PCR analysis has proven useful for detection of Mycoplasma Hominis in blood and CSF which are difficult to grow on standard culture media [7, 8]. The microbe is identified by direct sequencing analysis after amplification by PCR. Use of pathogen-specific primers in 16S RNA analysis results in rapid detection of the specific organism [4]. Prematurity, low birth weight, and neural tube defects are recognized to be the most common risk factors for neonatal meningitis with Mycoplasma Hominis [6]. However, it has also been seen in term neonates with no neurological birth malformations [1, 3].
The treatment options for Mycoplasma Hominis meningitis and its duration remains unclear [1, 9]. Due to the rarity of this infection in neonates, the current recommendations are based on clinical experiences and in-vitro susceptibility test results [9, 10].
Mycoplasma Hominis has shown susceptibility to Chloramphenicol, Tetracyclines, Lincosamide and Fluoroquinolones in in-vitro testing [11]. Fluoroquinolones have been used in past to treat neonatal mycoplasma hominins meningitis successfully [1, 3, 5]. Moxifloxacin, a fourth-generation fluoroquinolone is preferred because of its ability to concentrate in CSF and its bactericidal effects in CNS infections [1, 12, 13]. Although there are cases which were successfully treated with Moxifloxacin monotherapy [1, 6], there is a risk of development of resistance with fluoroquinolones during treatment [9, 14, 15]. Our literature search revealed only two reported cases of neonates who were given Moxifloxacin in combination with another antibiotic for Mycoplasma Hominis meningitis [3, 5] (Table 1).
Table 1 Characteristics of neonates treated with combination therapy (Moxifloxacin and another antibiotic) for Mycoplasma Hominis CNS infection
Gestational Age Age at presentation Clinical presentation Confirmation of diagnosis Empirical antibiotic therapy and duration Antibiotics for Mycoplasma Hominis Outcome
Hata and colleagues3 38 weeks 25 days Fever, vomiting, focal seizures 16S RNA PCR Ampicillin & Cefotaxime (day 1–2) Ciprofloxacin (day 6–17) Acyclovir (day 6–8) Chloramphenicol (day 8–17) Minocycline for 28 days (day 6–34) Moxifloxacin for 17 days (day 17–34) Recovery with left hemiplegia
Watt and colleagues5 26 weeks 7 days Apnea, hypotonia, generalized seizures 16S RNA PCR Ampicillin and Gentamycin (day1-8) Ceftazidime (day 1–5 ) Vancomycin (day 8–19 ) Acyclovir (day 8–19) Meropenem (day 12–19 ) Doxycycline for 6 weeks (day 19–60) Moxifloxacin for 6 weeks (day 19–60) Recovery, neurological outcomes not reported
Our case 25 + 6 weeks 7 days Lethargy, tachycardia, generalized seizures 16S RNA PCR Ampicillin and Gentamycin (day 1–2) Azithromycin (day 3–6) Vancomycin and cefotaxime (day 7–10) Doxycycline for 6 weeks (day 10–52) Moxifloxacin for 6 weeks (day 10–52) Recovery with normal neurological examination at discharge, follow up at 6 months showed normal neurological examination
Evidence from previously published cases show that 28 % neonates with Mycoplasma Hominis CNS infection died whereas 34 % had some CNS complications and 28 % cases developed some neurological sequelae mostly hemiparesis [3]. In our case, treatment with a combination therapy of Moxifloxacin and Doxycycline resulted in significant clinical and laboratory improvement in terms of negative CSF culture after 48 hours of initiating this regimen and decreased WBC count and protein in subsequent CSF analysis. Our patient was discharged home with a normal neurological examination and stable ventriculomegaly. His neurodevelopmental follow up at six months of age showed normal neurological findings.
It is important to consider Mycoplasma Hominis as a potential cause for neonatal meningitis in infants particularly those with previous colonization with this rare but devastating species. Our case demonstrates effective eradication of Mycoplasma Hominis with a combination therapy of Moxifloxacin and Doxycycline. However, further research is required to understand the pharmacokinetics of these antibiotics to establish optimal dosing and duration for effective treatment of CNS infections with Mycoplasma Hominis.
Abbreviations
G2P1Gravida2, Parity1
PCRPolymerase chain reaction
RNARibonucleic acid
IVFIn vitro fertilization
CSFCerebrospinal fluid
RBCRed blood cells
WBCWhite blood cells
CNSCentral nervous system
VDRLVenereal disease research laboratory test
NICUNeonatal intensive care unit
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Acknowledgements
Not applicable.
Authors’ contributions
NSA, EA, and AR conceptualized the idea of writing this case report. NSA drafted the initial manuscript which was revised by AR and EA. AR and EA supervised the literature review for this case study, critically reviewed the manuscript, and approved the final version.
Funding
No funding received from any public, commercial or non-profit organization.
Availability of data and materials
Not applicable.
Ethics approval and consent to participate
None.
Consent for publication
Written informed consent was obtained from patient’s parents for publication of this case report.
Competing interests
The authors declare that they have no competing interests. | AZITHROMYCIN, CEFOTAXIME SODIUM, VANCOMYCIN HYDROCHLORIDE | DrugsGivenReaction | CC BY | 33557784 | 18,988,595 | 2021-02-08 |
Give an alphabetized list of all active substances of drugs taken by the patient who experienced 'Haemorrhagic cerebral infarction'. | Mycoplasma hominis meningitis in an extremely preterm newborn: a case report.
Mycoplasma Hominis is a micro-organism which is a part of the human genitourinary tract flora. Neonates are susceptible to acquire this pathogen either in utero or through vertical transmission. In rare cases, it may cause central nervous system infections with severe morbidity and mortality in preterm and term neonates.
We present a case of Mycoplasma Hominis meningitis in an extremely preterm neonate who presented with lethargy, tachycardia and seizures on day 7 of life. There was no history of maternal systemic or genitourinary infection during pregnancy and at the time of delivery. Empirical antibiotic therapy for neonatal meningitis was commenced after sending blood and cerebrospinal fluid cultures. Cerebrospinal fluid analysis showed pleocytosis with neutrophilic predominance, but no bacteria was identified on gram staining. Blood culture yielded no growth of any bacterial pathogen. However, growth of Mycoplasma Hominis was suspected in cerebrospinal fluid culture which was confirmed by 16S ribosomal ribonucleic acid (RNA) polymerase chain reaction analysis. Subsequently, antibiotics were changed to Moxifloxacin and Doxycycline which were given for a total duration of 6 weeks. Multiple cerebrospinal fluid cultures were performed during this treatment. No growth of any pathogen was identified on any of these cerebrospinal fluid cultures.
We report a rare case of Mycoplasma Hominis meningitis in an extremely preterm neonate which was successfully treated with a combination therapy of Moxifloxacin and Doxycycline. It is important to consider the possibility of Mycoplasma Hominis meningitis in neonates who present with clinical signs and pleocytosis in cerebrospinal fluid but negative gram staining and no growth on conventional culture media.
Background
Mycoplasma Hominis is a frequent habitant of the human genital tract [1]. Neonates are susceptible to acquire this microbe either in utero or through the colonized birth canal during the process of parturition [2]. However, invasive infections with this organism in preterm and term infants are noted to be rare [1, 3]. We describe an unusual case of neonatal meningitis due to Mycoplasma Hominis, confirmed in bacterial cultures and 16s ribosomal RNA Polymerase chain reaction (PCR) analysis. This case report demonstrates the importance of suspecting Mycoplasma Hominis as a cause of central nervous system (CNS) infection in neonates who present with clinical signs but no growth on conventional bacterial cultures and no improvement on empirical antibiotic treatment.
Case presentation
A male neonate was born at 25 + 6 weeks of gestation to 35 years old gravida 2, parity1 (G2P1) mother with antiphospholipid antibody syndrome. This was an in vitro fertilization (IVF) pregnancy. She was Rubella immune and negative for Hepatitis B surface antigen, Venereal disease research laboratory test (VDRL), Human immunodeficiency virus, Gonococci and Chlamydia. Her urine culture and vaginal swab for Group B Streptococci was also negative. Her anatomy scan at 18 weeks of gestation showed normal fetal anatomy and a short cervix for which she underwent cervical cerclage placement at 20 + 5 weeks gestation. There was no history of chorioamnionitis or prolonged rupture of membranes. She presented at 25 + 5 weeks with preterm labor and had a spontaneous vaginal delivery the next day. She had received two doses of Betamethasone and Magnesium sulphate prior to delivery. He initially required positive pressure ventilation followed by intubation and surfactant administration with an acceptable response. Umbilical arterial and venous catheters were placed and the neonate was transferred to neonatal intensive care unit (NICU) in a stable condition.
A blood culture was drawn at birth and empiric treatment with Ampicillin and Gentamicin was intiated. The antibiotics were discontinued after 36 hours as the blood culture showed no growth and he remained clinically stable. In addition, as per unit protocol, an endotracheal aspirate was sent for a Ureaplasma culture on admission. This grew a Mycoplasma species for which 3 days of intravenous Azithromycin was given.
A head ultrasound on day 4 of life showed bilateral intraventricular hemorrhage (grade 3) with mild ventriculomegaly and a hemorrhagic venous infarct in the right frontoparietal region. Umbilical arterial catheter was removed on day 4 of life whereas umbilical venous catheter was removed on day 6 of life. He remained stable till day 7 of life when he presented with an acute clinical deterioration presenting as lethargy and tachycardia; a septic work up including blood and cerebrospinal fluid (CSF) cultures was completed and Vancomycin and Cefotaxime were started as empiric antibiotics. His CSF analysis showed red blood cells (RBC) count of 4887 × 10E6/l, pleocytosis of white blood cells (WBC) 9620 × 10E6/l with neutrophilic predominance, hyperproteorachia - protein 8300 mg/l and hypoglycorachia - glucose 0.1 mmoles/liter. Gram staining in CSF was negative. Within hours he developed generalized clinical seizures which was treated with Lorazepam and Phenobarbital followed by a Levetiracetam load and maintenance dose. He had further episodes of clinical and subclinical seizures which resolved after further adjustment of levetiracetam doses.
His first CSF culture was suspected to grow Mycoplasma Hominis and was sent to the regional national diagnostic laboratory for confirmation. The CSF culture was repeated along with a sample for 16s ribosomal RNA PCR analyses. The 16s ribosomal RNA PCR analysis confirmed Mycoplasma hominis in both CSF samples. Antibiotics were then changed to Moxifloxacin and Doxycycline. The repeat CSF culture after 48 hours of Moxifloxacin and Doxycycline showed no growth. CSF analysis done seven days after starting this treatment showed RBC 5650 × 10E6/l, WBC 449 × 10E6/l, protein 3763 mg/l and glucose 0.2 mmoles/liter. Subsequent CSF findings repeated after another three days showed further improvement, RBC 7187 × 10E6/l, WBC 93 × 10E6/l, protein 3691 mg/l and glucose 0.5 mmoles/liter. No growth was seen on any of these CSF cultures. Serial head ultrasound scans were done which showed progressive ventriculomegaly, post hemorrhagic ventricular dilatation and cystic evolution of hemorrhagic/venous infarct in the right frontoparietal region. Although these findings could be attributed to extreme prematurity; there is a likelihood that infection with Mycoplasma Hominis may have played a role in its progression. There have been documented cases of Mycoplasma Hominis meningitis resulting in CNS complications including intraventricular and periventricular hemorrhage, hydrocephalus, and infarction [3]. Lumbar taps were repeated as therapeutic measure to reduce ventriculomegaly, but optimal volumes of CSF were not obtained. Because of the ventriculomegaly, he was evaluated for a possible shunt on day 31; this was deferred because of the stable ventriculomegaly.
Antibiotics were given for a total duration of six weeks after which he was discharged home with a normal neurological examination. He was referred to Neurodevelopmental clinic for follow-up.
Discussion and conclusion
Neonatal CNS infections with Mycoplasma Hominis, although rare, can cause severe morbidity and mortality in neonates [1]. In a case series of 29 neonates with Mycoplasma Hominis infection (age of presentation day1-32 of life), Hata and colleagues reported complications such as brain abscess, hydrocephalus, infarction, cerebritis and periventricular/intraventricular hemorrhage in 34 % cases, death in 28 % and sequelae mostly hemiparesis in another 28 % cases [3]. This may be attributed to a delay in diagnosis, ineffective antibiotic treatment, or suboptimal treatment regimens for neonatal CNS disease [3, 4]. Therefore, prompt diagnosis, early initiation and optimal duration of appropriate antibiotic therapy is necessary for a favorable prognosis.
The clinical presentation may include apnea, temperature instability, lethargy, vomiting, irritability poor tone, twitching or seizures [7]. Detection of Mycoplasma Hominis can be challenging since they lack peptidoglycan cell wall which renders them unidentifiable by gram staining [5]. In addition to this, they grow very slowly on routine culture media and require a specific blood agar medium for their detection [1, 6]. Due to this, there is a likelihood that Mycoplasma Hominis infections may remain undiagnosed or diagnosed late in infants presenting with clinical signs and symptoms [2]. Hence, it is important to consider the possibility of Mycoplasma Hominis infection in cases where the CSF shows pleocytosis and no growth of organism on routine culture media. A 16S ribosomal RNA PCR analysis has proven useful for detection of Mycoplasma Hominis in blood and CSF which are difficult to grow on standard culture media [7, 8]. The microbe is identified by direct sequencing analysis after amplification by PCR. Use of pathogen-specific primers in 16S RNA analysis results in rapid detection of the specific organism [4]. Prematurity, low birth weight, and neural tube defects are recognized to be the most common risk factors for neonatal meningitis with Mycoplasma Hominis [6]. However, it has also been seen in term neonates with no neurological birth malformations [1, 3].
The treatment options for Mycoplasma Hominis meningitis and its duration remains unclear [1, 9]. Due to the rarity of this infection in neonates, the current recommendations are based on clinical experiences and in-vitro susceptibility test results [9, 10].
Mycoplasma Hominis has shown susceptibility to Chloramphenicol, Tetracyclines, Lincosamide and Fluoroquinolones in in-vitro testing [11]. Fluoroquinolones have been used in past to treat neonatal mycoplasma hominins meningitis successfully [1, 3, 5]. Moxifloxacin, a fourth-generation fluoroquinolone is preferred because of its ability to concentrate in CSF and its bactericidal effects in CNS infections [1, 12, 13]. Although there are cases which were successfully treated with Moxifloxacin monotherapy [1, 6], there is a risk of development of resistance with fluoroquinolones during treatment [9, 14, 15]. Our literature search revealed only two reported cases of neonates who were given Moxifloxacin in combination with another antibiotic for Mycoplasma Hominis meningitis [3, 5] (Table 1).
Table 1 Characteristics of neonates treated with combination therapy (Moxifloxacin and another antibiotic) for Mycoplasma Hominis CNS infection
Gestational Age Age at presentation Clinical presentation Confirmation of diagnosis Empirical antibiotic therapy and duration Antibiotics for Mycoplasma Hominis Outcome
Hata and colleagues3 38 weeks 25 days Fever, vomiting, focal seizures 16S RNA PCR Ampicillin & Cefotaxime (day 1–2) Ciprofloxacin (day 6–17) Acyclovir (day 6–8) Chloramphenicol (day 8–17) Minocycline for 28 days (day 6–34) Moxifloxacin for 17 days (day 17–34) Recovery with left hemiplegia
Watt and colleagues5 26 weeks 7 days Apnea, hypotonia, generalized seizures 16S RNA PCR Ampicillin and Gentamycin (day1-8) Ceftazidime (day 1–5 ) Vancomycin (day 8–19 ) Acyclovir (day 8–19) Meropenem (day 12–19 ) Doxycycline for 6 weeks (day 19–60) Moxifloxacin for 6 weeks (day 19–60) Recovery, neurological outcomes not reported
Our case 25 + 6 weeks 7 days Lethargy, tachycardia, generalized seizures 16S RNA PCR Ampicillin and Gentamycin (day 1–2) Azithromycin (day 3–6) Vancomycin and cefotaxime (day 7–10) Doxycycline for 6 weeks (day 10–52) Moxifloxacin for 6 weeks (day 10–52) Recovery with normal neurological examination at discharge, follow up at 6 months showed normal neurological examination
Evidence from previously published cases show that 28 % neonates with Mycoplasma Hominis CNS infection died whereas 34 % had some CNS complications and 28 % cases developed some neurological sequelae mostly hemiparesis [3]. In our case, treatment with a combination therapy of Moxifloxacin and Doxycycline resulted in significant clinical and laboratory improvement in terms of negative CSF culture after 48 hours of initiating this regimen and decreased WBC count and protein in subsequent CSF analysis. Our patient was discharged home with a normal neurological examination and stable ventriculomegaly. His neurodevelopmental follow up at six months of age showed normal neurological findings.
It is important to consider Mycoplasma Hominis as a potential cause for neonatal meningitis in infants particularly those with previous colonization with this rare but devastating species. Our case demonstrates effective eradication of Mycoplasma Hominis with a combination therapy of Moxifloxacin and Doxycycline. However, further research is required to understand the pharmacokinetics of these antibiotics to establish optimal dosing and duration for effective treatment of CNS infections with Mycoplasma Hominis.
Abbreviations
G2P1Gravida2, Parity1
PCRPolymerase chain reaction
RNARibonucleic acid
IVFIn vitro fertilization
CSFCerebrospinal fluid
RBCRed blood cells
WBCWhite blood cells
CNSCentral nervous system
VDRLVenereal disease research laboratory test
NICUNeonatal intensive care unit
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Acknowledgements
Not applicable.
Authors’ contributions
NSA, EA, and AR conceptualized the idea of writing this case report. NSA drafted the initial manuscript which was revised by AR and EA. AR and EA supervised the literature review for this case study, critically reviewed the manuscript, and approved the final version.
Funding
No funding received from any public, commercial or non-profit organization.
Availability of data and materials
Not applicable.
Ethics approval and consent to participate
None.
Consent for publication
Written informed consent was obtained from patient’s parents for publication of this case report.
Competing interests
The authors declare that they have no competing interests. | AZITHROMYCIN, CEFOTAXIME SODIUM, VANCOMYCIN HYDROCHLORIDE | DrugsGivenReaction | CC BY | 33557784 | 18,988,595 | 2021-02-08 |
Give an alphabetized list of all active substances of drugs taken by the patient who experienced 'Intraventricular haemorrhage neonatal'. | Mycoplasma hominis meningitis in an extremely preterm newborn: a case report.
Mycoplasma Hominis is a micro-organism which is a part of the human genitourinary tract flora. Neonates are susceptible to acquire this pathogen either in utero or through vertical transmission. In rare cases, it may cause central nervous system infections with severe morbidity and mortality in preterm and term neonates.
We present a case of Mycoplasma Hominis meningitis in an extremely preterm neonate who presented with lethargy, tachycardia and seizures on day 7 of life. There was no history of maternal systemic or genitourinary infection during pregnancy and at the time of delivery. Empirical antibiotic therapy for neonatal meningitis was commenced after sending blood and cerebrospinal fluid cultures. Cerebrospinal fluid analysis showed pleocytosis with neutrophilic predominance, but no bacteria was identified on gram staining. Blood culture yielded no growth of any bacterial pathogen. However, growth of Mycoplasma Hominis was suspected in cerebrospinal fluid culture which was confirmed by 16S ribosomal ribonucleic acid (RNA) polymerase chain reaction analysis. Subsequently, antibiotics were changed to Moxifloxacin and Doxycycline which were given for a total duration of 6 weeks. Multiple cerebrospinal fluid cultures were performed during this treatment. No growth of any pathogen was identified on any of these cerebrospinal fluid cultures.
We report a rare case of Mycoplasma Hominis meningitis in an extremely preterm neonate which was successfully treated with a combination therapy of Moxifloxacin and Doxycycline. It is important to consider the possibility of Mycoplasma Hominis meningitis in neonates who present with clinical signs and pleocytosis in cerebrospinal fluid but negative gram staining and no growth on conventional culture media.
Background
Mycoplasma Hominis is a frequent habitant of the human genital tract [1]. Neonates are susceptible to acquire this microbe either in utero or through the colonized birth canal during the process of parturition [2]. However, invasive infections with this organism in preterm and term infants are noted to be rare [1, 3]. We describe an unusual case of neonatal meningitis due to Mycoplasma Hominis, confirmed in bacterial cultures and 16s ribosomal RNA Polymerase chain reaction (PCR) analysis. This case report demonstrates the importance of suspecting Mycoplasma Hominis as a cause of central nervous system (CNS) infection in neonates who present with clinical signs but no growth on conventional bacterial cultures and no improvement on empirical antibiotic treatment.
Case presentation
A male neonate was born at 25 + 6 weeks of gestation to 35 years old gravida 2, parity1 (G2P1) mother with antiphospholipid antibody syndrome. This was an in vitro fertilization (IVF) pregnancy. She was Rubella immune and negative for Hepatitis B surface antigen, Venereal disease research laboratory test (VDRL), Human immunodeficiency virus, Gonococci and Chlamydia. Her urine culture and vaginal swab for Group B Streptococci was also negative. Her anatomy scan at 18 weeks of gestation showed normal fetal anatomy and a short cervix for which she underwent cervical cerclage placement at 20 + 5 weeks gestation. There was no history of chorioamnionitis or prolonged rupture of membranes. She presented at 25 + 5 weeks with preterm labor and had a spontaneous vaginal delivery the next day. She had received two doses of Betamethasone and Magnesium sulphate prior to delivery. He initially required positive pressure ventilation followed by intubation and surfactant administration with an acceptable response. Umbilical arterial and venous catheters were placed and the neonate was transferred to neonatal intensive care unit (NICU) in a stable condition.
A blood culture was drawn at birth and empiric treatment with Ampicillin and Gentamicin was intiated. The antibiotics were discontinued after 36 hours as the blood culture showed no growth and he remained clinically stable. In addition, as per unit protocol, an endotracheal aspirate was sent for a Ureaplasma culture on admission. This grew a Mycoplasma species for which 3 days of intravenous Azithromycin was given.
A head ultrasound on day 4 of life showed bilateral intraventricular hemorrhage (grade 3) with mild ventriculomegaly and a hemorrhagic venous infarct in the right frontoparietal region. Umbilical arterial catheter was removed on day 4 of life whereas umbilical venous catheter was removed on day 6 of life. He remained stable till day 7 of life when he presented with an acute clinical deterioration presenting as lethargy and tachycardia; a septic work up including blood and cerebrospinal fluid (CSF) cultures was completed and Vancomycin and Cefotaxime were started as empiric antibiotics. His CSF analysis showed red blood cells (RBC) count of 4887 × 10E6/l, pleocytosis of white blood cells (WBC) 9620 × 10E6/l with neutrophilic predominance, hyperproteorachia - protein 8300 mg/l and hypoglycorachia - glucose 0.1 mmoles/liter. Gram staining in CSF was negative. Within hours he developed generalized clinical seizures which was treated with Lorazepam and Phenobarbital followed by a Levetiracetam load and maintenance dose. He had further episodes of clinical and subclinical seizures which resolved after further adjustment of levetiracetam doses.
His first CSF culture was suspected to grow Mycoplasma Hominis and was sent to the regional national diagnostic laboratory for confirmation. The CSF culture was repeated along with a sample for 16s ribosomal RNA PCR analyses. The 16s ribosomal RNA PCR analysis confirmed Mycoplasma hominis in both CSF samples. Antibiotics were then changed to Moxifloxacin and Doxycycline. The repeat CSF culture after 48 hours of Moxifloxacin and Doxycycline showed no growth. CSF analysis done seven days after starting this treatment showed RBC 5650 × 10E6/l, WBC 449 × 10E6/l, protein 3763 mg/l and glucose 0.2 mmoles/liter. Subsequent CSF findings repeated after another three days showed further improvement, RBC 7187 × 10E6/l, WBC 93 × 10E6/l, protein 3691 mg/l and glucose 0.5 mmoles/liter. No growth was seen on any of these CSF cultures. Serial head ultrasound scans were done which showed progressive ventriculomegaly, post hemorrhagic ventricular dilatation and cystic evolution of hemorrhagic/venous infarct in the right frontoparietal region. Although these findings could be attributed to extreme prematurity; there is a likelihood that infection with Mycoplasma Hominis may have played a role in its progression. There have been documented cases of Mycoplasma Hominis meningitis resulting in CNS complications including intraventricular and periventricular hemorrhage, hydrocephalus, and infarction [3]. Lumbar taps were repeated as therapeutic measure to reduce ventriculomegaly, but optimal volumes of CSF were not obtained. Because of the ventriculomegaly, he was evaluated for a possible shunt on day 31; this was deferred because of the stable ventriculomegaly.
Antibiotics were given for a total duration of six weeks after which he was discharged home with a normal neurological examination. He was referred to Neurodevelopmental clinic for follow-up.
Discussion and conclusion
Neonatal CNS infections with Mycoplasma Hominis, although rare, can cause severe morbidity and mortality in neonates [1]. In a case series of 29 neonates with Mycoplasma Hominis infection (age of presentation day1-32 of life), Hata and colleagues reported complications such as brain abscess, hydrocephalus, infarction, cerebritis and periventricular/intraventricular hemorrhage in 34 % cases, death in 28 % and sequelae mostly hemiparesis in another 28 % cases [3]. This may be attributed to a delay in diagnosis, ineffective antibiotic treatment, or suboptimal treatment regimens for neonatal CNS disease [3, 4]. Therefore, prompt diagnosis, early initiation and optimal duration of appropriate antibiotic therapy is necessary for a favorable prognosis.
The clinical presentation may include apnea, temperature instability, lethargy, vomiting, irritability poor tone, twitching or seizures [7]. Detection of Mycoplasma Hominis can be challenging since they lack peptidoglycan cell wall which renders them unidentifiable by gram staining [5]. In addition to this, they grow very slowly on routine culture media and require a specific blood agar medium for their detection [1, 6]. Due to this, there is a likelihood that Mycoplasma Hominis infections may remain undiagnosed or diagnosed late in infants presenting with clinical signs and symptoms [2]. Hence, it is important to consider the possibility of Mycoplasma Hominis infection in cases where the CSF shows pleocytosis and no growth of organism on routine culture media. A 16S ribosomal RNA PCR analysis has proven useful for detection of Mycoplasma Hominis in blood and CSF which are difficult to grow on standard culture media [7, 8]. The microbe is identified by direct sequencing analysis after amplification by PCR. Use of pathogen-specific primers in 16S RNA analysis results in rapid detection of the specific organism [4]. Prematurity, low birth weight, and neural tube defects are recognized to be the most common risk factors for neonatal meningitis with Mycoplasma Hominis [6]. However, it has also been seen in term neonates with no neurological birth malformations [1, 3].
The treatment options for Mycoplasma Hominis meningitis and its duration remains unclear [1, 9]. Due to the rarity of this infection in neonates, the current recommendations are based on clinical experiences and in-vitro susceptibility test results [9, 10].
Mycoplasma Hominis has shown susceptibility to Chloramphenicol, Tetracyclines, Lincosamide and Fluoroquinolones in in-vitro testing [11]. Fluoroquinolones have been used in past to treat neonatal mycoplasma hominins meningitis successfully [1, 3, 5]. Moxifloxacin, a fourth-generation fluoroquinolone is preferred because of its ability to concentrate in CSF and its bactericidal effects in CNS infections [1, 12, 13]. Although there are cases which were successfully treated with Moxifloxacin monotherapy [1, 6], there is a risk of development of resistance with fluoroquinolones during treatment [9, 14, 15]. Our literature search revealed only two reported cases of neonates who were given Moxifloxacin in combination with another antibiotic for Mycoplasma Hominis meningitis [3, 5] (Table 1).
Table 1 Characteristics of neonates treated with combination therapy (Moxifloxacin and another antibiotic) for Mycoplasma Hominis CNS infection
Gestational Age Age at presentation Clinical presentation Confirmation of diagnosis Empirical antibiotic therapy and duration Antibiotics for Mycoplasma Hominis Outcome
Hata and colleagues3 38 weeks 25 days Fever, vomiting, focal seizures 16S RNA PCR Ampicillin & Cefotaxime (day 1–2) Ciprofloxacin (day 6–17) Acyclovir (day 6–8) Chloramphenicol (day 8–17) Minocycline for 28 days (day 6–34) Moxifloxacin for 17 days (day 17–34) Recovery with left hemiplegia
Watt and colleagues5 26 weeks 7 days Apnea, hypotonia, generalized seizures 16S RNA PCR Ampicillin and Gentamycin (day1-8) Ceftazidime (day 1–5 ) Vancomycin (day 8–19 ) Acyclovir (day 8–19) Meropenem (day 12–19 ) Doxycycline for 6 weeks (day 19–60) Moxifloxacin for 6 weeks (day 19–60) Recovery, neurological outcomes not reported
Our case 25 + 6 weeks 7 days Lethargy, tachycardia, generalized seizures 16S RNA PCR Ampicillin and Gentamycin (day 1–2) Azithromycin (day 3–6) Vancomycin and cefotaxime (day 7–10) Doxycycline for 6 weeks (day 10–52) Moxifloxacin for 6 weeks (day 10–52) Recovery with normal neurological examination at discharge, follow up at 6 months showed normal neurological examination
Evidence from previously published cases show that 28 % neonates with Mycoplasma Hominis CNS infection died whereas 34 % had some CNS complications and 28 % cases developed some neurological sequelae mostly hemiparesis [3]. In our case, treatment with a combination therapy of Moxifloxacin and Doxycycline resulted in significant clinical and laboratory improvement in terms of negative CSF culture after 48 hours of initiating this regimen and decreased WBC count and protein in subsequent CSF analysis. Our patient was discharged home with a normal neurological examination and stable ventriculomegaly. His neurodevelopmental follow up at six months of age showed normal neurological findings.
It is important to consider Mycoplasma Hominis as a potential cause for neonatal meningitis in infants particularly those with previous colonization with this rare but devastating species. Our case demonstrates effective eradication of Mycoplasma Hominis with a combination therapy of Moxifloxacin and Doxycycline. However, further research is required to understand the pharmacokinetics of these antibiotics to establish optimal dosing and duration for effective treatment of CNS infections with Mycoplasma Hominis.
Abbreviations
G2P1Gravida2, Parity1
PCRPolymerase chain reaction
RNARibonucleic acid
IVFIn vitro fertilization
CSFCerebrospinal fluid
RBCRed blood cells
WBCWhite blood cells
CNSCentral nervous system
VDRLVenereal disease research laboratory test
NICUNeonatal intensive care unit
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Acknowledgements
Not applicable.
Authors’ contributions
NSA, EA, and AR conceptualized the idea of writing this case report. NSA drafted the initial manuscript which was revised by AR and EA. AR and EA supervised the literature review for this case study, critically reviewed the manuscript, and approved the final version.
Funding
No funding received from any public, commercial or non-profit organization.
Availability of data and materials
Not applicable.
Ethics approval and consent to participate
None.
Consent for publication
Written informed consent was obtained from patient’s parents for publication of this case report.
Competing interests
The authors declare that they have no competing interests. | AZITHROMYCIN, CEFOTAXIME SODIUM, VANCOMYCIN HYDROCHLORIDE | DrugsGivenReaction | CC BY | 33557784 | 18,988,595 | 2021-02-08 |
Give an alphabetized list of all active substances of drugs taken by the patient who experienced 'Lethargy'. | Mycoplasma hominis meningitis in an extremely preterm newborn: a case report.
Mycoplasma Hominis is a micro-organism which is a part of the human genitourinary tract flora. Neonates are susceptible to acquire this pathogen either in utero or through vertical transmission. In rare cases, it may cause central nervous system infections with severe morbidity and mortality in preterm and term neonates.
We present a case of Mycoplasma Hominis meningitis in an extremely preterm neonate who presented with lethargy, tachycardia and seizures on day 7 of life. There was no history of maternal systemic or genitourinary infection during pregnancy and at the time of delivery. Empirical antibiotic therapy for neonatal meningitis was commenced after sending blood and cerebrospinal fluid cultures. Cerebrospinal fluid analysis showed pleocytosis with neutrophilic predominance, but no bacteria was identified on gram staining. Blood culture yielded no growth of any bacterial pathogen. However, growth of Mycoplasma Hominis was suspected in cerebrospinal fluid culture which was confirmed by 16S ribosomal ribonucleic acid (RNA) polymerase chain reaction analysis. Subsequently, antibiotics were changed to Moxifloxacin and Doxycycline which were given for a total duration of 6 weeks. Multiple cerebrospinal fluid cultures were performed during this treatment. No growth of any pathogen was identified on any of these cerebrospinal fluid cultures.
We report a rare case of Mycoplasma Hominis meningitis in an extremely preterm neonate which was successfully treated with a combination therapy of Moxifloxacin and Doxycycline. It is important to consider the possibility of Mycoplasma Hominis meningitis in neonates who present with clinical signs and pleocytosis in cerebrospinal fluid but negative gram staining and no growth on conventional culture media.
Background
Mycoplasma Hominis is a frequent habitant of the human genital tract [1]. Neonates are susceptible to acquire this microbe either in utero or through the colonized birth canal during the process of parturition [2]. However, invasive infections with this organism in preterm and term infants are noted to be rare [1, 3]. We describe an unusual case of neonatal meningitis due to Mycoplasma Hominis, confirmed in bacterial cultures and 16s ribosomal RNA Polymerase chain reaction (PCR) analysis. This case report demonstrates the importance of suspecting Mycoplasma Hominis as a cause of central nervous system (CNS) infection in neonates who present with clinical signs but no growth on conventional bacterial cultures and no improvement on empirical antibiotic treatment.
Case presentation
A male neonate was born at 25 + 6 weeks of gestation to 35 years old gravida 2, parity1 (G2P1) mother with antiphospholipid antibody syndrome. This was an in vitro fertilization (IVF) pregnancy. She was Rubella immune and negative for Hepatitis B surface antigen, Venereal disease research laboratory test (VDRL), Human immunodeficiency virus, Gonococci and Chlamydia. Her urine culture and vaginal swab for Group B Streptococci was also negative. Her anatomy scan at 18 weeks of gestation showed normal fetal anatomy and a short cervix for which she underwent cervical cerclage placement at 20 + 5 weeks gestation. There was no history of chorioamnionitis or prolonged rupture of membranes. She presented at 25 + 5 weeks with preterm labor and had a spontaneous vaginal delivery the next day. She had received two doses of Betamethasone and Magnesium sulphate prior to delivery. He initially required positive pressure ventilation followed by intubation and surfactant administration with an acceptable response. Umbilical arterial and venous catheters were placed and the neonate was transferred to neonatal intensive care unit (NICU) in a stable condition.
A blood culture was drawn at birth and empiric treatment with Ampicillin and Gentamicin was intiated. The antibiotics were discontinued after 36 hours as the blood culture showed no growth and he remained clinically stable. In addition, as per unit protocol, an endotracheal aspirate was sent for a Ureaplasma culture on admission. This grew a Mycoplasma species for which 3 days of intravenous Azithromycin was given.
A head ultrasound on day 4 of life showed bilateral intraventricular hemorrhage (grade 3) with mild ventriculomegaly and a hemorrhagic venous infarct in the right frontoparietal region. Umbilical arterial catheter was removed on day 4 of life whereas umbilical venous catheter was removed on day 6 of life. He remained stable till day 7 of life when he presented with an acute clinical deterioration presenting as lethargy and tachycardia; a septic work up including blood and cerebrospinal fluid (CSF) cultures was completed and Vancomycin and Cefotaxime were started as empiric antibiotics. His CSF analysis showed red blood cells (RBC) count of 4887 × 10E6/l, pleocytosis of white blood cells (WBC) 9620 × 10E6/l with neutrophilic predominance, hyperproteorachia - protein 8300 mg/l and hypoglycorachia - glucose 0.1 mmoles/liter. Gram staining in CSF was negative. Within hours he developed generalized clinical seizures which was treated with Lorazepam and Phenobarbital followed by a Levetiracetam load and maintenance dose. He had further episodes of clinical and subclinical seizures which resolved after further adjustment of levetiracetam doses.
His first CSF culture was suspected to grow Mycoplasma Hominis and was sent to the regional national diagnostic laboratory for confirmation. The CSF culture was repeated along with a sample for 16s ribosomal RNA PCR analyses. The 16s ribosomal RNA PCR analysis confirmed Mycoplasma hominis in both CSF samples. Antibiotics were then changed to Moxifloxacin and Doxycycline. The repeat CSF culture after 48 hours of Moxifloxacin and Doxycycline showed no growth. CSF analysis done seven days after starting this treatment showed RBC 5650 × 10E6/l, WBC 449 × 10E6/l, protein 3763 mg/l and glucose 0.2 mmoles/liter. Subsequent CSF findings repeated after another three days showed further improvement, RBC 7187 × 10E6/l, WBC 93 × 10E6/l, protein 3691 mg/l and glucose 0.5 mmoles/liter. No growth was seen on any of these CSF cultures. Serial head ultrasound scans were done which showed progressive ventriculomegaly, post hemorrhagic ventricular dilatation and cystic evolution of hemorrhagic/venous infarct in the right frontoparietal region. Although these findings could be attributed to extreme prematurity; there is a likelihood that infection with Mycoplasma Hominis may have played a role in its progression. There have been documented cases of Mycoplasma Hominis meningitis resulting in CNS complications including intraventricular and periventricular hemorrhage, hydrocephalus, and infarction [3]. Lumbar taps were repeated as therapeutic measure to reduce ventriculomegaly, but optimal volumes of CSF were not obtained. Because of the ventriculomegaly, he was evaluated for a possible shunt on day 31; this was deferred because of the stable ventriculomegaly.
Antibiotics were given for a total duration of six weeks after which he was discharged home with a normal neurological examination. He was referred to Neurodevelopmental clinic for follow-up.
Discussion and conclusion
Neonatal CNS infections with Mycoplasma Hominis, although rare, can cause severe morbidity and mortality in neonates [1]. In a case series of 29 neonates with Mycoplasma Hominis infection (age of presentation day1-32 of life), Hata and colleagues reported complications such as brain abscess, hydrocephalus, infarction, cerebritis and periventricular/intraventricular hemorrhage in 34 % cases, death in 28 % and sequelae mostly hemiparesis in another 28 % cases [3]. This may be attributed to a delay in diagnosis, ineffective antibiotic treatment, or suboptimal treatment regimens for neonatal CNS disease [3, 4]. Therefore, prompt diagnosis, early initiation and optimal duration of appropriate antibiotic therapy is necessary for a favorable prognosis.
The clinical presentation may include apnea, temperature instability, lethargy, vomiting, irritability poor tone, twitching or seizures [7]. Detection of Mycoplasma Hominis can be challenging since they lack peptidoglycan cell wall which renders them unidentifiable by gram staining [5]. In addition to this, they grow very slowly on routine culture media and require a specific blood agar medium for their detection [1, 6]. Due to this, there is a likelihood that Mycoplasma Hominis infections may remain undiagnosed or diagnosed late in infants presenting with clinical signs and symptoms [2]. Hence, it is important to consider the possibility of Mycoplasma Hominis infection in cases where the CSF shows pleocytosis and no growth of organism on routine culture media. A 16S ribosomal RNA PCR analysis has proven useful for detection of Mycoplasma Hominis in blood and CSF which are difficult to grow on standard culture media [7, 8]. The microbe is identified by direct sequencing analysis after amplification by PCR. Use of pathogen-specific primers in 16S RNA analysis results in rapid detection of the specific organism [4]. Prematurity, low birth weight, and neural tube defects are recognized to be the most common risk factors for neonatal meningitis with Mycoplasma Hominis [6]. However, it has also been seen in term neonates with no neurological birth malformations [1, 3].
The treatment options for Mycoplasma Hominis meningitis and its duration remains unclear [1, 9]. Due to the rarity of this infection in neonates, the current recommendations are based on clinical experiences and in-vitro susceptibility test results [9, 10].
Mycoplasma Hominis has shown susceptibility to Chloramphenicol, Tetracyclines, Lincosamide and Fluoroquinolones in in-vitro testing [11]. Fluoroquinolones have been used in past to treat neonatal mycoplasma hominins meningitis successfully [1, 3, 5]. Moxifloxacin, a fourth-generation fluoroquinolone is preferred because of its ability to concentrate in CSF and its bactericidal effects in CNS infections [1, 12, 13]. Although there are cases which were successfully treated with Moxifloxacin monotherapy [1, 6], there is a risk of development of resistance with fluoroquinolones during treatment [9, 14, 15]. Our literature search revealed only two reported cases of neonates who were given Moxifloxacin in combination with another antibiotic for Mycoplasma Hominis meningitis [3, 5] (Table 1).
Table 1 Characteristics of neonates treated with combination therapy (Moxifloxacin and another antibiotic) for Mycoplasma Hominis CNS infection
Gestational Age Age at presentation Clinical presentation Confirmation of diagnosis Empirical antibiotic therapy and duration Antibiotics for Mycoplasma Hominis Outcome
Hata and colleagues3 38 weeks 25 days Fever, vomiting, focal seizures 16S RNA PCR Ampicillin & Cefotaxime (day 1–2) Ciprofloxacin (day 6–17) Acyclovir (day 6–8) Chloramphenicol (day 8–17) Minocycline for 28 days (day 6–34) Moxifloxacin for 17 days (day 17–34) Recovery with left hemiplegia
Watt and colleagues5 26 weeks 7 days Apnea, hypotonia, generalized seizures 16S RNA PCR Ampicillin and Gentamycin (day1-8) Ceftazidime (day 1–5 ) Vancomycin (day 8–19 ) Acyclovir (day 8–19) Meropenem (day 12–19 ) Doxycycline for 6 weeks (day 19–60) Moxifloxacin for 6 weeks (day 19–60) Recovery, neurological outcomes not reported
Our case 25 + 6 weeks 7 days Lethargy, tachycardia, generalized seizures 16S RNA PCR Ampicillin and Gentamycin (day 1–2) Azithromycin (day 3–6) Vancomycin and cefotaxime (day 7–10) Doxycycline for 6 weeks (day 10–52) Moxifloxacin for 6 weeks (day 10–52) Recovery with normal neurological examination at discharge, follow up at 6 months showed normal neurological examination
Evidence from previously published cases show that 28 % neonates with Mycoplasma Hominis CNS infection died whereas 34 % had some CNS complications and 28 % cases developed some neurological sequelae mostly hemiparesis [3]. In our case, treatment with a combination therapy of Moxifloxacin and Doxycycline resulted in significant clinical and laboratory improvement in terms of negative CSF culture after 48 hours of initiating this regimen and decreased WBC count and protein in subsequent CSF analysis. Our patient was discharged home with a normal neurological examination and stable ventriculomegaly. His neurodevelopmental follow up at six months of age showed normal neurological findings.
It is important to consider Mycoplasma Hominis as a potential cause for neonatal meningitis in infants particularly those with previous colonization with this rare but devastating species. Our case demonstrates effective eradication of Mycoplasma Hominis with a combination therapy of Moxifloxacin and Doxycycline. However, further research is required to understand the pharmacokinetics of these antibiotics to establish optimal dosing and duration for effective treatment of CNS infections with Mycoplasma Hominis.
Abbreviations
G2P1Gravida2, Parity1
PCRPolymerase chain reaction
RNARibonucleic acid
IVFIn vitro fertilization
CSFCerebrospinal fluid
RBCRed blood cells
WBCWhite blood cells
CNSCentral nervous system
VDRLVenereal disease research laboratory test
NICUNeonatal intensive care unit
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Acknowledgements
Not applicable.
Authors’ contributions
NSA, EA, and AR conceptualized the idea of writing this case report. NSA drafted the initial manuscript which was revised by AR and EA. AR and EA supervised the literature review for this case study, critically reviewed the manuscript, and approved the final version.
Funding
No funding received from any public, commercial or non-profit organization.
Availability of data and materials
Not applicable.
Ethics approval and consent to participate
None.
Consent for publication
Written informed consent was obtained from patient’s parents for publication of this case report.
Competing interests
The authors declare that they have no competing interests. | AZITHROMYCIN, CEFOTAXIME SODIUM, VANCOMYCIN HYDROCHLORIDE | DrugsGivenReaction | CC BY | 33557784 | 18,988,595 | 2021-02-08 |
Give an alphabetized list of all active substances of drugs taken by the patient who experienced 'Neonatal tachycardia'. | Mycoplasma hominis meningitis in an extremely preterm newborn: a case report.
Mycoplasma Hominis is a micro-organism which is a part of the human genitourinary tract flora. Neonates are susceptible to acquire this pathogen either in utero or through vertical transmission. In rare cases, it may cause central nervous system infections with severe morbidity and mortality in preterm and term neonates.
We present a case of Mycoplasma Hominis meningitis in an extremely preterm neonate who presented with lethargy, tachycardia and seizures on day 7 of life. There was no history of maternal systemic or genitourinary infection during pregnancy and at the time of delivery. Empirical antibiotic therapy for neonatal meningitis was commenced after sending blood and cerebrospinal fluid cultures. Cerebrospinal fluid analysis showed pleocytosis with neutrophilic predominance, but no bacteria was identified on gram staining. Blood culture yielded no growth of any bacterial pathogen. However, growth of Mycoplasma Hominis was suspected in cerebrospinal fluid culture which was confirmed by 16S ribosomal ribonucleic acid (RNA) polymerase chain reaction analysis. Subsequently, antibiotics were changed to Moxifloxacin and Doxycycline which were given for a total duration of 6 weeks. Multiple cerebrospinal fluid cultures were performed during this treatment. No growth of any pathogen was identified on any of these cerebrospinal fluid cultures.
We report a rare case of Mycoplasma Hominis meningitis in an extremely preterm neonate which was successfully treated with a combination therapy of Moxifloxacin and Doxycycline. It is important to consider the possibility of Mycoplasma Hominis meningitis in neonates who present with clinical signs and pleocytosis in cerebrospinal fluid but negative gram staining and no growth on conventional culture media.
Background
Mycoplasma Hominis is a frequent habitant of the human genital tract [1]. Neonates are susceptible to acquire this microbe either in utero or through the colonized birth canal during the process of parturition [2]. However, invasive infections with this organism in preterm and term infants are noted to be rare [1, 3]. We describe an unusual case of neonatal meningitis due to Mycoplasma Hominis, confirmed in bacterial cultures and 16s ribosomal RNA Polymerase chain reaction (PCR) analysis. This case report demonstrates the importance of suspecting Mycoplasma Hominis as a cause of central nervous system (CNS) infection in neonates who present with clinical signs but no growth on conventional bacterial cultures and no improvement on empirical antibiotic treatment.
Case presentation
A male neonate was born at 25 + 6 weeks of gestation to 35 years old gravida 2, parity1 (G2P1) mother with antiphospholipid antibody syndrome. This was an in vitro fertilization (IVF) pregnancy. She was Rubella immune and negative for Hepatitis B surface antigen, Venereal disease research laboratory test (VDRL), Human immunodeficiency virus, Gonococci and Chlamydia. Her urine culture and vaginal swab for Group B Streptococci was also negative. Her anatomy scan at 18 weeks of gestation showed normal fetal anatomy and a short cervix for which she underwent cervical cerclage placement at 20 + 5 weeks gestation. There was no history of chorioamnionitis or prolonged rupture of membranes. She presented at 25 + 5 weeks with preterm labor and had a spontaneous vaginal delivery the next day. She had received two doses of Betamethasone and Magnesium sulphate prior to delivery. He initially required positive pressure ventilation followed by intubation and surfactant administration with an acceptable response. Umbilical arterial and venous catheters were placed and the neonate was transferred to neonatal intensive care unit (NICU) in a stable condition.
A blood culture was drawn at birth and empiric treatment with Ampicillin and Gentamicin was intiated. The antibiotics were discontinued after 36 hours as the blood culture showed no growth and he remained clinically stable. In addition, as per unit protocol, an endotracheal aspirate was sent for a Ureaplasma culture on admission. This grew a Mycoplasma species for which 3 days of intravenous Azithromycin was given.
A head ultrasound on day 4 of life showed bilateral intraventricular hemorrhage (grade 3) with mild ventriculomegaly and a hemorrhagic venous infarct in the right frontoparietal region. Umbilical arterial catheter was removed on day 4 of life whereas umbilical venous catheter was removed on day 6 of life. He remained stable till day 7 of life when he presented with an acute clinical deterioration presenting as lethargy and tachycardia; a septic work up including blood and cerebrospinal fluid (CSF) cultures was completed and Vancomycin and Cefotaxime were started as empiric antibiotics. His CSF analysis showed red blood cells (RBC) count of 4887 × 10E6/l, pleocytosis of white blood cells (WBC) 9620 × 10E6/l with neutrophilic predominance, hyperproteorachia - protein 8300 mg/l and hypoglycorachia - glucose 0.1 mmoles/liter. Gram staining in CSF was negative. Within hours he developed generalized clinical seizures which was treated with Lorazepam and Phenobarbital followed by a Levetiracetam load and maintenance dose. He had further episodes of clinical and subclinical seizures which resolved after further adjustment of levetiracetam doses.
His first CSF culture was suspected to grow Mycoplasma Hominis and was sent to the regional national diagnostic laboratory for confirmation. The CSF culture was repeated along with a sample for 16s ribosomal RNA PCR analyses. The 16s ribosomal RNA PCR analysis confirmed Mycoplasma hominis in both CSF samples. Antibiotics were then changed to Moxifloxacin and Doxycycline. The repeat CSF culture after 48 hours of Moxifloxacin and Doxycycline showed no growth. CSF analysis done seven days after starting this treatment showed RBC 5650 × 10E6/l, WBC 449 × 10E6/l, protein 3763 mg/l and glucose 0.2 mmoles/liter. Subsequent CSF findings repeated after another three days showed further improvement, RBC 7187 × 10E6/l, WBC 93 × 10E6/l, protein 3691 mg/l and glucose 0.5 mmoles/liter. No growth was seen on any of these CSF cultures. Serial head ultrasound scans were done which showed progressive ventriculomegaly, post hemorrhagic ventricular dilatation and cystic evolution of hemorrhagic/venous infarct in the right frontoparietal region. Although these findings could be attributed to extreme prematurity; there is a likelihood that infection with Mycoplasma Hominis may have played a role in its progression. There have been documented cases of Mycoplasma Hominis meningitis resulting in CNS complications including intraventricular and periventricular hemorrhage, hydrocephalus, and infarction [3]. Lumbar taps were repeated as therapeutic measure to reduce ventriculomegaly, but optimal volumes of CSF were not obtained. Because of the ventriculomegaly, he was evaluated for a possible shunt on day 31; this was deferred because of the stable ventriculomegaly.
Antibiotics were given for a total duration of six weeks after which he was discharged home with a normal neurological examination. He was referred to Neurodevelopmental clinic for follow-up.
Discussion and conclusion
Neonatal CNS infections with Mycoplasma Hominis, although rare, can cause severe morbidity and mortality in neonates [1]. In a case series of 29 neonates with Mycoplasma Hominis infection (age of presentation day1-32 of life), Hata and colleagues reported complications such as brain abscess, hydrocephalus, infarction, cerebritis and periventricular/intraventricular hemorrhage in 34 % cases, death in 28 % and sequelae mostly hemiparesis in another 28 % cases [3]. This may be attributed to a delay in diagnosis, ineffective antibiotic treatment, or suboptimal treatment regimens for neonatal CNS disease [3, 4]. Therefore, prompt diagnosis, early initiation and optimal duration of appropriate antibiotic therapy is necessary for a favorable prognosis.
The clinical presentation may include apnea, temperature instability, lethargy, vomiting, irritability poor tone, twitching or seizures [7]. Detection of Mycoplasma Hominis can be challenging since they lack peptidoglycan cell wall which renders them unidentifiable by gram staining [5]. In addition to this, they grow very slowly on routine culture media and require a specific blood agar medium for their detection [1, 6]. Due to this, there is a likelihood that Mycoplasma Hominis infections may remain undiagnosed or diagnosed late in infants presenting with clinical signs and symptoms [2]. Hence, it is important to consider the possibility of Mycoplasma Hominis infection in cases where the CSF shows pleocytosis and no growth of organism on routine culture media. A 16S ribosomal RNA PCR analysis has proven useful for detection of Mycoplasma Hominis in blood and CSF which are difficult to grow on standard culture media [7, 8]. The microbe is identified by direct sequencing analysis after amplification by PCR. Use of pathogen-specific primers in 16S RNA analysis results in rapid detection of the specific organism [4]. Prematurity, low birth weight, and neural tube defects are recognized to be the most common risk factors for neonatal meningitis with Mycoplasma Hominis [6]. However, it has also been seen in term neonates with no neurological birth malformations [1, 3].
The treatment options for Mycoplasma Hominis meningitis and its duration remains unclear [1, 9]. Due to the rarity of this infection in neonates, the current recommendations are based on clinical experiences and in-vitro susceptibility test results [9, 10].
Mycoplasma Hominis has shown susceptibility to Chloramphenicol, Tetracyclines, Lincosamide and Fluoroquinolones in in-vitro testing [11]. Fluoroquinolones have been used in past to treat neonatal mycoplasma hominins meningitis successfully [1, 3, 5]. Moxifloxacin, a fourth-generation fluoroquinolone is preferred because of its ability to concentrate in CSF and its bactericidal effects in CNS infections [1, 12, 13]. Although there are cases which were successfully treated with Moxifloxacin monotherapy [1, 6], there is a risk of development of resistance with fluoroquinolones during treatment [9, 14, 15]. Our literature search revealed only two reported cases of neonates who were given Moxifloxacin in combination with another antibiotic for Mycoplasma Hominis meningitis [3, 5] (Table 1).
Table 1 Characteristics of neonates treated with combination therapy (Moxifloxacin and another antibiotic) for Mycoplasma Hominis CNS infection
Gestational Age Age at presentation Clinical presentation Confirmation of diagnosis Empirical antibiotic therapy and duration Antibiotics for Mycoplasma Hominis Outcome
Hata and colleagues3 38 weeks 25 days Fever, vomiting, focal seizures 16S RNA PCR Ampicillin & Cefotaxime (day 1–2) Ciprofloxacin (day 6–17) Acyclovir (day 6–8) Chloramphenicol (day 8–17) Minocycline for 28 days (day 6–34) Moxifloxacin for 17 days (day 17–34) Recovery with left hemiplegia
Watt and colleagues5 26 weeks 7 days Apnea, hypotonia, generalized seizures 16S RNA PCR Ampicillin and Gentamycin (day1-8) Ceftazidime (day 1–5 ) Vancomycin (day 8–19 ) Acyclovir (day 8–19) Meropenem (day 12–19 ) Doxycycline for 6 weeks (day 19–60) Moxifloxacin for 6 weeks (day 19–60) Recovery, neurological outcomes not reported
Our case 25 + 6 weeks 7 days Lethargy, tachycardia, generalized seizures 16S RNA PCR Ampicillin and Gentamycin (day 1–2) Azithromycin (day 3–6) Vancomycin and cefotaxime (day 7–10) Doxycycline for 6 weeks (day 10–52) Moxifloxacin for 6 weeks (day 10–52) Recovery with normal neurological examination at discharge, follow up at 6 months showed normal neurological examination
Evidence from previously published cases show that 28 % neonates with Mycoplasma Hominis CNS infection died whereas 34 % had some CNS complications and 28 % cases developed some neurological sequelae mostly hemiparesis [3]. In our case, treatment with a combination therapy of Moxifloxacin and Doxycycline resulted in significant clinical and laboratory improvement in terms of negative CSF culture after 48 hours of initiating this regimen and decreased WBC count and protein in subsequent CSF analysis. Our patient was discharged home with a normal neurological examination and stable ventriculomegaly. His neurodevelopmental follow up at six months of age showed normal neurological findings.
It is important to consider Mycoplasma Hominis as a potential cause for neonatal meningitis in infants particularly those with previous colonization with this rare but devastating species. Our case demonstrates effective eradication of Mycoplasma Hominis with a combination therapy of Moxifloxacin and Doxycycline. However, further research is required to understand the pharmacokinetics of these antibiotics to establish optimal dosing and duration for effective treatment of CNS infections with Mycoplasma Hominis.
Abbreviations
G2P1Gravida2, Parity1
PCRPolymerase chain reaction
RNARibonucleic acid
IVFIn vitro fertilization
CSFCerebrospinal fluid
RBCRed blood cells
WBCWhite blood cells
CNSCentral nervous system
VDRLVenereal disease research laboratory test
NICUNeonatal intensive care unit
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Acknowledgements
Not applicable.
Authors’ contributions
NSA, EA, and AR conceptualized the idea of writing this case report. NSA drafted the initial manuscript which was revised by AR and EA. AR and EA supervised the literature review for this case study, critically reviewed the manuscript, and approved the final version.
Funding
No funding received from any public, commercial or non-profit organization.
Availability of data and materials
Not applicable.
Ethics approval and consent to participate
None.
Consent for publication
Written informed consent was obtained from patient’s parents for publication of this case report.
Competing interests
The authors declare that they have no competing interests. | AZITHROMYCIN, CEFOTAXIME SODIUM, VANCOMYCIN HYDROCHLORIDE | DrugsGivenReaction | CC BY | 33557784 | 18,988,595 | 2021-02-08 |
Give an alphabetized list of all active substances of drugs taken by the patient who experienced 'Off label use'. | Mycoplasma hominis meningitis in an extremely preterm newborn: a case report.
Mycoplasma Hominis is a micro-organism which is a part of the human genitourinary tract flora. Neonates are susceptible to acquire this pathogen either in utero or through vertical transmission. In rare cases, it may cause central nervous system infections with severe morbidity and mortality in preterm and term neonates.
We present a case of Mycoplasma Hominis meningitis in an extremely preterm neonate who presented with lethargy, tachycardia and seizures on day 7 of life. There was no history of maternal systemic or genitourinary infection during pregnancy and at the time of delivery. Empirical antibiotic therapy for neonatal meningitis was commenced after sending blood and cerebrospinal fluid cultures. Cerebrospinal fluid analysis showed pleocytosis with neutrophilic predominance, but no bacteria was identified on gram staining. Blood culture yielded no growth of any bacterial pathogen. However, growth of Mycoplasma Hominis was suspected in cerebrospinal fluid culture which was confirmed by 16S ribosomal ribonucleic acid (RNA) polymerase chain reaction analysis. Subsequently, antibiotics were changed to Moxifloxacin and Doxycycline which were given for a total duration of 6 weeks. Multiple cerebrospinal fluid cultures were performed during this treatment. No growth of any pathogen was identified on any of these cerebrospinal fluid cultures.
We report a rare case of Mycoplasma Hominis meningitis in an extremely preterm neonate which was successfully treated with a combination therapy of Moxifloxacin and Doxycycline. It is important to consider the possibility of Mycoplasma Hominis meningitis in neonates who present with clinical signs and pleocytosis in cerebrospinal fluid but negative gram staining and no growth on conventional culture media.
Background
Mycoplasma Hominis is a frequent habitant of the human genital tract [1]. Neonates are susceptible to acquire this microbe either in utero or through the colonized birth canal during the process of parturition [2]. However, invasive infections with this organism in preterm and term infants are noted to be rare [1, 3]. We describe an unusual case of neonatal meningitis due to Mycoplasma Hominis, confirmed in bacterial cultures and 16s ribosomal RNA Polymerase chain reaction (PCR) analysis. This case report demonstrates the importance of suspecting Mycoplasma Hominis as a cause of central nervous system (CNS) infection in neonates who present with clinical signs but no growth on conventional bacterial cultures and no improvement on empirical antibiotic treatment.
Case presentation
A male neonate was born at 25 + 6 weeks of gestation to 35 years old gravida 2, parity1 (G2P1) mother with antiphospholipid antibody syndrome. This was an in vitro fertilization (IVF) pregnancy. She was Rubella immune and negative for Hepatitis B surface antigen, Venereal disease research laboratory test (VDRL), Human immunodeficiency virus, Gonococci and Chlamydia. Her urine culture and vaginal swab for Group B Streptococci was also negative. Her anatomy scan at 18 weeks of gestation showed normal fetal anatomy and a short cervix for which she underwent cervical cerclage placement at 20 + 5 weeks gestation. There was no history of chorioamnionitis or prolonged rupture of membranes. She presented at 25 + 5 weeks with preterm labor and had a spontaneous vaginal delivery the next day. She had received two doses of Betamethasone and Magnesium sulphate prior to delivery. He initially required positive pressure ventilation followed by intubation and surfactant administration with an acceptable response. Umbilical arterial and venous catheters were placed and the neonate was transferred to neonatal intensive care unit (NICU) in a stable condition.
A blood culture was drawn at birth and empiric treatment with Ampicillin and Gentamicin was intiated. The antibiotics were discontinued after 36 hours as the blood culture showed no growth and he remained clinically stable. In addition, as per unit protocol, an endotracheal aspirate was sent for a Ureaplasma culture on admission. This grew a Mycoplasma species for which 3 days of intravenous Azithromycin was given.
A head ultrasound on day 4 of life showed bilateral intraventricular hemorrhage (grade 3) with mild ventriculomegaly and a hemorrhagic venous infarct in the right frontoparietal region. Umbilical arterial catheter was removed on day 4 of life whereas umbilical venous catheter was removed on day 6 of life. He remained stable till day 7 of life when he presented with an acute clinical deterioration presenting as lethargy and tachycardia; a septic work up including blood and cerebrospinal fluid (CSF) cultures was completed and Vancomycin and Cefotaxime were started as empiric antibiotics. His CSF analysis showed red blood cells (RBC) count of 4887 × 10E6/l, pleocytosis of white blood cells (WBC) 9620 × 10E6/l with neutrophilic predominance, hyperproteorachia - protein 8300 mg/l and hypoglycorachia - glucose 0.1 mmoles/liter. Gram staining in CSF was negative. Within hours he developed generalized clinical seizures which was treated with Lorazepam and Phenobarbital followed by a Levetiracetam load and maintenance dose. He had further episodes of clinical and subclinical seizures which resolved after further adjustment of levetiracetam doses.
His first CSF culture was suspected to grow Mycoplasma Hominis and was sent to the regional national diagnostic laboratory for confirmation. The CSF culture was repeated along with a sample for 16s ribosomal RNA PCR analyses. The 16s ribosomal RNA PCR analysis confirmed Mycoplasma hominis in both CSF samples. Antibiotics were then changed to Moxifloxacin and Doxycycline. The repeat CSF culture after 48 hours of Moxifloxacin and Doxycycline showed no growth. CSF analysis done seven days after starting this treatment showed RBC 5650 × 10E6/l, WBC 449 × 10E6/l, protein 3763 mg/l and glucose 0.2 mmoles/liter. Subsequent CSF findings repeated after another three days showed further improvement, RBC 7187 × 10E6/l, WBC 93 × 10E6/l, protein 3691 mg/l and glucose 0.5 mmoles/liter. No growth was seen on any of these CSF cultures. Serial head ultrasound scans were done which showed progressive ventriculomegaly, post hemorrhagic ventricular dilatation and cystic evolution of hemorrhagic/venous infarct in the right frontoparietal region. Although these findings could be attributed to extreme prematurity; there is a likelihood that infection with Mycoplasma Hominis may have played a role in its progression. There have been documented cases of Mycoplasma Hominis meningitis resulting in CNS complications including intraventricular and periventricular hemorrhage, hydrocephalus, and infarction [3]. Lumbar taps were repeated as therapeutic measure to reduce ventriculomegaly, but optimal volumes of CSF were not obtained. Because of the ventriculomegaly, he was evaluated for a possible shunt on day 31; this was deferred because of the stable ventriculomegaly.
Antibiotics were given for a total duration of six weeks after which he was discharged home with a normal neurological examination. He was referred to Neurodevelopmental clinic for follow-up.
Discussion and conclusion
Neonatal CNS infections with Mycoplasma Hominis, although rare, can cause severe morbidity and mortality in neonates [1]. In a case series of 29 neonates with Mycoplasma Hominis infection (age of presentation day1-32 of life), Hata and colleagues reported complications such as brain abscess, hydrocephalus, infarction, cerebritis and periventricular/intraventricular hemorrhage in 34 % cases, death in 28 % and sequelae mostly hemiparesis in another 28 % cases [3]. This may be attributed to a delay in diagnosis, ineffective antibiotic treatment, or suboptimal treatment regimens for neonatal CNS disease [3, 4]. Therefore, prompt diagnosis, early initiation and optimal duration of appropriate antibiotic therapy is necessary for a favorable prognosis.
The clinical presentation may include apnea, temperature instability, lethargy, vomiting, irritability poor tone, twitching or seizures [7]. Detection of Mycoplasma Hominis can be challenging since they lack peptidoglycan cell wall which renders them unidentifiable by gram staining [5]. In addition to this, they grow very slowly on routine culture media and require a specific blood agar medium for their detection [1, 6]. Due to this, there is a likelihood that Mycoplasma Hominis infections may remain undiagnosed or diagnosed late in infants presenting with clinical signs and symptoms [2]. Hence, it is important to consider the possibility of Mycoplasma Hominis infection in cases where the CSF shows pleocytosis and no growth of organism on routine culture media. A 16S ribosomal RNA PCR analysis has proven useful for detection of Mycoplasma Hominis in blood and CSF which are difficult to grow on standard culture media [7, 8]. The microbe is identified by direct sequencing analysis after amplification by PCR. Use of pathogen-specific primers in 16S RNA analysis results in rapid detection of the specific organism [4]. Prematurity, low birth weight, and neural tube defects are recognized to be the most common risk factors for neonatal meningitis with Mycoplasma Hominis [6]. However, it has also been seen in term neonates with no neurological birth malformations [1, 3].
The treatment options for Mycoplasma Hominis meningitis and its duration remains unclear [1, 9]. Due to the rarity of this infection in neonates, the current recommendations are based on clinical experiences and in-vitro susceptibility test results [9, 10].
Mycoplasma Hominis has shown susceptibility to Chloramphenicol, Tetracyclines, Lincosamide and Fluoroquinolones in in-vitro testing [11]. Fluoroquinolones have been used in past to treat neonatal mycoplasma hominins meningitis successfully [1, 3, 5]. Moxifloxacin, a fourth-generation fluoroquinolone is preferred because of its ability to concentrate in CSF and its bactericidal effects in CNS infections [1, 12, 13]. Although there are cases which were successfully treated with Moxifloxacin monotherapy [1, 6], there is a risk of development of resistance with fluoroquinolones during treatment [9, 14, 15]. Our literature search revealed only two reported cases of neonates who were given Moxifloxacin in combination with another antibiotic for Mycoplasma Hominis meningitis [3, 5] (Table 1).
Table 1 Characteristics of neonates treated with combination therapy (Moxifloxacin and another antibiotic) for Mycoplasma Hominis CNS infection
Gestational Age Age at presentation Clinical presentation Confirmation of diagnosis Empirical antibiotic therapy and duration Antibiotics for Mycoplasma Hominis Outcome
Hata and colleagues3 38 weeks 25 days Fever, vomiting, focal seizures 16S RNA PCR Ampicillin & Cefotaxime (day 1–2) Ciprofloxacin (day 6–17) Acyclovir (day 6–8) Chloramphenicol (day 8–17) Minocycline for 28 days (day 6–34) Moxifloxacin for 17 days (day 17–34) Recovery with left hemiplegia
Watt and colleagues5 26 weeks 7 days Apnea, hypotonia, generalized seizures 16S RNA PCR Ampicillin and Gentamycin (day1-8) Ceftazidime (day 1–5 ) Vancomycin (day 8–19 ) Acyclovir (day 8–19) Meropenem (day 12–19 ) Doxycycline for 6 weeks (day 19–60) Moxifloxacin for 6 weeks (day 19–60) Recovery, neurological outcomes not reported
Our case 25 + 6 weeks 7 days Lethargy, tachycardia, generalized seizures 16S RNA PCR Ampicillin and Gentamycin (day 1–2) Azithromycin (day 3–6) Vancomycin and cefotaxime (day 7–10) Doxycycline for 6 weeks (day 10–52) Moxifloxacin for 6 weeks (day 10–52) Recovery with normal neurological examination at discharge, follow up at 6 months showed normal neurological examination
Evidence from previously published cases show that 28 % neonates with Mycoplasma Hominis CNS infection died whereas 34 % had some CNS complications and 28 % cases developed some neurological sequelae mostly hemiparesis [3]. In our case, treatment with a combination therapy of Moxifloxacin and Doxycycline resulted in significant clinical and laboratory improvement in terms of negative CSF culture after 48 hours of initiating this regimen and decreased WBC count and protein in subsequent CSF analysis. Our patient was discharged home with a normal neurological examination and stable ventriculomegaly. His neurodevelopmental follow up at six months of age showed normal neurological findings.
It is important to consider Mycoplasma Hominis as a potential cause for neonatal meningitis in infants particularly those with previous colonization with this rare but devastating species. Our case demonstrates effective eradication of Mycoplasma Hominis with a combination therapy of Moxifloxacin and Doxycycline. However, further research is required to understand the pharmacokinetics of these antibiotics to establish optimal dosing and duration for effective treatment of CNS infections with Mycoplasma Hominis.
Abbreviations
G2P1Gravida2, Parity1
PCRPolymerase chain reaction
RNARibonucleic acid
IVFIn vitro fertilization
CSFCerebrospinal fluid
RBCRed blood cells
WBCWhite blood cells
CNSCentral nervous system
VDRLVenereal disease research laboratory test
NICUNeonatal intensive care unit
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Acknowledgements
Not applicable.
Authors’ contributions
NSA, EA, and AR conceptualized the idea of writing this case report. NSA drafted the initial manuscript which was revised by AR and EA. AR and EA supervised the literature review for this case study, critically reviewed the manuscript, and approved the final version.
Funding
No funding received from any public, commercial or non-profit organization.
Availability of data and materials
Not applicable.
Ethics approval and consent to participate
None.
Consent for publication
Written informed consent was obtained from patient’s parents for publication of this case report.
Competing interests
The authors declare that they have no competing interests. | AZITHROMYCIN, CEFOTAXIME SODIUM, VANCOMYCIN HYDROCHLORIDE | DrugsGivenReaction | CC BY | 33557784 | 18,988,595 | 2021-02-08 |
Give an alphabetized list of all active substances of drugs taken by the patient who experienced 'Seizure'. | Mycoplasma hominis meningitis in an extremely preterm newborn: a case report.
Mycoplasma Hominis is a micro-organism which is a part of the human genitourinary tract flora. Neonates are susceptible to acquire this pathogen either in utero or through vertical transmission. In rare cases, it may cause central nervous system infections with severe morbidity and mortality in preterm and term neonates.
We present a case of Mycoplasma Hominis meningitis in an extremely preterm neonate who presented with lethargy, tachycardia and seizures on day 7 of life. There was no history of maternal systemic or genitourinary infection during pregnancy and at the time of delivery. Empirical antibiotic therapy for neonatal meningitis was commenced after sending blood and cerebrospinal fluid cultures. Cerebrospinal fluid analysis showed pleocytosis with neutrophilic predominance, but no bacteria was identified on gram staining. Blood culture yielded no growth of any bacterial pathogen. However, growth of Mycoplasma Hominis was suspected in cerebrospinal fluid culture which was confirmed by 16S ribosomal ribonucleic acid (RNA) polymerase chain reaction analysis. Subsequently, antibiotics were changed to Moxifloxacin and Doxycycline which were given for a total duration of 6 weeks. Multiple cerebrospinal fluid cultures were performed during this treatment. No growth of any pathogen was identified on any of these cerebrospinal fluid cultures.
We report a rare case of Mycoplasma Hominis meningitis in an extremely preterm neonate which was successfully treated with a combination therapy of Moxifloxacin and Doxycycline. It is important to consider the possibility of Mycoplasma Hominis meningitis in neonates who present with clinical signs and pleocytosis in cerebrospinal fluid but negative gram staining and no growth on conventional culture media.
Background
Mycoplasma Hominis is a frequent habitant of the human genital tract [1]. Neonates are susceptible to acquire this microbe either in utero or through the colonized birth canal during the process of parturition [2]. However, invasive infections with this organism in preterm and term infants are noted to be rare [1, 3]. We describe an unusual case of neonatal meningitis due to Mycoplasma Hominis, confirmed in bacterial cultures and 16s ribosomal RNA Polymerase chain reaction (PCR) analysis. This case report demonstrates the importance of suspecting Mycoplasma Hominis as a cause of central nervous system (CNS) infection in neonates who present with clinical signs but no growth on conventional bacterial cultures and no improvement on empirical antibiotic treatment.
Case presentation
A male neonate was born at 25 + 6 weeks of gestation to 35 years old gravida 2, parity1 (G2P1) mother with antiphospholipid antibody syndrome. This was an in vitro fertilization (IVF) pregnancy. She was Rubella immune and negative for Hepatitis B surface antigen, Venereal disease research laboratory test (VDRL), Human immunodeficiency virus, Gonococci and Chlamydia. Her urine culture and vaginal swab for Group B Streptococci was also negative. Her anatomy scan at 18 weeks of gestation showed normal fetal anatomy and a short cervix for which she underwent cervical cerclage placement at 20 + 5 weeks gestation. There was no history of chorioamnionitis or prolonged rupture of membranes. She presented at 25 + 5 weeks with preterm labor and had a spontaneous vaginal delivery the next day. She had received two doses of Betamethasone and Magnesium sulphate prior to delivery. He initially required positive pressure ventilation followed by intubation and surfactant administration with an acceptable response. Umbilical arterial and venous catheters were placed and the neonate was transferred to neonatal intensive care unit (NICU) in a stable condition.
A blood culture was drawn at birth and empiric treatment with Ampicillin and Gentamicin was intiated. The antibiotics were discontinued after 36 hours as the blood culture showed no growth and he remained clinically stable. In addition, as per unit protocol, an endotracheal aspirate was sent for a Ureaplasma culture on admission. This grew a Mycoplasma species for which 3 days of intravenous Azithromycin was given.
A head ultrasound on day 4 of life showed bilateral intraventricular hemorrhage (grade 3) with mild ventriculomegaly and a hemorrhagic venous infarct in the right frontoparietal region. Umbilical arterial catheter was removed on day 4 of life whereas umbilical venous catheter was removed on day 6 of life. He remained stable till day 7 of life when he presented with an acute clinical deterioration presenting as lethargy and tachycardia; a septic work up including blood and cerebrospinal fluid (CSF) cultures was completed and Vancomycin and Cefotaxime were started as empiric antibiotics. His CSF analysis showed red blood cells (RBC) count of 4887 × 10E6/l, pleocytosis of white blood cells (WBC) 9620 × 10E6/l with neutrophilic predominance, hyperproteorachia - protein 8300 mg/l and hypoglycorachia - glucose 0.1 mmoles/liter. Gram staining in CSF was negative. Within hours he developed generalized clinical seizures which was treated with Lorazepam and Phenobarbital followed by a Levetiracetam load and maintenance dose. He had further episodes of clinical and subclinical seizures which resolved after further adjustment of levetiracetam doses.
His first CSF culture was suspected to grow Mycoplasma Hominis and was sent to the regional national diagnostic laboratory for confirmation. The CSF culture was repeated along with a sample for 16s ribosomal RNA PCR analyses. The 16s ribosomal RNA PCR analysis confirmed Mycoplasma hominis in both CSF samples. Antibiotics were then changed to Moxifloxacin and Doxycycline. The repeat CSF culture after 48 hours of Moxifloxacin and Doxycycline showed no growth. CSF analysis done seven days after starting this treatment showed RBC 5650 × 10E6/l, WBC 449 × 10E6/l, protein 3763 mg/l and glucose 0.2 mmoles/liter. Subsequent CSF findings repeated after another three days showed further improvement, RBC 7187 × 10E6/l, WBC 93 × 10E6/l, protein 3691 mg/l and glucose 0.5 mmoles/liter. No growth was seen on any of these CSF cultures. Serial head ultrasound scans were done which showed progressive ventriculomegaly, post hemorrhagic ventricular dilatation and cystic evolution of hemorrhagic/venous infarct in the right frontoparietal region. Although these findings could be attributed to extreme prematurity; there is a likelihood that infection with Mycoplasma Hominis may have played a role in its progression. There have been documented cases of Mycoplasma Hominis meningitis resulting in CNS complications including intraventricular and periventricular hemorrhage, hydrocephalus, and infarction [3]. Lumbar taps were repeated as therapeutic measure to reduce ventriculomegaly, but optimal volumes of CSF were not obtained. Because of the ventriculomegaly, he was evaluated for a possible shunt on day 31; this was deferred because of the stable ventriculomegaly.
Antibiotics were given for a total duration of six weeks after which he was discharged home with a normal neurological examination. He was referred to Neurodevelopmental clinic for follow-up.
Discussion and conclusion
Neonatal CNS infections with Mycoplasma Hominis, although rare, can cause severe morbidity and mortality in neonates [1]. In a case series of 29 neonates with Mycoplasma Hominis infection (age of presentation day1-32 of life), Hata and colleagues reported complications such as brain abscess, hydrocephalus, infarction, cerebritis and periventricular/intraventricular hemorrhage in 34 % cases, death in 28 % and sequelae mostly hemiparesis in another 28 % cases [3]. This may be attributed to a delay in diagnosis, ineffective antibiotic treatment, or suboptimal treatment regimens for neonatal CNS disease [3, 4]. Therefore, prompt diagnosis, early initiation and optimal duration of appropriate antibiotic therapy is necessary for a favorable prognosis.
The clinical presentation may include apnea, temperature instability, lethargy, vomiting, irritability poor tone, twitching or seizures [7]. Detection of Mycoplasma Hominis can be challenging since they lack peptidoglycan cell wall which renders them unidentifiable by gram staining [5]. In addition to this, they grow very slowly on routine culture media and require a specific blood agar medium for their detection [1, 6]. Due to this, there is a likelihood that Mycoplasma Hominis infections may remain undiagnosed or diagnosed late in infants presenting with clinical signs and symptoms [2]. Hence, it is important to consider the possibility of Mycoplasma Hominis infection in cases where the CSF shows pleocytosis and no growth of organism on routine culture media. A 16S ribosomal RNA PCR analysis has proven useful for detection of Mycoplasma Hominis in blood and CSF which are difficult to grow on standard culture media [7, 8]. The microbe is identified by direct sequencing analysis after amplification by PCR. Use of pathogen-specific primers in 16S RNA analysis results in rapid detection of the specific organism [4]. Prematurity, low birth weight, and neural tube defects are recognized to be the most common risk factors for neonatal meningitis with Mycoplasma Hominis [6]. However, it has also been seen in term neonates with no neurological birth malformations [1, 3].
The treatment options for Mycoplasma Hominis meningitis and its duration remains unclear [1, 9]. Due to the rarity of this infection in neonates, the current recommendations are based on clinical experiences and in-vitro susceptibility test results [9, 10].
Mycoplasma Hominis has shown susceptibility to Chloramphenicol, Tetracyclines, Lincosamide and Fluoroquinolones in in-vitro testing [11]. Fluoroquinolones have been used in past to treat neonatal mycoplasma hominins meningitis successfully [1, 3, 5]. Moxifloxacin, a fourth-generation fluoroquinolone is preferred because of its ability to concentrate in CSF and its bactericidal effects in CNS infections [1, 12, 13]. Although there are cases which were successfully treated with Moxifloxacin monotherapy [1, 6], there is a risk of development of resistance with fluoroquinolones during treatment [9, 14, 15]. Our literature search revealed only two reported cases of neonates who were given Moxifloxacin in combination with another antibiotic for Mycoplasma Hominis meningitis [3, 5] (Table 1).
Table 1 Characteristics of neonates treated with combination therapy (Moxifloxacin and another antibiotic) for Mycoplasma Hominis CNS infection
Gestational Age Age at presentation Clinical presentation Confirmation of diagnosis Empirical antibiotic therapy and duration Antibiotics for Mycoplasma Hominis Outcome
Hata and colleagues3 38 weeks 25 days Fever, vomiting, focal seizures 16S RNA PCR Ampicillin & Cefotaxime (day 1–2) Ciprofloxacin (day 6–17) Acyclovir (day 6–8) Chloramphenicol (day 8–17) Minocycline for 28 days (day 6–34) Moxifloxacin for 17 days (day 17–34) Recovery with left hemiplegia
Watt and colleagues5 26 weeks 7 days Apnea, hypotonia, generalized seizures 16S RNA PCR Ampicillin and Gentamycin (day1-8) Ceftazidime (day 1–5 ) Vancomycin (day 8–19 ) Acyclovir (day 8–19) Meropenem (day 12–19 ) Doxycycline for 6 weeks (day 19–60) Moxifloxacin for 6 weeks (day 19–60) Recovery, neurological outcomes not reported
Our case 25 + 6 weeks 7 days Lethargy, tachycardia, generalized seizures 16S RNA PCR Ampicillin and Gentamycin (day 1–2) Azithromycin (day 3–6) Vancomycin and cefotaxime (day 7–10) Doxycycline for 6 weeks (day 10–52) Moxifloxacin for 6 weeks (day 10–52) Recovery with normal neurological examination at discharge, follow up at 6 months showed normal neurological examination
Evidence from previously published cases show that 28 % neonates with Mycoplasma Hominis CNS infection died whereas 34 % had some CNS complications and 28 % cases developed some neurological sequelae mostly hemiparesis [3]. In our case, treatment with a combination therapy of Moxifloxacin and Doxycycline resulted in significant clinical and laboratory improvement in terms of negative CSF culture after 48 hours of initiating this regimen and decreased WBC count and protein in subsequent CSF analysis. Our patient was discharged home with a normal neurological examination and stable ventriculomegaly. His neurodevelopmental follow up at six months of age showed normal neurological findings.
It is important to consider Mycoplasma Hominis as a potential cause for neonatal meningitis in infants particularly those with previous colonization with this rare but devastating species. Our case demonstrates effective eradication of Mycoplasma Hominis with a combination therapy of Moxifloxacin and Doxycycline. However, further research is required to understand the pharmacokinetics of these antibiotics to establish optimal dosing and duration for effective treatment of CNS infections with Mycoplasma Hominis.
Abbreviations
G2P1Gravida2, Parity1
PCRPolymerase chain reaction
RNARibonucleic acid
IVFIn vitro fertilization
CSFCerebrospinal fluid
RBCRed blood cells
WBCWhite blood cells
CNSCentral nervous system
VDRLVenereal disease research laboratory test
NICUNeonatal intensive care unit
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Acknowledgements
Not applicable.
Authors’ contributions
NSA, EA, and AR conceptualized the idea of writing this case report. NSA drafted the initial manuscript which was revised by AR and EA. AR and EA supervised the literature review for this case study, critically reviewed the manuscript, and approved the final version.
Funding
No funding received from any public, commercial or non-profit organization.
Availability of data and materials
Not applicable.
Ethics approval and consent to participate
None.
Consent for publication
Written informed consent was obtained from patient’s parents for publication of this case report.
Competing interests
The authors declare that they have no competing interests. | AZITHROMYCIN, CEFOTAXIME SODIUM, VANCOMYCIN HYDROCHLORIDE | DrugsGivenReaction | CC BY | 33557784 | 18,988,595 | 2021-02-08 |
What was the administration route of drug 'AZITHROMYCIN'? | Mycoplasma hominis meningitis in an extremely preterm newborn: a case report.
Mycoplasma Hominis is a micro-organism which is a part of the human genitourinary tract flora. Neonates are susceptible to acquire this pathogen either in utero or through vertical transmission. In rare cases, it may cause central nervous system infections with severe morbidity and mortality in preterm and term neonates.
We present a case of Mycoplasma Hominis meningitis in an extremely preterm neonate who presented with lethargy, tachycardia and seizures on day 7 of life. There was no history of maternal systemic or genitourinary infection during pregnancy and at the time of delivery. Empirical antibiotic therapy for neonatal meningitis was commenced after sending blood and cerebrospinal fluid cultures. Cerebrospinal fluid analysis showed pleocytosis with neutrophilic predominance, but no bacteria was identified on gram staining. Blood culture yielded no growth of any bacterial pathogen. However, growth of Mycoplasma Hominis was suspected in cerebrospinal fluid culture which was confirmed by 16S ribosomal ribonucleic acid (RNA) polymerase chain reaction analysis. Subsequently, antibiotics were changed to Moxifloxacin and Doxycycline which were given for a total duration of 6 weeks. Multiple cerebrospinal fluid cultures were performed during this treatment. No growth of any pathogen was identified on any of these cerebrospinal fluid cultures.
We report a rare case of Mycoplasma Hominis meningitis in an extremely preterm neonate which was successfully treated with a combination therapy of Moxifloxacin and Doxycycline. It is important to consider the possibility of Mycoplasma Hominis meningitis in neonates who present with clinical signs and pleocytosis in cerebrospinal fluid but negative gram staining and no growth on conventional culture media.
Background
Mycoplasma Hominis is a frequent habitant of the human genital tract [1]. Neonates are susceptible to acquire this microbe either in utero or through the colonized birth canal during the process of parturition [2]. However, invasive infections with this organism in preterm and term infants are noted to be rare [1, 3]. We describe an unusual case of neonatal meningitis due to Mycoplasma Hominis, confirmed in bacterial cultures and 16s ribosomal RNA Polymerase chain reaction (PCR) analysis. This case report demonstrates the importance of suspecting Mycoplasma Hominis as a cause of central nervous system (CNS) infection in neonates who present with clinical signs but no growth on conventional bacterial cultures and no improvement on empirical antibiotic treatment.
Case presentation
A male neonate was born at 25 + 6 weeks of gestation to 35 years old gravida 2, parity1 (G2P1) mother with antiphospholipid antibody syndrome. This was an in vitro fertilization (IVF) pregnancy. She was Rubella immune and negative for Hepatitis B surface antigen, Venereal disease research laboratory test (VDRL), Human immunodeficiency virus, Gonococci and Chlamydia. Her urine culture and vaginal swab for Group B Streptococci was also negative. Her anatomy scan at 18 weeks of gestation showed normal fetal anatomy and a short cervix for which she underwent cervical cerclage placement at 20 + 5 weeks gestation. There was no history of chorioamnionitis or prolonged rupture of membranes. She presented at 25 + 5 weeks with preterm labor and had a spontaneous vaginal delivery the next day. She had received two doses of Betamethasone and Magnesium sulphate prior to delivery. He initially required positive pressure ventilation followed by intubation and surfactant administration with an acceptable response. Umbilical arterial and venous catheters were placed and the neonate was transferred to neonatal intensive care unit (NICU) in a stable condition.
A blood culture was drawn at birth and empiric treatment with Ampicillin and Gentamicin was intiated. The antibiotics were discontinued after 36 hours as the blood culture showed no growth and he remained clinically stable. In addition, as per unit protocol, an endotracheal aspirate was sent for a Ureaplasma culture on admission. This grew a Mycoplasma species for which 3 days of intravenous Azithromycin was given.
A head ultrasound on day 4 of life showed bilateral intraventricular hemorrhage (grade 3) with mild ventriculomegaly and a hemorrhagic venous infarct in the right frontoparietal region. Umbilical arterial catheter was removed on day 4 of life whereas umbilical venous catheter was removed on day 6 of life. He remained stable till day 7 of life when he presented with an acute clinical deterioration presenting as lethargy and tachycardia; a septic work up including blood and cerebrospinal fluid (CSF) cultures was completed and Vancomycin and Cefotaxime were started as empiric antibiotics. His CSF analysis showed red blood cells (RBC) count of 4887 × 10E6/l, pleocytosis of white blood cells (WBC) 9620 × 10E6/l with neutrophilic predominance, hyperproteorachia - protein 8300 mg/l and hypoglycorachia - glucose 0.1 mmoles/liter. Gram staining in CSF was negative. Within hours he developed generalized clinical seizures which was treated with Lorazepam and Phenobarbital followed by a Levetiracetam load and maintenance dose. He had further episodes of clinical and subclinical seizures which resolved after further adjustment of levetiracetam doses.
His first CSF culture was suspected to grow Mycoplasma Hominis and was sent to the regional national diagnostic laboratory for confirmation. The CSF culture was repeated along with a sample for 16s ribosomal RNA PCR analyses. The 16s ribosomal RNA PCR analysis confirmed Mycoplasma hominis in both CSF samples. Antibiotics were then changed to Moxifloxacin and Doxycycline. The repeat CSF culture after 48 hours of Moxifloxacin and Doxycycline showed no growth. CSF analysis done seven days after starting this treatment showed RBC 5650 × 10E6/l, WBC 449 × 10E6/l, protein 3763 mg/l and glucose 0.2 mmoles/liter. Subsequent CSF findings repeated after another three days showed further improvement, RBC 7187 × 10E6/l, WBC 93 × 10E6/l, protein 3691 mg/l and glucose 0.5 mmoles/liter. No growth was seen on any of these CSF cultures. Serial head ultrasound scans were done which showed progressive ventriculomegaly, post hemorrhagic ventricular dilatation and cystic evolution of hemorrhagic/venous infarct in the right frontoparietal region. Although these findings could be attributed to extreme prematurity; there is a likelihood that infection with Mycoplasma Hominis may have played a role in its progression. There have been documented cases of Mycoplasma Hominis meningitis resulting in CNS complications including intraventricular and periventricular hemorrhage, hydrocephalus, and infarction [3]. Lumbar taps were repeated as therapeutic measure to reduce ventriculomegaly, but optimal volumes of CSF were not obtained. Because of the ventriculomegaly, he was evaluated for a possible shunt on day 31; this was deferred because of the stable ventriculomegaly.
Antibiotics were given for a total duration of six weeks after which he was discharged home with a normal neurological examination. He was referred to Neurodevelopmental clinic for follow-up.
Discussion and conclusion
Neonatal CNS infections with Mycoplasma Hominis, although rare, can cause severe morbidity and mortality in neonates [1]. In a case series of 29 neonates with Mycoplasma Hominis infection (age of presentation day1-32 of life), Hata and colleagues reported complications such as brain abscess, hydrocephalus, infarction, cerebritis and periventricular/intraventricular hemorrhage in 34 % cases, death in 28 % and sequelae mostly hemiparesis in another 28 % cases [3]. This may be attributed to a delay in diagnosis, ineffective antibiotic treatment, or suboptimal treatment regimens for neonatal CNS disease [3, 4]. Therefore, prompt diagnosis, early initiation and optimal duration of appropriate antibiotic therapy is necessary for a favorable prognosis.
The clinical presentation may include apnea, temperature instability, lethargy, vomiting, irritability poor tone, twitching or seizures [7]. Detection of Mycoplasma Hominis can be challenging since they lack peptidoglycan cell wall which renders them unidentifiable by gram staining [5]. In addition to this, they grow very slowly on routine culture media and require a specific blood agar medium for their detection [1, 6]. Due to this, there is a likelihood that Mycoplasma Hominis infections may remain undiagnosed or diagnosed late in infants presenting with clinical signs and symptoms [2]. Hence, it is important to consider the possibility of Mycoplasma Hominis infection in cases where the CSF shows pleocytosis and no growth of organism on routine culture media. A 16S ribosomal RNA PCR analysis has proven useful for detection of Mycoplasma Hominis in blood and CSF which are difficult to grow on standard culture media [7, 8]. The microbe is identified by direct sequencing analysis after amplification by PCR. Use of pathogen-specific primers in 16S RNA analysis results in rapid detection of the specific organism [4]. Prematurity, low birth weight, and neural tube defects are recognized to be the most common risk factors for neonatal meningitis with Mycoplasma Hominis [6]. However, it has also been seen in term neonates with no neurological birth malformations [1, 3].
The treatment options for Mycoplasma Hominis meningitis and its duration remains unclear [1, 9]. Due to the rarity of this infection in neonates, the current recommendations are based on clinical experiences and in-vitro susceptibility test results [9, 10].
Mycoplasma Hominis has shown susceptibility to Chloramphenicol, Tetracyclines, Lincosamide and Fluoroquinolones in in-vitro testing [11]. Fluoroquinolones have been used in past to treat neonatal mycoplasma hominins meningitis successfully [1, 3, 5]. Moxifloxacin, a fourth-generation fluoroquinolone is preferred because of its ability to concentrate in CSF and its bactericidal effects in CNS infections [1, 12, 13]. Although there are cases which were successfully treated with Moxifloxacin monotherapy [1, 6], there is a risk of development of resistance with fluoroquinolones during treatment [9, 14, 15]. Our literature search revealed only two reported cases of neonates who were given Moxifloxacin in combination with another antibiotic for Mycoplasma Hominis meningitis [3, 5] (Table 1).
Table 1 Characteristics of neonates treated with combination therapy (Moxifloxacin and another antibiotic) for Mycoplasma Hominis CNS infection
Gestational Age Age at presentation Clinical presentation Confirmation of diagnosis Empirical antibiotic therapy and duration Antibiotics for Mycoplasma Hominis Outcome
Hata and colleagues3 38 weeks 25 days Fever, vomiting, focal seizures 16S RNA PCR Ampicillin & Cefotaxime (day 1–2) Ciprofloxacin (day 6–17) Acyclovir (day 6–8) Chloramphenicol (day 8–17) Minocycline for 28 days (day 6–34) Moxifloxacin for 17 days (day 17–34) Recovery with left hemiplegia
Watt and colleagues5 26 weeks 7 days Apnea, hypotonia, generalized seizures 16S RNA PCR Ampicillin and Gentamycin (day1-8) Ceftazidime (day 1–5 ) Vancomycin (day 8–19 ) Acyclovir (day 8–19) Meropenem (day 12–19 ) Doxycycline for 6 weeks (day 19–60) Moxifloxacin for 6 weeks (day 19–60) Recovery, neurological outcomes not reported
Our case 25 + 6 weeks 7 days Lethargy, tachycardia, generalized seizures 16S RNA PCR Ampicillin and Gentamycin (day 1–2) Azithromycin (day 3–6) Vancomycin and cefotaxime (day 7–10) Doxycycline for 6 weeks (day 10–52) Moxifloxacin for 6 weeks (day 10–52) Recovery with normal neurological examination at discharge, follow up at 6 months showed normal neurological examination
Evidence from previously published cases show that 28 % neonates with Mycoplasma Hominis CNS infection died whereas 34 % had some CNS complications and 28 % cases developed some neurological sequelae mostly hemiparesis [3]. In our case, treatment with a combination therapy of Moxifloxacin and Doxycycline resulted in significant clinical and laboratory improvement in terms of negative CSF culture after 48 hours of initiating this regimen and decreased WBC count and protein in subsequent CSF analysis. Our patient was discharged home with a normal neurological examination and stable ventriculomegaly. His neurodevelopmental follow up at six months of age showed normal neurological findings.
It is important to consider Mycoplasma Hominis as a potential cause for neonatal meningitis in infants particularly those with previous colonization with this rare but devastating species. Our case demonstrates effective eradication of Mycoplasma Hominis with a combination therapy of Moxifloxacin and Doxycycline. However, further research is required to understand the pharmacokinetics of these antibiotics to establish optimal dosing and duration for effective treatment of CNS infections with Mycoplasma Hominis.
Abbreviations
G2P1Gravida2, Parity1
PCRPolymerase chain reaction
RNARibonucleic acid
IVFIn vitro fertilization
CSFCerebrospinal fluid
RBCRed blood cells
WBCWhite blood cells
CNSCentral nervous system
VDRLVenereal disease research laboratory test
NICUNeonatal intensive care unit
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Acknowledgements
Not applicable.
Authors’ contributions
NSA, EA, and AR conceptualized the idea of writing this case report. NSA drafted the initial manuscript which was revised by AR and EA. AR and EA supervised the literature review for this case study, critically reviewed the manuscript, and approved the final version.
Funding
No funding received from any public, commercial or non-profit organization.
Availability of data and materials
Not applicable.
Ethics approval and consent to participate
None.
Consent for publication
Written informed consent was obtained from patient’s parents for publication of this case report.
Competing interests
The authors declare that they have no competing interests. | Intravenous (not otherwise specified) | DrugAdministrationRoute | CC BY | 33557784 | 18,988,595 | 2021-02-08 |
What was the outcome of reaction 'Cerebral ventricle dilatation'? | Mycoplasma hominis meningitis in an extremely preterm newborn: a case report.
Mycoplasma Hominis is a micro-organism which is a part of the human genitourinary tract flora. Neonates are susceptible to acquire this pathogen either in utero or through vertical transmission. In rare cases, it may cause central nervous system infections with severe morbidity and mortality in preterm and term neonates.
We present a case of Mycoplasma Hominis meningitis in an extremely preterm neonate who presented with lethargy, tachycardia and seizures on day 7 of life. There was no history of maternal systemic or genitourinary infection during pregnancy and at the time of delivery. Empirical antibiotic therapy for neonatal meningitis was commenced after sending blood and cerebrospinal fluid cultures. Cerebrospinal fluid analysis showed pleocytosis with neutrophilic predominance, but no bacteria was identified on gram staining. Blood culture yielded no growth of any bacterial pathogen. However, growth of Mycoplasma Hominis was suspected in cerebrospinal fluid culture which was confirmed by 16S ribosomal ribonucleic acid (RNA) polymerase chain reaction analysis. Subsequently, antibiotics were changed to Moxifloxacin and Doxycycline which were given for a total duration of 6 weeks. Multiple cerebrospinal fluid cultures were performed during this treatment. No growth of any pathogen was identified on any of these cerebrospinal fluid cultures.
We report a rare case of Mycoplasma Hominis meningitis in an extremely preterm neonate which was successfully treated with a combination therapy of Moxifloxacin and Doxycycline. It is important to consider the possibility of Mycoplasma Hominis meningitis in neonates who present with clinical signs and pleocytosis in cerebrospinal fluid but negative gram staining and no growth on conventional culture media.
Background
Mycoplasma Hominis is a frequent habitant of the human genital tract [1]. Neonates are susceptible to acquire this microbe either in utero or through the colonized birth canal during the process of parturition [2]. However, invasive infections with this organism in preterm and term infants are noted to be rare [1, 3]. We describe an unusual case of neonatal meningitis due to Mycoplasma Hominis, confirmed in bacterial cultures and 16s ribosomal RNA Polymerase chain reaction (PCR) analysis. This case report demonstrates the importance of suspecting Mycoplasma Hominis as a cause of central nervous system (CNS) infection in neonates who present with clinical signs but no growth on conventional bacterial cultures and no improvement on empirical antibiotic treatment.
Case presentation
A male neonate was born at 25 + 6 weeks of gestation to 35 years old gravida 2, parity1 (G2P1) mother with antiphospholipid antibody syndrome. This was an in vitro fertilization (IVF) pregnancy. She was Rubella immune and negative for Hepatitis B surface antigen, Venereal disease research laboratory test (VDRL), Human immunodeficiency virus, Gonococci and Chlamydia. Her urine culture and vaginal swab for Group B Streptococci was also negative. Her anatomy scan at 18 weeks of gestation showed normal fetal anatomy and a short cervix for which she underwent cervical cerclage placement at 20 + 5 weeks gestation. There was no history of chorioamnionitis or prolonged rupture of membranes. She presented at 25 + 5 weeks with preterm labor and had a spontaneous vaginal delivery the next day. She had received two doses of Betamethasone and Magnesium sulphate prior to delivery. He initially required positive pressure ventilation followed by intubation and surfactant administration with an acceptable response. Umbilical arterial and venous catheters were placed and the neonate was transferred to neonatal intensive care unit (NICU) in a stable condition.
A blood culture was drawn at birth and empiric treatment with Ampicillin and Gentamicin was intiated. The antibiotics were discontinued after 36 hours as the blood culture showed no growth and he remained clinically stable. In addition, as per unit protocol, an endotracheal aspirate was sent for a Ureaplasma culture on admission. This grew a Mycoplasma species for which 3 days of intravenous Azithromycin was given.
A head ultrasound on day 4 of life showed bilateral intraventricular hemorrhage (grade 3) with mild ventriculomegaly and a hemorrhagic venous infarct in the right frontoparietal region. Umbilical arterial catheter was removed on day 4 of life whereas umbilical venous catheter was removed on day 6 of life. He remained stable till day 7 of life when he presented with an acute clinical deterioration presenting as lethargy and tachycardia; a septic work up including blood and cerebrospinal fluid (CSF) cultures was completed and Vancomycin and Cefotaxime were started as empiric antibiotics. His CSF analysis showed red blood cells (RBC) count of 4887 × 10E6/l, pleocytosis of white blood cells (WBC) 9620 × 10E6/l with neutrophilic predominance, hyperproteorachia - protein 8300 mg/l and hypoglycorachia - glucose 0.1 mmoles/liter. Gram staining in CSF was negative. Within hours he developed generalized clinical seizures which was treated with Lorazepam and Phenobarbital followed by a Levetiracetam load and maintenance dose. He had further episodes of clinical and subclinical seizures which resolved after further adjustment of levetiracetam doses.
His first CSF culture was suspected to grow Mycoplasma Hominis and was sent to the regional national diagnostic laboratory for confirmation. The CSF culture was repeated along with a sample for 16s ribosomal RNA PCR analyses. The 16s ribosomal RNA PCR analysis confirmed Mycoplasma hominis in both CSF samples. Antibiotics were then changed to Moxifloxacin and Doxycycline. The repeat CSF culture after 48 hours of Moxifloxacin and Doxycycline showed no growth. CSF analysis done seven days after starting this treatment showed RBC 5650 × 10E6/l, WBC 449 × 10E6/l, protein 3763 mg/l and glucose 0.2 mmoles/liter. Subsequent CSF findings repeated after another three days showed further improvement, RBC 7187 × 10E6/l, WBC 93 × 10E6/l, protein 3691 mg/l and glucose 0.5 mmoles/liter. No growth was seen on any of these CSF cultures. Serial head ultrasound scans were done which showed progressive ventriculomegaly, post hemorrhagic ventricular dilatation and cystic evolution of hemorrhagic/venous infarct in the right frontoparietal region. Although these findings could be attributed to extreme prematurity; there is a likelihood that infection with Mycoplasma Hominis may have played a role in its progression. There have been documented cases of Mycoplasma Hominis meningitis resulting in CNS complications including intraventricular and periventricular hemorrhage, hydrocephalus, and infarction [3]. Lumbar taps were repeated as therapeutic measure to reduce ventriculomegaly, but optimal volumes of CSF were not obtained. Because of the ventriculomegaly, he was evaluated for a possible shunt on day 31; this was deferred because of the stable ventriculomegaly.
Antibiotics were given for a total duration of six weeks after which he was discharged home with a normal neurological examination. He was referred to Neurodevelopmental clinic for follow-up.
Discussion and conclusion
Neonatal CNS infections with Mycoplasma Hominis, although rare, can cause severe morbidity and mortality in neonates [1]. In a case series of 29 neonates with Mycoplasma Hominis infection (age of presentation day1-32 of life), Hata and colleagues reported complications such as brain abscess, hydrocephalus, infarction, cerebritis and periventricular/intraventricular hemorrhage in 34 % cases, death in 28 % and sequelae mostly hemiparesis in another 28 % cases [3]. This may be attributed to a delay in diagnosis, ineffective antibiotic treatment, or suboptimal treatment regimens for neonatal CNS disease [3, 4]. Therefore, prompt diagnosis, early initiation and optimal duration of appropriate antibiotic therapy is necessary for a favorable prognosis.
The clinical presentation may include apnea, temperature instability, lethargy, vomiting, irritability poor tone, twitching or seizures [7]. Detection of Mycoplasma Hominis can be challenging since they lack peptidoglycan cell wall which renders them unidentifiable by gram staining [5]. In addition to this, they grow very slowly on routine culture media and require a specific blood agar medium for their detection [1, 6]. Due to this, there is a likelihood that Mycoplasma Hominis infections may remain undiagnosed or diagnosed late in infants presenting with clinical signs and symptoms [2]. Hence, it is important to consider the possibility of Mycoplasma Hominis infection in cases where the CSF shows pleocytosis and no growth of organism on routine culture media. A 16S ribosomal RNA PCR analysis has proven useful for detection of Mycoplasma Hominis in blood and CSF which are difficult to grow on standard culture media [7, 8]. The microbe is identified by direct sequencing analysis after amplification by PCR. Use of pathogen-specific primers in 16S RNA analysis results in rapid detection of the specific organism [4]. Prematurity, low birth weight, and neural tube defects are recognized to be the most common risk factors for neonatal meningitis with Mycoplasma Hominis [6]. However, it has also been seen in term neonates with no neurological birth malformations [1, 3].
The treatment options for Mycoplasma Hominis meningitis and its duration remains unclear [1, 9]. Due to the rarity of this infection in neonates, the current recommendations are based on clinical experiences and in-vitro susceptibility test results [9, 10].
Mycoplasma Hominis has shown susceptibility to Chloramphenicol, Tetracyclines, Lincosamide and Fluoroquinolones in in-vitro testing [11]. Fluoroquinolones have been used in past to treat neonatal mycoplasma hominins meningitis successfully [1, 3, 5]. Moxifloxacin, a fourth-generation fluoroquinolone is preferred because of its ability to concentrate in CSF and its bactericidal effects in CNS infections [1, 12, 13]. Although there are cases which were successfully treated with Moxifloxacin monotherapy [1, 6], there is a risk of development of resistance with fluoroquinolones during treatment [9, 14, 15]. Our literature search revealed only two reported cases of neonates who were given Moxifloxacin in combination with another antibiotic for Mycoplasma Hominis meningitis [3, 5] (Table 1).
Table 1 Characteristics of neonates treated with combination therapy (Moxifloxacin and another antibiotic) for Mycoplasma Hominis CNS infection
Gestational Age Age at presentation Clinical presentation Confirmation of diagnosis Empirical antibiotic therapy and duration Antibiotics for Mycoplasma Hominis Outcome
Hata and colleagues3 38 weeks 25 days Fever, vomiting, focal seizures 16S RNA PCR Ampicillin & Cefotaxime (day 1–2) Ciprofloxacin (day 6–17) Acyclovir (day 6–8) Chloramphenicol (day 8–17) Minocycline for 28 days (day 6–34) Moxifloxacin for 17 days (day 17–34) Recovery with left hemiplegia
Watt and colleagues5 26 weeks 7 days Apnea, hypotonia, generalized seizures 16S RNA PCR Ampicillin and Gentamycin (day1-8) Ceftazidime (day 1–5 ) Vancomycin (day 8–19 ) Acyclovir (day 8–19) Meropenem (day 12–19 ) Doxycycline for 6 weeks (day 19–60) Moxifloxacin for 6 weeks (day 19–60) Recovery, neurological outcomes not reported
Our case 25 + 6 weeks 7 days Lethargy, tachycardia, generalized seizures 16S RNA PCR Ampicillin and Gentamycin (day 1–2) Azithromycin (day 3–6) Vancomycin and cefotaxime (day 7–10) Doxycycline for 6 weeks (day 10–52) Moxifloxacin for 6 weeks (day 10–52) Recovery with normal neurological examination at discharge, follow up at 6 months showed normal neurological examination
Evidence from previously published cases show that 28 % neonates with Mycoplasma Hominis CNS infection died whereas 34 % had some CNS complications and 28 % cases developed some neurological sequelae mostly hemiparesis [3]. In our case, treatment with a combination therapy of Moxifloxacin and Doxycycline resulted in significant clinical and laboratory improvement in terms of negative CSF culture after 48 hours of initiating this regimen and decreased WBC count and protein in subsequent CSF analysis. Our patient was discharged home with a normal neurological examination and stable ventriculomegaly. His neurodevelopmental follow up at six months of age showed normal neurological findings.
It is important to consider Mycoplasma Hominis as a potential cause for neonatal meningitis in infants particularly those with previous colonization with this rare but devastating species. Our case demonstrates effective eradication of Mycoplasma Hominis with a combination therapy of Moxifloxacin and Doxycycline. However, further research is required to understand the pharmacokinetics of these antibiotics to establish optimal dosing and duration for effective treatment of CNS infections with Mycoplasma Hominis.
Abbreviations
G2P1Gravida2, Parity1
PCRPolymerase chain reaction
RNARibonucleic acid
IVFIn vitro fertilization
CSFCerebrospinal fluid
RBCRed blood cells
WBCWhite blood cells
CNSCentral nervous system
VDRLVenereal disease research laboratory test
NICUNeonatal intensive care unit
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Acknowledgements
Not applicable.
Authors’ contributions
NSA, EA, and AR conceptualized the idea of writing this case report. NSA drafted the initial manuscript which was revised by AR and EA. AR and EA supervised the literature review for this case study, critically reviewed the manuscript, and approved the final version.
Funding
No funding received from any public, commercial or non-profit organization.
Availability of data and materials
Not applicable.
Ethics approval and consent to participate
None.
Consent for publication
Written informed consent was obtained from patient’s parents for publication of this case report.
Competing interests
The authors declare that they have no competing interests. | Recovered | ReactionOutcome | CC BY | 33557784 | 18,988,595 | 2021-02-08 |
What was the outcome of reaction 'Haemorrhagic cerebral infarction'? | Mycoplasma hominis meningitis in an extremely preterm newborn: a case report.
Mycoplasma Hominis is a micro-organism which is a part of the human genitourinary tract flora. Neonates are susceptible to acquire this pathogen either in utero or through vertical transmission. In rare cases, it may cause central nervous system infections with severe morbidity and mortality in preterm and term neonates.
We present a case of Mycoplasma Hominis meningitis in an extremely preterm neonate who presented with lethargy, tachycardia and seizures on day 7 of life. There was no history of maternal systemic or genitourinary infection during pregnancy and at the time of delivery. Empirical antibiotic therapy for neonatal meningitis was commenced after sending blood and cerebrospinal fluid cultures. Cerebrospinal fluid analysis showed pleocytosis with neutrophilic predominance, but no bacteria was identified on gram staining. Blood culture yielded no growth of any bacterial pathogen. However, growth of Mycoplasma Hominis was suspected in cerebrospinal fluid culture which was confirmed by 16S ribosomal ribonucleic acid (RNA) polymerase chain reaction analysis. Subsequently, antibiotics were changed to Moxifloxacin and Doxycycline which were given for a total duration of 6 weeks. Multiple cerebrospinal fluid cultures were performed during this treatment. No growth of any pathogen was identified on any of these cerebrospinal fluid cultures.
We report a rare case of Mycoplasma Hominis meningitis in an extremely preterm neonate which was successfully treated with a combination therapy of Moxifloxacin and Doxycycline. It is important to consider the possibility of Mycoplasma Hominis meningitis in neonates who present with clinical signs and pleocytosis in cerebrospinal fluid but negative gram staining and no growth on conventional culture media.
Background
Mycoplasma Hominis is a frequent habitant of the human genital tract [1]. Neonates are susceptible to acquire this microbe either in utero or through the colonized birth canal during the process of parturition [2]. However, invasive infections with this organism in preterm and term infants are noted to be rare [1, 3]. We describe an unusual case of neonatal meningitis due to Mycoplasma Hominis, confirmed in bacterial cultures and 16s ribosomal RNA Polymerase chain reaction (PCR) analysis. This case report demonstrates the importance of suspecting Mycoplasma Hominis as a cause of central nervous system (CNS) infection in neonates who present with clinical signs but no growth on conventional bacterial cultures and no improvement on empirical antibiotic treatment.
Case presentation
A male neonate was born at 25 + 6 weeks of gestation to 35 years old gravida 2, parity1 (G2P1) mother with antiphospholipid antibody syndrome. This was an in vitro fertilization (IVF) pregnancy. She was Rubella immune and negative for Hepatitis B surface antigen, Venereal disease research laboratory test (VDRL), Human immunodeficiency virus, Gonococci and Chlamydia. Her urine culture and vaginal swab for Group B Streptococci was also negative. Her anatomy scan at 18 weeks of gestation showed normal fetal anatomy and a short cervix for which she underwent cervical cerclage placement at 20 + 5 weeks gestation. There was no history of chorioamnionitis or prolonged rupture of membranes. She presented at 25 + 5 weeks with preterm labor and had a spontaneous vaginal delivery the next day. She had received two doses of Betamethasone and Magnesium sulphate prior to delivery. He initially required positive pressure ventilation followed by intubation and surfactant administration with an acceptable response. Umbilical arterial and venous catheters were placed and the neonate was transferred to neonatal intensive care unit (NICU) in a stable condition.
A blood culture was drawn at birth and empiric treatment with Ampicillin and Gentamicin was intiated. The antibiotics were discontinued after 36 hours as the blood culture showed no growth and he remained clinically stable. In addition, as per unit protocol, an endotracheal aspirate was sent for a Ureaplasma culture on admission. This grew a Mycoplasma species for which 3 days of intravenous Azithromycin was given.
A head ultrasound on day 4 of life showed bilateral intraventricular hemorrhage (grade 3) with mild ventriculomegaly and a hemorrhagic venous infarct in the right frontoparietal region. Umbilical arterial catheter was removed on day 4 of life whereas umbilical venous catheter was removed on day 6 of life. He remained stable till day 7 of life when he presented with an acute clinical deterioration presenting as lethargy and tachycardia; a septic work up including blood and cerebrospinal fluid (CSF) cultures was completed and Vancomycin and Cefotaxime were started as empiric antibiotics. His CSF analysis showed red blood cells (RBC) count of 4887 × 10E6/l, pleocytosis of white blood cells (WBC) 9620 × 10E6/l with neutrophilic predominance, hyperproteorachia - protein 8300 mg/l and hypoglycorachia - glucose 0.1 mmoles/liter. Gram staining in CSF was negative. Within hours he developed generalized clinical seizures which was treated with Lorazepam and Phenobarbital followed by a Levetiracetam load and maintenance dose. He had further episodes of clinical and subclinical seizures which resolved after further adjustment of levetiracetam doses.
His first CSF culture was suspected to grow Mycoplasma Hominis and was sent to the regional national diagnostic laboratory for confirmation. The CSF culture was repeated along with a sample for 16s ribosomal RNA PCR analyses. The 16s ribosomal RNA PCR analysis confirmed Mycoplasma hominis in both CSF samples. Antibiotics were then changed to Moxifloxacin and Doxycycline. The repeat CSF culture after 48 hours of Moxifloxacin and Doxycycline showed no growth. CSF analysis done seven days after starting this treatment showed RBC 5650 × 10E6/l, WBC 449 × 10E6/l, protein 3763 mg/l and glucose 0.2 mmoles/liter. Subsequent CSF findings repeated after another three days showed further improvement, RBC 7187 × 10E6/l, WBC 93 × 10E6/l, protein 3691 mg/l and glucose 0.5 mmoles/liter. No growth was seen on any of these CSF cultures. Serial head ultrasound scans were done which showed progressive ventriculomegaly, post hemorrhagic ventricular dilatation and cystic evolution of hemorrhagic/venous infarct in the right frontoparietal region. Although these findings could be attributed to extreme prematurity; there is a likelihood that infection with Mycoplasma Hominis may have played a role in its progression. There have been documented cases of Mycoplasma Hominis meningitis resulting in CNS complications including intraventricular and periventricular hemorrhage, hydrocephalus, and infarction [3]. Lumbar taps were repeated as therapeutic measure to reduce ventriculomegaly, but optimal volumes of CSF were not obtained. Because of the ventriculomegaly, he was evaluated for a possible shunt on day 31; this was deferred because of the stable ventriculomegaly.
Antibiotics were given for a total duration of six weeks after which he was discharged home with a normal neurological examination. He was referred to Neurodevelopmental clinic for follow-up.
Discussion and conclusion
Neonatal CNS infections with Mycoplasma Hominis, although rare, can cause severe morbidity and mortality in neonates [1]. In a case series of 29 neonates with Mycoplasma Hominis infection (age of presentation day1-32 of life), Hata and colleagues reported complications such as brain abscess, hydrocephalus, infarction, cerebritis and periventricular/intraventricular hemorrhage in 34 % cases, death in 28 % and sequelae mostly hemiparesis in another 28 % cases [3]. This may be attributed to a delay in diagnosis, ineffective antibiotic treatment, or suboptimal treatment regimens for neonatal CNS disease [3, 4]. Therefore, prompt diagnosis, early initiation and optimal duration of appropriate antibiotic therapy is necessary for a favorable prognosis.
The clinical presentation may include apnea, temperature instability, lethargy, vomiting, irritability poor tone, twitching or seizures [7]. Detection of Mycoplasma Hominis can be challenging since they lack peptidoglycan cell wall which renders them unidentifiable by gram staining [5]. In addition to this, they grow very slowly on routine culture media and require a specific blood agar medium for their detection [1, 6]. Due to this, there is a likelihood that Mycoplasma Hominis infections may remain undiagnosed or diagnosed late in infants presenting with clinical signs and symptoms [2]. Hence, it is important to consider the possibility of Mycoplasma Hominis infection in cases where the CSF shows pleocytosis and no growth of organism on routine culture media. A 16S ribosomal RNA PCR analysis has proven useful for detection of Mycoplasma Hominis in blood and CSF which are difficult to grow on standard culture media [7, 8]. The microbe is identified by direct sequencing analysis after amplification by PCR. Use of pathogen-specific primers in 16S RNA analysis results in rapid detection of the specific organism [4]. Prematurity, low birth weight, and neural tube defects are recognized to be the most common risk factors for neonatal meningitis with Mycoplasma Hominis [6]. However, it has also been seen in term neonates with no neurological birth malformations [1, 3].
The treatment options for Mycoplasma Hominis meningitis and its duration remains unclear [1, 9]. Due to the rarity of this infection in neonates, the current recommendations are based on clinical experiences and in-vitro susceptibility test results [9, 10].
Mycoplasma Hominis has shown susceptibility to Chloramphenicol, Tetracyclines, Lincosamide and Fluoroquinolones in in-vitro testing [11]. Fluoroquinolones have been used in past to treat neonatal mycoplasma hominins meningitis successfully [1, 3, 5]. Moxifloxacin, a fourth-generation fluoroquinolone is preferred because of its ability to concentrate in CSF and its bactericidal effects in CNS infections [1, 12, 13]. Although there are cases which were successfully treated with Moxifloxacin monotherapy [1, 6], there is a risk of development of resistance with fluoroquinolones during treatment [9, 14, 15]. Our literature search revealed only two reported cases of neonates who were given Moxifloxacin in combination with another antibiotic for Mycoplasma Hominis meningitis [3, 5] (Table 1).
Table 1 Characteristics of neonates treated with combination therapy (Moxifloxacin and another antibiotic) for Mycoplasma Hominis CNS infection
Gestational Age Age at presentation Clinical presentation Confirmation of diagnosis Empirical antibiotic therapy and duration Antibiotics for Mycoplasma Hominis Outcome
Hata and colleagues3 38 weeks 25 days Fever, vomiting, focal seizures 16S RNA PCR Ampicillin & Cefotaxime (day 1–2) Ciprofloxacin (day 6–17) Acyclovir (day 6–8) Chloramphenicol (day 8–17) Minocycline for 28 days (day 6–34) Moxifloxacin for 17 days (day 17–34) Recovery with left hemiplegia
Watt and colleagues5 26 weeks 7 days Apnea, hypotonia, generalized seizures 16S RNA PCR Ampicillin and Gentamycin (day1-8) Ceftazidime (day 1–5 ) Vancomycin (day 8–19 ) Acyclovir (day 8–19) Meropenem (day 12–19 ) Doxycycline for 6 weeks (day 19–60) Moxifloxacin for 6 weeks (day 19–60) Recovery, neurological outcomes not reported
Our case 25 + 6 weeks 7 days Lethargy, tachycardia, generalized seizures 16S RNA PCR Ampicillin and Gentamycin (day 1–2) Azithromycin (day 3–6) Vancomycin and cefotaxime (day 7–10) Doxycycline for 6 weeks (day 10–52) Moxifloxacin for 6 weeks (day 10–52) Recovery with normal neurological examination at discharge, follow up at 6 months showed normal neurological examination
Evidence from previously published cases show that 28 % neonates with Mycoplasma Hominis CNS infection died whereas 34 % had some CNS complications and 28 % cases developed some neurological sequelae mostly hemiparesis [3]. In our case, treatment with a combination therapy of Moxifloxacin and Doxycycline resulted in significant clinical and laboratory improvement in terms of negative CSF culture after 48 hours of initiating this regimen and decreased WBC count and protein in subsequent CSF analysis. Our patient was discharged home with a normal neurological examination and stable ventriculomegaly. His neurodevelopmental follow up at six months of age showed normal neurological findings.
It is important to consider Mycoplasma Hominis as a potential cause for neonatal meningitis in infants particularly those with previous colonization with this rare but devastating species. Our case demonstrates effective eradication of Mycoplasma Hominis with a combination therapy of Moxifloxacin and Doxycycline. However, further research is required to understand the pharmacokinetics of these antibiotics to establish optimal dosing and duration for effective treatment of CNS infections with Mycoplasma Hominis.
Abbreviations
G2P1Gravida2, Parity1
PCRPolymerase chain reaction
RNARibonucleic acid
IVFIn vitro fertilization
CSFCerebrospinal fluid
RBCRed blood cells
WBCWhite blood cells
CNSCentral nervous system
VDRLVenereal disease research laboratory test
NICUNeonatal intensive care unit
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Acknowledgements
Not applicable.
Authors’ contributions
NSA, EA, and AR conceptualized the idea of writing this case report. NSA drafted the initial manuscript which was revised by AR and EA. AR and EA supervised the literature review for this case study, critically reviewed the manuscript, and approved the final version.
Funding
No funding received from any public, commercial or non-profit organization.
Availability of data and materials
Not applicable.
Ethics approval and consent to participate
None.
Consent for publication
Written informed consent was obtained from patient’s parents for publication of this case report.
Competing interests
The authors declare that they have no competing interests. | Recovered | ReactionOutcome | CC BY | 33557784 | 18,988,595 | 2021-02-08 |
What was the outcome of reaction 'Intraventricular haemorrhage neonatal'? | Mycoplasma hominis meningitis in an extremely preterm newborn: a case report.
Mycoplasma Hominis is a micro-organism which is a part of the human genitourinary tract flora. Neonates are susceptible to acquire this pathogen either in utero or through vertical transmission. In rare cases, it may cause central nervous system infections with severe morbidity and mortality in preterm and term neonates.
We present a case of Mycoplasma Hominis meningitis in an extremely preterm neonate who presented with lethargy, tachycardia and seizures on day 7 of life. There was no history of maternal systemic or genitourinary infection during pregnancy and at the time of delivery. Empirical antibiotic therapy for neonatal meningitis was commenced after sending blood and cerebrospinal fluid cultures. Cerebrospinal fluid analysis showed pleocytosis with neutrophilic predominance, but no bacteria was identified on gram staining. Blood culture yielded no growth of any bacterial pathogen. However, growth of Mycoplasma Hominis was suspected in cerebrospinal fluid culture which was confirmed by 16S ribosomal ribonucleic acid (RNA) polymerase chain reaction analysis. Subsequently, antibiotics were changed to Moxifloxacin and Doxycycline which were given for a total duration of 6 weeks. Multiple cerebrospinal fluid cultures were performed during this treatment. No growth of any pathogen was identified on any of these cerebrospinal fluid cultures.
We report a rare case of Mycoplasma Hominis meningitis in an extremely preterm neonate which was successfully treated with a combination therapy of Moxifloxacin and Doxycycline. It is important to consider the possibility of Mycoplasma Hominis meningitis in neonates who present with clinical signs and pleocytosis in cerebrospinal fluid but negative gram staining and no growth on conventional culture media.
Background
Mycoplasma Hominis is a frequent habitant of the human genital tract [1]. Neonates are susceptible to acquire this microbe either in utero or through the colonized birth canal during the process of parturition [2]. However, invasive infections with this organism in preterm and term infants are noted to be rare [1, 3]. We describe an unusual case of neonatal meningitis due to Mycoplasma Hominis, confirmed in bacterial cultures and 16s ribosomal RNA Polymerase chain reaction (PCR) analysis. This case report demonstrates the importance of suspecting Mycoplasma Hominis as a cause of central nervous system (CNS) infection in neonates who present with clinical signs but no growth on conventional bacterial cultures and no improvement on empirical antibiotic treatment.
Case presentation
A male neonate was born at 25 + 6 weeks of gestation to 35 years old gravida 2, parity1 (G2P1) mother with antiphospholipid antibody syndrome. This was an in vitro fertilization (IVF) pregnancy. She was Rubella immune and negative for Hepatitis B surface antigen, Venereal disease research laboratory test (VDRL), Human immunodeficiency virus, Gonococci and Chlamydia. Her urine culture and vaginal swab for Group B Streptococci was also negative. Her anatomy scan at 18 weeks of gestation showed normal fetal anatomy and a short cervix for which she underwent cervical cerclage placement at 20 + 5 weeks gestation. There was no history of chorioamnionitis or prolonged rupture of membranes. She presented at 25 + 5 weeks with preterm labor and had a spontaneous vaginal delivery the next day. She had received two doses of Betamethasone and Magnesium sulphate prior to delivery. He initially required positive pressure ventilation followed by intubation and surfactant administration with an acceptable response. Umbilical arterial and venous catheters were placed and the neonate was transferred to neonatal intensive care unit (NICU) in a stable condition.
A blood culture was drawn at birth and empiric treatment with Ampicillin and Gentamicin was intiated. The antibiotics were discontinued after 36 hours as the blood culture showed no growth and he remained clinically stable. In addition, as per unit protocol, an endotracheal aspirate was sent for a Ureaplasma culture on admission. This grew a Mycoplasma species for which 3 days of intravenous Azithromycin was given.
A head ultrasound on day 4 of life showed bilateral intraventricular hemorrhage (grade 3) with mild ventriculomegaly and a hemorrhagic venous infarct in the right frontoparietal region. Umbilical arterial catheter was removed on day 4 of life whereas umbilical venous catheter was removed on day 6 of life. He remained stable till day 7 of life when he presented with an acute clinical deterioration presenting as lethargy and tachycardia; a septic work up including blood and cerebrospinal fluid (CSF) cultures was completed and Vancomycin and Cefotaxime were started as empiric antibiotics. His CSF analysis showed red blood cells (RBC) count of 4887 × 10E6/l, pleocytosis of white blood cells (WBC) 9620 × 10E6/l with neutrophilic predominance, hyperproteorachia - protein 8300 mg/l and hypoglycorachia - glucose 0.1 mmoles/liter. Gram staining in CSF was negative. Within hours he developed generalized clinical seizures which was treated with Lorazepam and Phenobarbital followed by a Levetiracetam load and maintenance dose. He had further episodes of clinical and subclinical seizures which resolved after further adjustment of levetiracetam doses.
His first CSF culture was suspected to grow Mycoplasma Hominis and was sent to the regional national diagnostic laboratory for confirmation. The CSF culture was repeated along with a sample for 16s ribosomal RNA PCR analyses. The 16s ribosomal RNA PCR analysis confirmed Mycoplasma hominis in both CSF samples. Antibiotics were then changed to Moxifloxacin and Doxycycline. The repeat CSF culture after 48 hours of Moxifloxacin and Doxycycline showed no growth. CSF analysis done seven days after starting this treatment showed RBC 5650 × 10E6/l, WBC 449 × 10E6/l, protein 3763 mg/l and glucose 0.2 mmoles/liter. Subsequent CSF findings repeated after another three days showed further improvement, RBC 7187 × 10E6/l, WBC 93 × 10E6/l, protein 3691 mg/l and glucose 0.5 mmoles/liter. No growth was seen on any of these CSF cultures. Serial head ultrasound scans were done which showed progressive ventriculomegaly, post hemorrhagic ventricular dilatation and cystic evolution of hemorrhagic/venous infarct in the right frontoparietal region. Although these findings could be attributed to extreme prematurity; there is a likelihood that infection with Mycoplasma Hominis may have played a role in its progression. There have been documented cases of Mycoplasma Hominis meningitis resulting in CNS complications including intraventricular and periventricular hemorrhage, hydrocephalus, and infarction [3]. Lumbar taps were repeated as therapeutic measure to reduce ventriculomegaly, but optimal volumes of CSF were not obtained. Because of the ventriculomegaly, he was evaluated for a possible shunt on day 31; this was deferred because of the stable ventriculomegaly.
Antibiotics were given for a total duration of six weeks after which he was discharged home with a normal neurological examination. He was referred to Neurodevelopmental clinic for follow-up.
Discussion and conclusion
Neonatal CNS infections with Mycoplasma Hominis, although rare, can cause severe morbidity and mortality in neonates [1]. In a case series of 29 neonates with Mycoplasma Hominis infection (age of presentation day1-32 of life), Hata and colleagues reported complications such as brain abscess, hydrocephalus, infarction, cerebritis and periventricular/intraventricular hemorrhage in 34 % cases, death in 28 % and sequelae mostly hemiparesis in another 28 % cases [3]. This may be attributed to a delay in diagnosis, ineffective antibiotic treatment, or suboptimal treatment regimens for neonatal CNS disease [3, 4]. Therefore, prompt diagnosis, early initiation and optimal duration of appropriate antibiotic therapy is necessary for a favorable prognosis.
The clinical presentation may include apnea, temperature instability, lethargy, vomiting, irritability poor tone, twitching or seizures [7]. Detection of Mycoplasma Hominis can be challenging since they lack peptidoglycan cell wall which renders them unidentifiable by gram staining [5]. In addition to this, they grow very slowly on routine culture media and require a specific blood agar medium for their detection [1, 6]. Due to this, there is a likelihood that Mycoplasma Hominis infections may remain undiagnosed or diagnosed late in infants presenting with clinical signs and symptoms [2]. Hence, it is important to consider the possibility of Mycoplasma Hominis infection in cases where the CSF shows pleocytosis and no growth of organism on routine culture media. A 16S ribosomal RNA PCR analysis has proven useful for detection of Mycoplasma Hominis in blood and CSF which are difficult to grow on standard culture media [7, 8]. The microbe is identified by direct sequencing analysis after amplification by PCR. Use of pathogen-specific primers in 16S RNA analysis results in rapid detection of the specific organism [4]. Prematurity, low birth weight, and neural tube defects are recognized to be the most common risk factors for neonatal meningitis with Mycoplasma Hominis [6]. However, it has also been seen in term neonates with no neurological birth malformations [1, 3].
The treatment options for Mycoplasma Hominis meningitis and its duration remains unclear [1, 9]. Due to the rarity of this infection in neonates, the current recommendations are based on clinical experiences and in-vitro susceptibility test results [9, 10].
Mycoplasma Hominis has shown susceptibility to Chloramphenicol, Tetracyclines, Lincosamide and Fluoroquinolones in in-vitro testing [11]. Fluoroquinolones have been used in past to treat neonatal mycoplasma hominins meningitis successfully [1, 3, 5]. Moxifloxacin, a fourth-generation fluoroquinolone is preferred because of its ability to concentrate in CSF and its bactericidal effects in CNS infections [1, 12, 13]. Although there are cases which were successfully treated with Moxifloxacin monotherapy [1, 6], there is a risk of development of resistance with fluoroquinolones during treatment [9, 14, 15]. Our literature search revealed only two reported cases of neonates who were given Moxifloxacin in combination with another antibiotic for Mycoplasma Hominis meningitis [3, 5] (Table 1).
Table 1 Characteristics of neonates treated with combination therapy (Moxifloxacin and another antibiotic) for Mycoplasma Hominis CNS infection
Gestational Age Age at presentation Clinical presentation Confirmation of diagnosis Empirical antibiotic therapy and duration Antibiotics for Mycoplasma Hominis Outcome
Hata and colleagues3 38 weeks 25 days Fever, vomiting, focal seizures 16S RNA PCR Ampicillin & Cefotaxime (day 1–2) Ciprofloxacin (day 6–17) Acyclovir (day 6–8) Chloramphenicol (day 8–17) Minocycline for 28 days (day 6–34) Moxifloxacin for 17 days (day 17–34) Recovery with left hemiplegia
Watt and colleagues5 26 weeks 7 days Apnea, hypotonia, generalized seizures 16S RNA PCR Ampicillin and Gentamycin (day1-8) Ceftazidime (day 1–5 ) Vancomycin (day 8–19 ) Acyclovir (day 8–19) Meropenem (day 12–19 ) Doxycycline for 6 weeks (day 19–60) Moxifloxacin for 6 weeks (day 19–60) Recovery, neurological outcomes not reported
Our case 25 + 6 weeks 7 days Lethargy, tachycardia, generalized seizures 16S RNA PCR Ampicillin and Gentamycin (day 1–2) Azithromycin (day 3–6) Vancomycin and cefotaxime (day 7–10) Doxycycline for 6 weeks (day 10–52) Moxifloxacin for 6 weeks (day 10–52) Recovery with normal neurological examination at discharge, follow up at 6 months showed normal neurological examination
Evidence from previously published cases show that 28 % neonates with Mycoplasma Hominis CNS infection died whereas 34 % had some CNS complications and 28 % cases developed some neurological sequelae mostly hemiparesis [3]. In our case, treatment with a combination therapy of Moxifloxacin and Doxycycline resulted in significant clinical and laboratory improvement in terms of negative CSF culture after 48 hours of initiating this regimen and decreased WBC count and protein in subsequent CSF analysis. Our patient was discharged home with a normal neurological examination and stable ventriculomegaly. His neurodevelopmental follow up at six months of age showed normal neurological findings.
It is important to consider Mycoplasma Hominis as a potential cause for neonatal meningitis in infants particularly those with previous colonization with this rare but devastating species. Our case demonstrates effective eradication of Mycoplasma Hominis with a combination therapy of Moxifloxacin and Doxycycline. However, further research is required to understand the pharmacokinetics of these antibiotics to establish optimal dosing and duration for effective treatment of CNS infections with Mycoplasma Hominis.
Abbreviations
G2P1Gravida2, Parity1
PCRPolymerase chain reaction
RNARibonucleic acid
IVFIn vitro fertilization
CSFCerebrospinal fluid
RBCRed blood cells
WBCWhite blood cells
CNSCentral nervous system
VDRLVenereal disease research laboratory test
NICUNeonatal intensive care unit
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Acknowledgements
Not applicable.
Authors’ contributions
NSA, EA, and AR conceptualized the idea of writing this case report. NSA drafted the initial manuscript which was revised by AR and EA. AR and EA supervised the literature review for this case study, critically reviewed the manuscript, and approved the final version.
Funding
No funding received from any public, commercial or non-profit organization.
Availability of data and materials
Not applicable.
Ethics approval and consent to participate
None.
Consent for publication
Written informed consent was obtained from patient’s parents for publication of this case report.
Competing interests
The authors declare that they have no competing interests. | Recovered | ReactionOutcome | CC BY | 33557784 | 18,988,595 | 2021-02-08 |
What was the outcome of reaction 'Lethargy'? | Mycoplasma hominis meningitis in an extremely preterm newborn: a case report.
Mycoplasma Hominis is a micro-organism which is a part of the human genitourinary tract flora. Neonates are susceptible to acquire this pathogen either in utero or through vertical transmission. In rare cases, it may cause central nervous system infections with severe morbidity and mortality in preterm and term neonates.
We present a case of Mycoplasma Hominis meningitis in an extremely preterm neonate who presented with lethargy, tachycardia and seizures on day 7 of life. There was no history of maternal systemic or genitourinary infection during pregnancy and at the time of delivery. Empirical antibiotic therapy for neonatal meningitis was commenced after sending blood and cerebrospinal fluid cultures. Cerebrospinal fluid analysis showed pleocytosis with neutrophilic predominance, but no bacteria was identified on gram staining. Blood culture yielded no growth of any bacterial pathogen. However, growth of Mycoplasma Hominis was suspected in cerebrospinal fluid culture which was confirmed by 16S ribosomal ribonucleic acid (RNA) polymerase chain reaction analysis. Subsequently, antibiotics were changed to Moxifloxacin and Doxycycline which were given for a total duration of 6 weeks. Multiple cerebrospinal fluid cultures were performed during this treatment. No growth of any pathogen was identified on any of these cerebrospinal fluid cultures.
We report a rare case of Mycoplasma Hominis meningitis in an extremely preterm neonate which was successfully treated with a combination therapy of Moxifloxacin and Doxycycline. It is important to consider the possibility of Mycoplasma Hominis meningitis in neonates who present with clinical signs and pleocytosis in cerebrospinal fluid but negative gram staining and no growth on conventional culture media.
Background
Mycoplasma Hominis is a frequent habitant of the human genital tract [1]. Neonates are susceptible to acquire this microbe either in utero or through the colonized birth canal during the process of parturition [2]. However, invasive infections with this organism in preterm and term infants are noted to be rare [1, 3]. We describe an unusual case of neonatal meningitis due to Mycoplasma Hominis, confirmed in bacterial cultures and 16s ribosomal RNA Polymerase chain reaction (PCR) analysis. This case report demonstrates the importance of suspecting Mycoplasma Hominis as a cause of central nervous system (CNS) infection in neonates who present with clinical signs but no growth on conventional bacterial cultures and no improvement on empirical antibiotic treatment.
Case presentation
A male neonate was born at 25 + 6 weeks of gestation to 35 years old gravida 2, parity1 (G2P1) mother with antiphospholipid antibody syndrome. This was an in vitro fertilization (IVF) pregnancy. She was Rubella immune and negative for Hepatitis B surface antigen, Venereal disease research laboratory test (VDRL), Human immunodeficiency virus, Gonococci and Chlamydia. Her urine culture and vaginal swab for Group B Streptococci was also negative. Her anatomy scan at 18 weeks of gestation showed normal fetal anatomy and a short cervix for which she underwent cervical cerclage placement at 20 + 5 weeks gestation. There was no history of chorioamnionitis or prolonged rupture of membranes. She presented at 25 + 5 weeks with preterm labor and had a spontaneous vaginal delivery the next day. She had received two doses of Betamethasone and Magnesium sulphate prior to delivery. He initially required positive pressure ventilation followed by intubation and surfactant administration with an acceptable response. Umbilical arterial and venous catheters were placed and the neonate was transferred to neonatal intensive care unit (NICU) in a stable condition.
A blood culture was drawn at birth and empiric treatment with Ampicillin and Gentamicin was intiated. The antibiotics were discontinued after 36 hours as the blood culture showed no growth and he remained clinically stable. In addition, as per unit protocol, an endotracheal aspirate was sent for a Ureaplasma culture on admission. This grew a Mycoplasma species for which 3 days of intravenous Azithromycin was given.
A head ultrasound on day 4 of life showed bilateral intraventricular hemorrhage (grade 3) with mild ventriculomegaly and a hemorrhagic venous infarct in the right frontoparietal region. Umbilical arterial catheter was removed on day 4 of life whereas umbilical venous catheter was removed on day 6 of life. He remained stable till day 7 of life when he presented with an acute clinical deterioration presenting as lethargy and tachycardia; a septic work up including blood and cerebrospinal fluid (CSF) cultures was completed and Vancomycin and Cefotaxime were started as empiric antibiotics. His CSF analysis showed red blood cells (RBC) count of 4887 × 10E6/l, pleocytosis of white blood cells (WBC) 9620 × 10E6/l with neutrophilic predominance, hyperproteorachia - protein 8300 mg/l and hypoglycorachia - glucose 0.1 mmoles/liter. Gram staining in CSF was negative. Within hours he developed generalized clinical seizures which was treated with Lorazepam and Phenobarbital followed by a Levetiracetam load and maintenance dose. He had further episodes of clinical and subclinical seizures which resolved after further adjustment of levetiracetam doses.
His first CSF culture was suspected to grow Mycoplasma Hominis and was sent to the regional national diagnostic laboratory for confirmation. The CSF culture was repeated along with a sample for 16s ribosomal RNA PCR analyses. The 16s ribosomal RNA PCR analysis confirmed Mycoplasma hominis in both CSF samples. Antibiotics were then changed to Moxifloxacin and Doxycycline. The repeat CSF culture after 48 hours of Moxifloxacin and Doxycycline showed no growth. CSF analysis done seven days after starting this treatment showed RBC 5650 × 10E6/l, WBC 449 × 10E6/l, protein 3763 mg/l and glucose 0.2 mmoles/liter. Subsequent CSF findings repeated after another three days showed further improvement, RBC 7187 × 10E6/l, WBC 93 × 10E6/l, protein 3691 mg/l and glucose 0.5 mmoles/liter. No growth was seen on any of these CSF cultures. Serial head ultrasound scans were done which showed progressive ventriculomegaly, post hemorrhagic ventricular dilatation and cystic evolution of hemorrhagic/venous infarct in the right frontoparietal region. Although these findings could be attributed to extreme prematurity; there is a likelihood that infection with Mycoplasma Hominis may have played a role in its progression. There have been documented cases of Mycoplasma Hominis meningitis resulting in CNS complications including intraventricular and periventricular hemorrhage, hydrocephalus, and infarction [3]. Lumbar taps were repeated as therapeutic measure to reduce ventriculomegaly, but optimal volumes of CSF were not obtained. Because of the ventriculomegaly, he was evaluated for a possible shunt on day 31; this was deferred because of the stable ventriculomegaly.
Antibiotics were given for a total duration of six weeks after which he was discharged home with a normal neurological examination. He was referred to Neurodevelopmental clinic for follow-up.
Discussion and conclusion
Neonatal CNS infections with Mycoplasma Hominis, although rare, can cause severe morbidity and mortality in neonates [1]. In a case series of 29 neonates with Mycoplasma Hominis infection (age of presentation day1-32 of life), Hata and colleagues reported complications such as brain abscess, hydrocephalus, infarction, cerebritis and periventricular/intraventricular hemorrhage in 34 % cases, death in 28 % and sequelae mostly hemiparesis in another 28 % cases [3]. This may be attributed to a delay in diagnosis, ineffective antibiotic treatment, or suboptimal treatment regimens for neonatal CNS disease [3, 4]. Therefore, prompt diagnosis, early initiation and optimal duration of appropriate antibiotic therapy is necessary for a favorable prognosis.
The clinical presentation may include apnea, temperature instability, lethargy, vomiting, irritability poor tone, twitching or seizures [7]. Detection of Mycoplasma Hominis can be challenging since they lack peptidoglycan cell wall which renders them unidentifiable by gram staining [5]. In addition to this, they grow very slowly on routine culture media and require a specific blood agar medium for their detection [1, 6]. Due to this, there is a likelihood that Mycoplasma Hominis infections may remain undiagnosed or diagnosed late in infants presenting with clinical signs and symptoms [2]. Hence, it is important to consider the possibility of Mycoplasma Hominis infection in cases where the CSF shows pleocytosis and no growth of organism on routine culture media. A 16S ribosomal RNA PCR analysis has proven useful for detection of Mycoplasma Hominis in blood and CSF which are difficult to grow on standard culture media [7, 8]. The microbe is identified by direct sequencing analysis after amplification by PCR. Use of pathogen-specific primers in 16S RNA analysis results in rapid detection of the specific organism [4]. Prematurity, low birth weight, and neural tube defects are recognized to be the most common risk factors for neonatal meningitis with Mycoplasma Hominis [6]. However, it has also been seen in term neonates with no neurological birth malformations [1, 3].
The treatment options for Mycoplasma Hominis meningitis and its duration remains unclear [1, 9]. Due to the rarity of this infection in neonates, the current recommendations are based on clinical experiences and in-vitro susceptibility test results [9, 10].
Mycoplasma Hominis has shown susceptibility to Chloramphenicol, Tetracyclines, Lincosamide and Fluoroquinolones in in-vitro testing [11]. Fluoroquinolones have been used in past to treat neonatal mycoplasma hominins meningitis successfully [1, 3, 5]. Moxifloxacin, a fourth-generation fluoroquinolone is preferred because of its ability to concentrate in CSF and its bactericidal effects in CNS infections [1, 12, 13]. Although there are cases which were successfully treated with Moxifloxacin monotherapy [1, 6], there is a risk of development of resistance with fluoroquinolones during treatment [9, 14, 15]. Our literature search revealed only two reported cases of neonates who were given Moxifloxacin in combination with another antibiotic for Mycoplasma Hominis meningitis [3, 5] (Table 1).
Table 1 Characteristics of neonates treated with combination therapy (Moxifloxacin and another antibiotic) for Mycoplasma Hominis CNS infection
Gestational Age Age at presentation Clinical presentation Confirmation of diagnosis Empirical antibiotic therapy and duration Antibiotics for Mycoplasma Hominis Outcome
Hata and colleagues3 38 weeks 25 days Fever, vomiting, focal seizures 16S RNA PCR Ampicillin & Cefotaxime (day 1–2) Ciprofloxacin (day 6–17) Acyclovir (day 6–8) Chloramphenicol (day 8–17) Minocycline for 28 days (day 6–34) Moxifloxacin for 17 days (day 17–34) Recovery with left hemiplegia
Watt and colleagues5 26 weeks 7 days Apnea, hypotonia, generalized seizures 16S RNA PCR Ampicillin and Gentamycin (day1-8) Ceftazidime (day 1–5 ) Vancomycin (day 8–19 ) Acyclovir (day 8–19) Meropenem (day 12–19 ) Doxycycline for 6 weeks (day 19–60) Moxifloxacin for 6 weeks (day 19–60) Recovery, neurological outcomes not reported
Our case 25 + 6 weeks 7 days Lethargy, tachycardia, generalized seizures 16S RNA PCR Ampicillin and Gentamycin (day 1–2) Azithromycin (day 3–6) Vancomycin and cefotaxime (day 7–10) Doxycycline for 6 weeks (day 10–52) Moxifloxacin for 6 weeks (day 10–52) Recovery with normal neurological examination at discharge, follow up at 6 months showed normal neurological examination
Evidence from previously published cases show that 28 % neonates with Mycoplasma Hominis CNS infection died whereas 34 % had some CNS complications and 28 % cases developed some neurological sequelae mostly hemiparesis [3]. In our case, treatment with a combination therapy of Moxifloxacin and Doxycycline resulted in significant clinical and laboratory improvement in terms of negative CSF culture after 48 hours of initiating this regimen and decreased WBC count and protein in subsequent CSF analysis. Our patient was discharged home with a normal neurological examination and stable ventriculomegaly. His neurodevelopmental follow up at six months of age showed normal neurological findings.
It is important to consider Mycoplasma Hominis as a potential cause for neonatal meningitis in infants particularly those with previous colonization with this rare but devastating species. Our case demonstrates effective eradication of Mycoplasma Hominis with a combination therapy of Moxifloxacin and Doxycycline. However, further research is required to understand the pharmacokinetics of these antibiotics to establish optimal dosing and duration for effective treatment of CNS infections with Mycoplasma Hominis.
Abbreviations
G2P1Gravida2, Parity1
PCRPolymerase chain reaction
RNARibonucleic acid
IVFIn vitro fertilization
CSFCerebrospinal fluid
RBCRed blood cells
WBCWhite blood cells
CNSCentral nervous system
VDRLVenereal disease research laboratory test
NICUNeonatal intensive care unit
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Acknowledgements
Not applicable.
Authors’ contributions
NSA, EA, and AR conceptualized the idea of writing this case report. NSA drafted the initial manuscript which was revised by AR and EA. AR and EA supervised the literature review for this case study, critically reviewed the manuscript, and approved the final version.
Funding
No funding received from any public, commercial or non-profit organization.
Availability of data and materials
Not applicable.
Ethics approval and consent to participate
None.
Consent for publication
Written informed consent was obtained from patient’s parents for publication of this case report.
Competing interests
The authors declare that they have no competing interests. | Recovered | ReactionOutcome | CC BY | 33557784 | 18,988,595 | 2021-02-08 |
What was the outcome of reaction 'Neonatal tachycardia'? | Mycoplasma hominis meningitis in an extremely preterm newborn: a case report.
Mycoplasma Hominis is a micro-organism which is a part of the human genitourinary tract flora. Neonates are susceptible to acquire this pathogen either in utero or through vertical transmission. In rare cases, it may cause central nervous system infections with severe morbidity and mortality in preterm and term neonates.
We present a case of Mycoplasma Hominis meningitis in an extremely preterm neonate who presented with lethargy, tachycardia and seizures on day 7 of life. There was no history of maternal systemic or genitourinary infection during pregnancy and at the time of delivery. Empirical antibiotic therapy for neonatal meningitis was commenced after sending blood and cerebrospinal fluid cultures. Cerebrospinal fluid analysis showed pleocytosis with neutrophilic predominance, but no bacteria was identified on gram staining. Blood culture yielded no growth of any bacterial pathogen. However, growth of Mycoplasma Hominis was suspected in cerebrospinal fluid culture which was confirmed by 16S ribosomal ribonucleic acid (RNA) polymerase chain reaction analysis. Subsequently, antibiotics were changed to Moxifloxacin and Doxycycline which were given for a total duration of 6 weeks. Multiple cerebrospinal fluid cultures were performed during this treatment. No growth of any pathogen was identified on any of these cerebrospinal fluid cultures.
We report a rare case of Mycoplasma Hominis meningitis in an extremely preterm neonate which was successfully treated with a combination therapy of Moxifloxacin and Doxycycline. It is important to consider the possibility of Mycoplasma Hominis meningitis in neonates who present with clinical signs and pleocytosis in cerebrospinal fluid but negative gram staining and no growth on conventional culture media.
Background
Mycoplasma Hominis is a frequent habitant of the human genital tract [1]. Neonates are susceptible to acquire this microbe either in utero or through the colonized birth canal during the process of parturition [2]. However, invasive infections with this organism in preterm and term infants are noted to be rare [1, 3]. We describe an unusual case of neonatal meningitis due to Mycoplasma Hominis, confirmed in bacterial cultures and 16s ribosomal RNA Polymerase chain reaction (PCR) analysis. This case report demonstrates the importance of suspecting Mycoplasma Hominis as a cause of central nervous system (CNS) infection in neonates who present with clinical signs but no growth on conventional bacterial cultures and no improvement on empirical antibiotic treatment.
Case presentation
A male neonate was born at 25 + 6 weeks of gestation to 35 years old gravida 2, parity1 (G2P1) mother with antiphospholipid antibody syndrome. This was an in vitro fertilization (IVF) pregnancy. She was Rubella immune and negative for Hepatitis B surface antigen, Venereal disease research laboratory test (VDRL), Human immunodeficiency virus, Gonococci and Chlamydia. Her urine culture and vaginal swab for Group B Streptococci was also negative. Her anatomy scan at 18 weeks of gestation showed normal fetal anatomy and a short cervix for which she underwent cervical cerclage placement at 20 + 5 weeks gestation. There was no history of chorioamnionitis or prolonged rupture of membranes. She presented at 25 + 5 weeks with preterm labor and had a spontaneous vaginal delivery the next day. She had received two doses of Betamethasone and Magnesium sulphate prior to delivery. He initially required positive pressure ventilation followed by intubation and surfactant administration with an acceptable response. Umbilical arterial and venous catheters were placed and the neonate was transferred to neonatal intensive care unit (NICU) in a stable condition.
A blood culture was drawn at birth and empiric treatment with Ampicillin and Gentamicin was intiated. The antibiotics were discontinued after 36 hours as the blood culture showed no growth and he remained clinically stable. In addition, as per unit protocol, an endotracheal aspirate was sent for a Ureaplasma culture on admission. This grew a Mycoplasma species for which 3 days of intravenous Azithromycin was given.
A head ultrasound on day 4 of life showed bilateral intraventricular hemorrhage (grade 3) with mild ventriculomegaly and a hemorrhagic venous infarct in the right frontoparietal region. Umbilical arterial catheter was removed on day 4 of life whereas umbilical venous catheter was removed on day 6 of life. He remained stable till day 7 of life when he presented with an acute clinical deterioration presenting as lethargy and tachycardia; a septic work up including blood and cerebrospinal fluid (CSF) cultures was completed and Vancomycin and Cefotaxime were started as empiric antibiotics. His CSF analysis showed red blood cells (RBC) count of 4887 × 10E6/l, pleocytosis of white blood cells (WBC) 9620 × 10E6/l with neutrophilic predominance, hyperproteorachia - protein 8300 mg/l and hypoglycorachia - glucose 0.1 mmoles/liter. Gram staining in CSF was negative. Within hours he developed generalized clinical seizures which was treated with Lorazepam and Phenobarbital followed by a Levetiracetam load and maintenance dose. He had further episodes of clinical and subclinical seizures which resolved after further adjustment of levetiracetam doses.
His first CSF culture was suspected to grow Mycoplasma Hominis and was sent to the regional national diagnostic laboratory for confirmation. The CSF culture was repeated along with a sample for 16s ribosomal RNA PCR analyses. The 16s ribosomal RNA PCR analysis confirmed Mycoplasma hominis in both CSF samples. Antibiotics were then changed to Moxifloxacin and Doxycycline. The repeat CSF culture after 48 hours of Moxifloxacin and Doxycycline showed no growth. CSF analysis done seven days after starting this treatment showed RBC 5650 × 10E6/l, WBC 449 × 10E6/l, protein 3763 mg/l and glucose 0.2 mmoles/liter. Subsequent CSF findings repeated after another three days showed further improvement, RBC 7187 × 10E6/l, WBC 93 × 10E6/l, protein 3691 mg/l and glucose 0.5 mmoles/liter. No growth was seen on any of these CSF cultures. Serial head ultrasound scans were done which showed progressive ventriculomegaly, post hemorrhagic ventricular dilatation and cystic evolution of hemorrhagic/venous infarct in the right frontoparietal region. Although these findings could be attributed to extreme prematurity; there is a likelihood that infection with Mycoplasma Hominis may have played a role in its progression. There have been documented cases of Mycoplasma Hominis meningitis resulting in CNS complications including intraventricular and periventricular hemorrhage, hydrocephalus, and infarction [3]. Lumbar taps were repeated as therapeutic measure to reduce ventriculomegaly, but optimal volumes of CSF were not obtained. Because of the ventriculomegaly, he was evaluated for a possible shunt on day 31; this was deferred because of the stable ventriculomegaly.
Antibiotics were given for a total duration of six weeks after which he was discharged home with a normal neurological examination. He was referred to Neurodevelopmental clinic for follow-up.
Discussion and conclusion
Neonatal CNS infections with Mycoplasma Hominis, although rare, can cause severe morbidity and mortality in neonates [1]. In a case series of 29 neonates with Mycoplasma Hominis infection (age of presentation day1-32 of life), Hata and colleagues reported complications such as brain abscess, hydrocephalus, infarction, cerebritis and periventricular/intraventricular hemorrhage in 34 % cases, death in 28 % and sequelae mostly hemiparesis in another 28 % cases [3]. This may be attributed to a delay in diagnosis, ineffective antibiotic treatment, or suboptimal treatment regimens for neonatal CNS disease [3, 4]. Therefore, prompt diagnosis, early initiation and optimal duration of appropriate antibiotic therapy is necessary for a favorable prognosis.
The clinical presentation may include apnea, temperature instability, lethargy, vomiting, irritability poor tone, twitching or seizures [7]. Detection of Mycoplasma Hominis can be challenging since they lack peptidoglycan cell wall which renders them unidentifiable by gram staining [5]. In addition to this, they grow very slowly on routine culture media and require a specific blood agar medium for their detection [1, 6]. Due to this, there is a likelihood that Mycoplasma Hominis infections may remain undiagnosed or diagnosed late in infants presenting with clinical signs and symptoms [2]. Hence, it is important to consider the possibility of Mycoplasma Hominis infection in cases where the CSF shows pleocytosis and no growth of organism on routine culture media. A 16S ribosomal RNA PCR analysis has proven useful for detection of Mycoplasma Hominis in blood and CSF which are difficult to grow on standard culture media [7, 8]. The microbe is identified by direct sequencing analysis after amplification by PCR. Use of pathogen-specific primers in 16S RNA analysis results in rapid detection of the specific organism [4]. Prematurity, low birth weight, and neural tube defects are recognized to be the most common risk factors for neonatal meningitis with Mycoplasma Hominis [6]. However, it has also been seen in term neonates with no neurological birth malformations [1, 3].
The treatment options for Mycoplasma Hominis meningitis and its duration remains unclear [1, 9]. Due to the rarity of this infection in neonates, the current recommendations are based on clinical experiences and in-vitro susceptibility test results [9, 10].
Mycoplasma Hominis has shown susceptibility to Chloramphenicol, Tetracyclines, Lincosamide and Fluoroquinolones in in-vitro testing [11]. Fluoroquinolones have been used in past to treat neonatal mycoplasma hominins meningitis successfully [1, 3, 5]. Moxifloxacin, a fourth-generation fluoroquinolone is preferred because of its ability to concentrate in CSF and its bactericidal effects in CNS infections [1, 12, 13]. Although there are cases which were successfully treated with Moxifloxacin monotherapy [1, 6], there is a risk of development of resistance with fluoroquinolones during treatment [9, 14, 15]. Our literature search revealed only two reported cases of neonates who were given Moxifloxacin in combination with another antibiotic for Mycoplasma Hominis meningitis [3, 5] (Table 1).
Table 1 Characteristics of neonates treated with combination therapy (Moxifloxacin and another antibiotic) for Mycoplasma Hominis CNS infection
Gestational Age Age at presentation Clinical presentation Confirmation of diagnosis Empirical antibiotic therapy and duration Antibiotics for Mycoplasma Hominis Outcome
Hata and colleagues3 38 weeks 25 days Fever, vomiting, focal seizures 16S RNA PCR Ampicillin & Cefotaxime (day 1–2) Ciprofloxacin (day 6–17) Acyclovir (day 6–8) Chloramphenicol (day 8–17) Minocycline for 28 days (day 6–34) Moxifloxacin for 17 days (day 17–34) Recovery with left hemiplegia
Watt and colleagues5 26 weeks 7 days Apnea, hypotonia, generalized seizures 16S RNA PCR Ampicillin and Gentamycin (day1-8) Ceftazidime (day 1–5 ) Vancomycin (day 8–19 ) Acyclovir (day 8–19) Meropenem (day 12–19 ) Doxycycline for 6 weeks (day 19–60) Moxifloxacin for 6 weeks (day 19–60) Recovery, neurological outcomes not reported
Our case 25 + 6 weeks 7 days Lethargy, tachycardia, generalized seizures 16S RNA PCR Ampicillin and Gentamycin (day 1–2) Azithromycin (day 3–6) Vancomycin and cefotaxime (day 7–10) Doxycycline for 6 weeks (day 10–52) Moxifloxacin for 6 weeks (day 10–52) Recovery with normal neurological examination at discharge, follow up at 6 months showed normal neurological examination
Evidence from previously published cases show that 28 % neonates with Mycoplasma Hominis CNS infection died whereas 34 % had some CNS complications and 28 % cases developed some neurological sequelae mostly hemiparesis [3]. In our case, treatment with a combination therapy of Moxifloxacin and Doxycycline resulted in significant clinical and laboratory improvement in terms of negative CSF culture after 48 hours of initiating this regimen and decreased WBC count and protein in subsequent CSF analysis. Our patient was discharged home with a normal neurological examination and stable ventriculomegaly. His neurodevelopmental follow up at six months of age showed normal neurological findings.
It is important to consider Mycoplasma Hominis as a potential cause for neonatal meningitis in infants particularly those with previous colonization with this rare but devastating species. Our case demonstrates effective eradication of Mycoplasma Hominis with a combination therapy of Moxifloxacin and Doxycycline. However, further research is required to understand the pharmacokinetics of these antibiotics to establish optimal dosing and duration for effective treatment of CNS infections with Mycoplasma Hominis.
Abbreviations
G2P1Gravida2, Parity1
PCRPolymerase chain reaction
RNARibonucleic acid
IVFIn vitro fertilization
CSFCerebrospinal fluid
RBCRed blood cells
WBCWhite blood cells
CNSCentral nervous system
VDRLVenereal disease research laboratory test
NICUNeonatal intensive care unit
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Acknowledgements
Not applicable.
Authors’ contributions
NSA, EA, and AR conceptualized the idea of writing this case report. NSA drafted the initial manuscript which was revised by AR and EA. AR and EA supervised the literature review for this case study, critically reviewed the manuscript, and approved the final version.
Funding
No funding received from any public, commercial or non-profit organization.
Availability of data and materials
Not applicable.
Ethics approval and consent to participate
None.
Consent for publication
Written informed consent was obtained from patient’s parents for publication of this case report.
Competing interests
The authors declare that they have no competing interests. | Recovered | ReactionOutcome | CC BY | 33557784 | 18,988,595 | 2021-02-08 |
What was the outcome of reaction 'Seizure'? | Mycoplasma hominis meningitis in an extremely preterm newborn: a case report.
Mycoplasma Hominis is a micro-organism which is a part of the human genitourinary tract flora. Neonates are susceptible to acquire this pathogen either in utero or through vertical transmission. In rare cases, it may cause central nervous system infections with severe morbidity and mortality in preterm and term neonates.
We present a case of Mycoplasma Hominis meningitis in an extremely preterm neonate who presented with lethargy, tachycardia and seizures on day 7 of life. There was no history of maternal systemic or genitourinary infection during pregnancy and at the time of delivery. Empirical antibiotic therapy for neonatal meningitis was commenced after sending blood and cerebrospinal fluid cultures. Cerebrospinal fluid analysis showed pleocytosis with neutrophilic predominance, but no bacteria was identified on gram staining. Blood culture yielded no growth of any bacterial pathogen. However, growth of Mycoplasma Hominis was suspected in cerebrospinal fluid culture which was confirmed by 16S ribosomal ribonucleic acid (RNA) polymerase chain reaction analysis. Subsequently, antibiotics were changed to Moxifloxacin and Doxycycline which were given for a total duration of 6 weeks. Multiple cerebrospinal fluid cultures were performed during this treatment. No growth of any pathogen was identified on any of these cerebrospinal fluid cultures.
We report a rare case of Mycoplasma Hominis meningitis in an extremely preterm neonate which was successfully treated with a combination therapy of Moxifloxacin and Doxycycline. It is important to consider the possibility of Mycoplasma Hominis meningitis in neonates who present with clinical signs and pleocytosis in cerebrospinal fluid but negative gram staining and no growth on conventional culture media.
Background
Mycoplasma Hominis is a frequent habitant of the human genital tract [1]. Neonates are susceptible to acquire this microbe either in utero or through the colonized birth canal during the process of parturition [2]. However, invasive infections with this organism in preterm and term infants are noted to be rare [1, 3]. We describe an unusual case of neonatal meningitis due to Mycoplasma Hominis, confirmed in bacterial cultures and 16s ribosomal RNA Polymerase chain reaction (PCR) analysis. This case report demonstrates the importance of suspecting Mycoplasma Hominis as a cause of central nervous system (CNS) infection in neonates who present with clinical signs but no growth on conventional bacterial cultures and no improvement on empirical antibiotic treatment.
Case presentation
A male neonate was born at 25 + 6 weeks of gestation to 35 years old gravida 2, parity1 (G2P1) mother with antiphospholipid antibody syndrome. This was an in vitro fertilization (IVF) pregnancy. She was Rubella immune and negative for Hepatitis B surface antigen, Venereal disease research laboratory test (VDRL), Human immunodeficiency virus, Gonococci and Chlamydia. Her urine culture and vaginal swab for Group B Streptococci was also negative. Her anatomy scan at 18 weeks of gestation showed normal fetal anatomy and a short cervix for which she underwent cervical cerclage placement at 20 + 5 weeks gestation. There was no history of chorioamnionitis or prolonged rupture of membranes. She presented at 25 + 5 weeks with preterm labor and had a spontaneous vaginal delivery the next day. She had received two doses of Betamethasone and Magnesium sulphate prior to delivery. He initially required positive pressure ventilation followed by intubation and surfactant administration with an acceptable response. Umbilical arterial and venous catheters were placed and the neonate was transferred to neonatal intensive care unit (NICU) in a stable condition.
A blood culture was drawn at birth and empiric treatment with Ampicillin and Gentamicin was intiated. The antibiotics were discontinued after 36 hours as the blood culture showed no growth and he remained clinically stable. In addition, as per unit protocol, an endotracheal aspirate was sent for a Ureaplasma culture on admission. This grew a Mycoplasma species for which 3 days of intravenous Azithromycin was given.
A head ultrasound on day 4 of life showed bilateral intraventricular hemorrhage (grade 3) with mild ventriculomegaly and a hemorrhagic venous infarct in the right frontoparietal region. Umbilical arterial catheter was removed on day 4 of life whereas umbilical venous catheter was removed on day 6 of life. He remained stable till day 7 of life when he presented with an acute clinical deterioration presenting as lethargy and tachycardia; a septic work up including blood and cerebrospinal fluid (CSF) cultures was completed and Vancomycin and Cefotaxime were started as empiric antibiotics. His CSF analysis showed red blood cells (RBC) count of 4887 × 10E6/l, pleocytosis of white blood cells (WBC) 9620 × 10E6/l with neutrophilic predominance, hyperproteorachia - protein 8300 mg/l and hypoglycorachia - glucose 0.1 mmoles/liter. Gram staining in CSF was negative. Within hours he developed generalized clinical seizures which was treated with Lorazepam and Phenobarbital followed by a Levetiracetam load and maintenance dose. He had further episodes of clinical and subclinical seizures which resolved after further adjustment of levetiracetam doses.
His first CSF culture was suspected to grow Mycoplasma Hominis and was sent to the regional national diagnostic laboratory for confirmation. The CSF culture was repeated along with a sample for 16s ribosomal RNA PCR analyses. The 16s ribosomal RNA PCR analysis confirmed Mycoplasma hominis in both CSF samples. Antibiotics were then changed to Moxifloxacin and Doxycycline. The repeat CSF culture after 48 hours of Moxifloxacin and Doxycycline showed no growth. CSF analysis done seven days after starting this treatment showed RBC 5650 × 10E6/l, WBC 449 × 10E6/l, protein 3763 mg/l and glucose 0.2 mmoles/liter. Subsequent CSF findings repeated after another three days showed further improvement, RBC 7187 × 10E6/l, WBC 93 × 10E6/l, protein 3691 mg/l and glucose 0.5 mmoles/liter. No growth was seen on any of these CSF cultures. Serial head ultrasound scans were done which showed progressive ventriculomegaly, post hemorrhagic ventricular dilatation and cystic evolution of hemorrhagic/venous infarct in the right frontoparietal region. Although these findings could be attributed to extreme prematurity; there is a likelihood that infection with Mycoplasma Hominis may have played a role in its progression. There have been documented cases of Mycoplasma Hominis meningitis resulting in CNS complications including intraventricular and periventricular hemorrhage, hydrocephalus, and infarction [3]. Lumbar taps were repeated as therapeutic measure to reduce ventriculomegaly, but optimal volumes of CSF were not obtained. Because of the ventriculomegaly, he was evaluated for a possible shunt on day 31; this was deferred because of the stable ventriculomegaly.
Antibiotics were given for a total duration of six weeks after which he was discharged home with a normal neurological examination. He was referred to Neurodevelopmental clinic for follow-up.
Discussion and conclusion
Neonatal CNS infections with Mycoplasma Hominis, although rare, can cause severe morbidity and mortality in neonates [1]. In a case series of 29 neonates with Mycoplasma Hominis infection (age of presentation day1-32 of life), Hata and colleagues reported complications such as brain abscess, hydrocephalus, infarction, cerebritis and periventricular/intraventricular hemorrhage in 34 % cases, death in 28 % and sequelae mostly hemiparesis in another 28 % cases [3]. This may be attributed to a delay in diagnosis, ineffective antibiotic treatment, or suboptimal treatment regimens for neonatal CNS disease [3, 4]. Therefore, prompt diagnosis, early initiation and optimal duration of appropriate antibiotic therapy is necessary for a favorable prognosis.
The clinical presentation may include apnea, temperature instability, lethargy, vomiting, irritability poor tone, twitching or seizures [7]. Detection of Mycoplasma Hominis can be challenging since they lack peptidoglycan cell wall which renders them unidentifiable by gram staining [5]. In addition to this, they grow very slowly on routine culture media and require a specific blood agar medium for their detection [1, 6]. Due to this, there is a likelihood that Mycoplasma Hominis infections may remain undiagnosed or diagnosed late in infants presenting with clinical signs and symptoms [2]. Hence, it is important to consider the possibility of Mycoplasma Hominis infection in cases where the CSF shows pleocytosis and no growth of organism on routine culture media. A 16S ribosomal RNA PCR analysis has proven useful for detection of Mycoplasma Hominis in blood and CSF which are difficult to grow on standard culture media [7, 8]. The microbe is identified by direct sequencing analysis after amplification by PCR. Use of pathogen-specific primers in 16S RNA analysis results in rapid detection of the specific organism [4]. Prematurity, low birth weight, and neural tube defects are recognized to be the most common risk factors for neonatal meningitis with Mycoplasma Hominis [6]. However, it has also been seen in term neonates with no neurological birth malformations [1, 3].
The treatment options for Mycoplasma Hominis meningitis and its duration remains unclear [1, 9]. Due to the rarity of this infection in neonates, the current recommendations are based on clinical experiences and in-vitro susceptibility test results [9, 10].
Mycoplasma Hominis has shown susceptibility to Chloramphenicol, Tetracyclines, Lincosamide and Fluoroquinolones in in-vitro testing [11]. Fluoroquinolones have been used in past to treat neonatal mycoplasma hominins meningitis successfully [1, 3, 5]. Moxifloxacin, a fourth-generation fluoroquinolone is preferred because of its ability to concentrate in CSF and its bactericidal effects in CNS infections [1, 12, 13]. Although there are cases which were successfully treated with Moxifloxacin monotherapy [1, 6], there is a risk of development of resistance with fluoroquinolones during treatment [9, 14, 15]. Our literature search revealed only two reported cases of neonates who were given Moxifloxacin in combination with another antibiotic for Mycoplasma Hominis meningitis [3, 5] (Table 1).
Table 1 Characteristics of neonates treated with combination therapy (Moxifloxacin and another antibiotic) for Mycoplasma Hominis CNS infection
Gestational Age Age at presentation Clinical presentation Confirmation of diagnosis Empirical antibiotic therapy and duration Antibiotics for Mycoplasma Hominis Outcome
Hata and colleagues3 38 weeks 25 days Fever, vomiting, focal seizures 16S RNA PCR Ampicillin & Cefotaxime (day 1–2) Ciprofloxacin (day 6–17) Acyclovir (day 6–8) Chloramphenicol (day 8–17) Minocycline for 28 days (day 6–34) Moxifloxacin for 17 days (day 17–34) Recovery with left hemiplegia
Watt and colleagues5 26 weeks 7 days Apnea, hypotonia, generalized seizures 16S RNA PCR Ampicillin and Gentamycin (day1-8) Ceftazidime (day 1–5 ) Vancomycin (day 8–19 ) Acyclovir (day 8–19) Meropenem (day 12–19 ) Doxycycline for 6 weeks (day 19–60) Moxifloxacin for 6 weeks (day 19–60) Recovery, neurological outcomes not reported
Our case 25 + 6 weeks 7 days Lethargy, tachycardia, generalized seizures 16S RNA PCR Ampicillin and Gentamycin (day 1–2) Azithromycin (day 3–6) Vancomycin and cefotaxime (day 7–10) Doxycycline for 6 weeks (day 10–52) Moxifloxacin for 6 weeks (day 10–52) Recovery with normal neurological examination at discharge, follow up at 6 months showed normal neurological examination
Evidence from previously published cases show that 28 % neonates with Mycoplasma Hominis CNS infection died whereas 34 % had some CNS complications and 28 % cases developed some neurological sequelae mostly hemiparesis [3]. In our case, treatment with a combination therapy of Moxifloxacin and Doxycycline resulted in significant clinical and laboratory improvement in terms of negative CSF culture after 48 hours of initiating this regimen and decreased WBC count and protein in subsequent CSF analysis. Our patient was discharged home with a normal neurological examination and stable ventriculomegaly. His neurodevelopmental follow up at six months of age showed normal neurological findings.
It is important to consider Mycoplasma Hominis as a potential cause for neonatal meningitis in infants particularly those with previous colonization with this rare but devastating species. Our case demonstrates effective eradication of Mycoplasma Hominis with a combination therapy of Moxifloxacin and Doxycycline. However, further research is required to understand the pharmacokinetics of these antibiotics to establish optimal dosing and duration for effective treatment of CNS infections with Mycoplasma Hominis.
Abbreviations
G2P1Gravida2, Parity1
PCRPolymerase chain reaction
RNARibonucleic acid
IVFIn vitro fertilization
CSFCerebrospinal fluid
RBCRed blood cells
WBCWhite blood cells
CNSCentral nervous system
VDRLVenereal disease research laboratory test
NICUNeonatal intensive care unit
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Acknowledgements
Not applicable.
Authors’ contributions
NSA, EA, and AR conceptualized the idea of writing this case report. NSA drafted the initial manuscript which was revised by AR and EA. AR and EA supervised the literature review for this case study, critically reviewed the manuscript, and approved the final version.
Funding
No funding received from any public, commercial or non-profit organization.
Availability of data and materials
Not applicable.
Ethics approval and consent to participate
None.
Consent for publication
Written informed consent was obtained from patient’s parents for publication of this case report.
Competing interests
The authors declare that they have no competing interests. | Recovered | ReactionOutcome | CC BY | 33557784 | 18,988,595 | 2021-02-08 |
Give an alphabetized list of all active substances of drugs taken by the patient who experienced 'Multiple-drug resistance'. | Selective treatment pressure in colon cancer drives the molecular profile of resistant circulating tumor cell clones.
The characterization of circulating tumor cells (CTCs) holds promises for precision medicine because these cells are an important clinical indicator of treatment efficacy. We established the first and still only nine permanent colon CTC lines from peripheral blood samples of a patient with metastatic colon cancer collected at different time points during treatment and cancer progression. The study objectives were (i) to compare the gene expression profiles of these CTC lines, and (ii) to determine the main features acquired during treatment. The number of upregulated genes was higher in the CTC lines obtained after treatment, indicating that they acquired properties to escape treatment pressure. Among these upregulated genes, some are involved in the mTOR and PI3K/AKT signaling pathways. Moreover, cytidine deaminase expression was significantly increased in the CTC lines obtained after failure of the first- and second-line 5-fluorouracile-based treatments, suggesting that these CTCs can eliminate this specific drug and resist to therapy. Several enzymes involved in xenobiotic metabolism also were upregulated after treatment, suggesting the activation of detoxification mechanisms in response to chemotherapy. Finally, the significant higher expression of aldolase B in four of the six CTC lines obtained after treatment withdrawal and cancer progression indicated that these clones originated from liver metastases. In conclusion, these CTC lines generated at different time points during treatment of metastatic colon cancer in a single patient are characterized by the deregulation of different genes that promote (i) drug resistance, (ii) xenobiotic and energy metabolism, and (iii) stem cell properties and plasticity.
Main text
Liquid biopsy-based strategies may transform oncology in the near future [1]. Many studies analyzed circulating tumor cells (CTCs) as a real-time liquid biopsy in epithelial tumors (i.e. breast, prostate, and colon cancer) [2] and showed that their study contributes to the prognostic evaluation, patient stratification, and real-time monitoring of treatment efficacy, as well as to the identification of therapeutic targets and tumor resistance mechanisms. However, the low CTC concentration in blood is a crucial limiting factor for the identification of CTCs that may initiate a new tumor at a distant site (i.e. “metastasis-initiator CTCs” or “metastasis-competent CTCs”). Moreover, the establishment and long-term maintenance of in vitro CTC cultures are a major challenge, achieved only by few groups [3, 4].
We established the first nine permanent CTC lines from a 57-year-old patient with metastatic colon cancer (MCC). At diagnosis, he had unresectable widespread MCC with abdominal and mediastinal lymph node invasion and liver metastases. The patient was first treated with the 5-fluorouracile (5-FU)-irinotecan (FOLFIRI) combination and bevacizumab (5 cycles). The first biological progression was observed after the fifth FOLFIRI cycle, and second-line treatment was initiated with 5-FU-oxaliplatin (FOLXFOX) and bevacizumab, but was stopped after the third cycle because of disease progression (clinical and morphological). The patient died about 6 months after diagnosis due to cancer progression. We derived these CTC lines from blood samples collected before treatment initiation (CTC-MCC-41) [5], after the first- and second-line treatments (CTC-MCC-41.4), and 1 week before the patient’s death (CTC-MCC-41.5 [A-G]) [6]. Their phenotypic and molecular characterization indicated that they present common traits and all display epithelial-to-mesenchymal plasticity and stem cell-like characteristics [6, 7].
Here, we obtained and compared the transcriptomic profiles of these CTC lines to identify expression changes linked to tumor progression and treatment pressure, with the aim of identifying biomarkers and mechanisms involved in colon cancer progression.
Results and discussion
CTC selection during cancer progression and treatment pressure
The analysis of the transcriptomic profiles of the nine CTC lines using Affymetrix HG-U133P microarray chips clearly separated them in four distinct groups: CTC-MCC-41, CTC-MCC-41.4, CTC-MCC-41.5 [ABFG], and CTC-MCC-41.5 [CDE] (Fig. 1a). We then compared the transcriptomic profiles of the pre-treatment CTC-MCC-41 line and of the other eight CTC lines (CTC-MCC-41.4 and CTC-MCC-41.5[A-G]) to understand the treatment impact on CTC clonal selection (Fig. 1b and Additional file 2: Tables S1–2). The significantly higher number of upregulated genes in the eight cell lines obtained after treatment initiation (Fig. 1c) suggests that they acquired properties to adapt and resist to treatment. For instance, genes involved in the mTOR and PI3K/AKT signaling cascades, which are implicated in cancer development by coordinating cell growth, survival and proliferation, and in resistance to chemotherapy, were upregulated in the post-treatment CTC lines (Fig. 1d). Colon cancer-specific mortality is higher in patients with tumors harboring mutated PIK3CA than wild type PIK3CA [8]. All our CTC lines harbored wild type PIK3CA and AKT [6], but these signaling pathways were deregulated. Some studies demonstrated that PI3K/mTOR pathway inhibitors could be used in primary and metastatic colorectal cancer [9]. We recently reported that CTC-MCC-41 cells also respond to mTOR and AKT inhibitors, suggesting these therapies are effective even in the absence of mutations [10].
Fig. 1 Transcriptomic analysis of the nine CTC lines obtained from a patient with metastatic colon cancer at different times during disease progression. a Unsupervised 3D PCA representing the gene expression patterns of the CTC line obtained before treatment (n = 3 samples) and the eight CTC lines obtained after treatment initiation (n = 10 samples); b Hierarchical clustering of the CTC lines based on the differentially expressed transcripts (DETs) in CTC-MCC-41 (before treatment) and the other eight lines. The color intensity indicates the transcript expression level (red for upregulated transcripts and blue for downregulated transcripts); c Volcano plots showing the distribution of gene expression fold changes and p-values using the TAC software. Transcripts upregulated in CTC-MCC-41 are indicated in green, and transcripts upregulated in the other eight CTC lines are in red. d Top enriched pathways for the DETs (ANOVA analysis), ranked in increasing order (Fisher’s exact test p-value) identified by Ingenuity® Pathway Analysis, by comparing CTC-MCC-41 (before treatment) and the other eight lines. The “EIF2 signaling”, “mTOR and “PI3K/AKT signaling” pathways were significantly deregulated. Red: genes upregulated in CTC-MCC-41 compared with the other eight CTC lines; green: genes upregulated in the eight post-treatment CTC lines; white: no overlap with the data set; Orange - log (p-value); e Volcano plots showing the distribution of gene expression fold changes and p-values using the TAC software, with transcripts upregulated in the CTC-MCC-41.5 [ABFG] subgroup (green) and in the CTC-MCC-41.5 [CDE] subgroup (red). f Top enriched pathways for the DETs based on the ANOVA analysis, ranked in increasing order (Fisher’s exact test p-values) identified by Ingenuity® Pathway Analysis, in the comparison of the seven CTC-MCC-41.5 lines obtained just before the patient’s death. Many “metabolism” pathways were significantly deregulated, including “xenobiotic metabolism signaling”. Abbreviations: TAC, Transcriptome Analysis Console; DET, differentially expressed transcripts
Conversely, we did not observe many differences between the CTC-MCC-41.4 line, obtained after the last treatment, and the seven CTC-MCC-41.5 [A-G] lines obtained before the patient’s death (Additional file 2: Table S3). This suggests that, without drug pressure, the rapid cancer worsening was not link anymore to a clonal evolution but is due to natural disease progression with the replication of the CTC clones already selected under treatment. Indeed, the seven last CTC lines seem to be already present in the pooled CTC-MCC-41.4 line and they have been selected in the in vitro culture from the last blood sample. However, we could clearly segregate the last seven CTC cell lines (CTC-MCC-41.5 [A-G]), in two groups, [ABFG] and [CDE] (Fig. 1a), with different gene expression profiles (Fig. 1e). Most of the significantly deregulated pathways were involved in metabolism signaling (Fig. 1f), including xenobiotic metabolism. This suggests that detoxification mechanisms were induced upon exposure to anti-cancer drugs, as indicated by the deregulation of the irinotecan/SN38 pathway specifically in the [CDE] group. Furthermore, lipid metabolism upregulation appeared to be more represented in the “CDE signature”. Lipid metabolism is a key function on the basis of the enrichment of different signaling cascades leading to energy metabolism. Since Warburg’s work, metabolic reprogramming is one of the main hallmarks of cancer cells and plays a critical role in the continued tumor growth and progression and is driven by a complex interplay between the tumor mutational landscape, epigenetic modifications, and microenvironmental influences [11]. This topic is actively studied and a high-throughput metabolic-based assay was developed for rapid detection of rare metabolically active disseminated tumor cells in pleural effusion of lung cancer [12].
Cytidine deaminase as a drug resistance biomarker
Besides deregulation of the irinotecan/SN38 pathway in the [CDE] group, the gene encoding cytidine deaminase (CDA) was deregulated in the post-treatment CTC lines (Additional file 2: Table S2). This finding in a patient treated with 5-FU, a pyrimidine analogue, is interesting because CDA maintains the cellular pyrimidine pool by catalyzing the hydrolytic deamination of cytidine and deoxycytidine to uridine and deoxyuridine. Some studies showed that in patients treated with direct cytidine analogues, such as gemcitabine and cytosine arabinoside, CDA overexpression might be a marker of resistance [13]. Analysis of CDA expression in colorectal cancer using publicly available data [14] indicated that it was significantly downregulated in colon adenocarcinoma compared with normal colon (Fig. 2a). However, CDA was strongly upregulated in the CTC-MCC41.4 cell line obtained directly after failure of the first- and second-line 5-FU-based treatments (RT-qPCR analysis in Fig. 2b) and also, to a lower extent, in the CTC lines (CTC-MCC-41.5 A-G) obtained just before death, compared with the pre-treatment CTC-MCC-41 line.
Fig. 2 Major features of the aggressive colon cancer CTC clones selected after treatment. a Boxplot showing cytidine deaminase (CDA) relative expression in normal colon (n = 41) and colon adenocarcinoma (n = 286) samples using UALCAN (p-value = 1.45E-06). b RT-qPCR analysis of CDA gene expression in the nine CTC lines (mean values of triplicate experiments with standard deviation). c ELISA measurement of CDA protein level (ng/ml) in the conditioned medium from the nine CTC lines (mean values from triplicate experiments with standard deviation). Aldolase B (ALDOB) expression analysis (d) by RT-qPCR in the nine CTC lines [*significant upregulation in the CTC-MCC-41.5 [ABFG] cell lines compared with all the other CTC lines (p-value = 0.0134), and only with the CTC-MCC-41.5 [CDE] lines (p-value = 0.0466); **significantly upregulation compared with all the other CTC lines (p-value = 0.0017)], and e in tissue samples (normal colon, normal liver, primary colorectal tumor, liver metastases of colon cancer) (n = 5/tissue). f Representation of the cancer hallmarks of the CTC lines resistant to treatment: (i) Stemness and Plasticity: metastasis-competent potential, (ii) Drug resistance: different molecules and pathways involved in treatment resistance and drug detoxification, such as the CDA enzyme implicated in pyrimidine analogue metabolism (e.g. for 5-FU), (iii) Metabolism: xenobiotic metabolism linked to therapy resistance, energy metabolism linked to mitochondrial activity, and ALDOB activity that gave information also on the liver metastasis origin of the CTC41.5[ABFG] lines. Abbreviation: EMT, epithelial-mesenchymal transition
As CDA is secreted in the extracellular compartment (https://www.uniprot.org/uniprot/P32320) and can be detected in blood, we quantified CDA concentration by ELISA in conditioned medium from the nine CTC-MCC lines. As observed for the CDA gene, CDA protein level was highest in CTC-MCC-41.4 cells (Fig. 2c). These findings suggest that in this patient, CDA was directly produced and secreted by resistant and aggressive CTCs in response to 5-FU-based chemotherapy. Therefore, CDA might represent a candidate plasmatic biomarker to monitor 5-FU efficacy and resistance development.
Aldolase B as a marker to identify CTCs released only by liver metastases
Comparison of the signatures of the two CTC-MCC-41.5 sub-groups ([ABFG] and [CDE]) (Additional file 2: Tables S4–5) highlighted ALDOB upregulation in the [ABFG] group (Fig. 2d). This gene encodes the aldolase B enzyme (fructose-bisphosphate aldolase B or liver-type aldolase), one of three isoenzymes (A, B, and C) of the class I fructose 1,6-bisphosphate aldolase enzyme (EC 4.1.2.1) that plays a key role in glycolysis and gluconeogenesis. This enzyme is preferentially expressed in the liver and at lower extend in the kidney and the small intestine. ALDOB downregulation correlates with poor overall survival in liver and gastric cancer [15, 16], whereas ALDOB overexpression in colorectal cancer has been associated with poor overall survival and epithelial-to-mesenchymal transition promotion [17]. Colorectal cancer is known to preferentially metastasize (∼70% patients) to the liver [18], which is the main organ for glycogenesis and gluconeogenesis. In addition, this specific patient had liver metastases. Comparison of ALDOB expression in different tissues using publicly available data showed that: (i) ALDOB was strongly expressed in normal liver compared with normal colon, (ii) ALDOB expression was comparable in primary colon adenocarcinoma and normal colon samples, and (iii) ALDOB was upregulated in colon cancer liver metastases compared with primary tumors (Fig. 2e). Bu et al. showed that during liver colonization, colon cancer cells undergo metabolic reprogramming by upregulating ALDOB [19]. This enhances fructose metabolism and promotes the growth of colon cancer liver metastases. These data suggest that the [ABFG] lines were derived from CTCs released by liver metastases. It is thought that CTCs are released by the primary tumor and/or metastases; however, to our knowledge, this is the first time that this could be demonstrated in a patient.
Conclusions
From Nowell’s work in 1976, it is acknowledged that cancer is an evolutionary process and that treatments exert selective pressures that drive the tumor cell evolution, favoring the appearance of resistant clones. The present results confirm that CTC line profiling is a relevant approach to study clonal selection during disease progression and to discover new CTC biomarkers for monitoring treatment response. The transcriptomic analysis of the CTC lines obtained after treatments (CTC-MCC-41.4 and CTC-MCC-41.5[A-G]) showed the progressive deregulation of genes involved in cancer aggressiveness hallmarks: (i) drug resistance, with the upregulation of molecules and pathways implicated in drug detoxification (e.g. CDA and the irinotecan/SN38 pathway), (ii) metabolism changes, including upregulation of genes implicated in the xenobiotic metabolism, linked to therapy resistance, and energy metabolism (mitochondrial activity to provide energy to hyper-metabolic cells), and the ALDOB gene linked to liver metabolism, and (iii) stemness and plasticity, highlighting their metastasis-competent potential (Fig. 2f). This work is, however, specific of this cancer patient and the biomarkers found and highlighted in these CTC lines need now to be validated on CTCs and plasma from independent patients with colorectal cancer.
Supplementary Information
Additional file 1. Supplementary materials and methods.
Additional file 2: Table S1. List of DETs upregulated in CTC-MCC-41 vs all the other CTC lines. Table S2. List of DETs downregulated in CTC-MCC-41 vs all the other CTC lines. Table S3. List of DETs upregulated in all CTC-MCC-41.5 cell lines vs the CTC-MCC-41.4 cell line. Table S4. List of DETs upregulated in the [ABFG] subgroup vs the [CDE] subgroup of the CTC-MCC-41.5 cell lines. Table S5. List of DETs downregulated in the [ABFG] subgroup vs the [CDE] subgroup of the CTC-MCC-41.5 cell lines. Table S6. Primer sequences.
Additional file 3: Figure S1. Box-plots showing the expression level of a set of differentially expressed transcripts (DETs) in the CTC-MCC-41, CTC-MCC-41.4, and CTC-MCC-41.5 [ABFG] and [CDE] cell lines. Abbreviations: CTC-BT, CTC line derived before treatment initiation; CTC-AT, CTC lines derived after treatment initiation. Figure S2. RT-qPCR validation of the microarray data. Abbreviations: CTC-BT, CTC line derived before treatment initiation; CTC-AT, CTC lines derived after treatment initiation.
Abbreviations
5-FU5-fluorouracile
ALDOBAldolase B
CDACytidine deaminase
CTCCirculating tumor cell
EMTEpithelial to mesenchymal transition
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Acknowledgements
The authors thank Dr. Elisabetta Andermarcher for assistance with her comments and proofreading that greatly improved the manuscript.
Authors’ contributions
LC and SA analyzed and interpreted the data. LC, SA and CAP were major contributors in the conception of the study and in the writing of the manuscript. All authors red and approved the final manuscript.
Funding
This work was supported by the National Cancer Institute (INCA) and the General Direction for Caregiving (DGOS) for patient recruitment and analysis in the COLOSPOT study (NCT01596790), by SIRIC Montpellier Cancer Grant INCa_Inserm_DGOS_12553 for staff salary as well as by the MAVA Foundation, the CNRS and the ANR project TRANSCAN (ANR-18-CE35–0009).
Availability of data and materials
The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.
The 20 publicly available Affymetrix datasets on normal colon (n = 5 samples), primary tumor (n = 5 samples), liver metastases (n = 5 samples) and normal liver (n = 5 samples) are accessible at the gene expression Omnibus (GEO) repository (https://www-ncbi-nlm-nih-gov.proxy.insermbiblio.inist.fr/geo) through the accession numbers: GSM1198032, GSM1198034, GSM1198038, GSM1198047, GSM1198050, GSM1198030, GSM1198035, GSM1198037, GSM1198046, GSM1198048, GSM1198023, GSM1198031, GSM1198033, GSM1198042, GSM1198052, GSM557089, GSM557091, GSM557093, GSM557099, GSM557107.
Ethics approval and consent to participate
The patient gave his consent to participate in the COLOSPOT study to investigate CTCs in metastatic colorectal cancer. The bioethics committee gave its approval (ID-RCB 2011-A01130–41).
Consent for publication
The content of this manuscript has not been previously published and is not under consideration for publication elsewhere.
Competing interests
CAP declare to have had an honorarium from Menarini. The other authors declare that they have no competing interests. | BEVACIZUMAB, FLUOROURACIL, IRINOTECAN, OXALIPLATIN | DrugsGivenReaction | CC BY | 33557844 | 19,135,051 | 2021-02-08 |
What was the dosage of drug 'BEVACIZUMAB'? | Selective treatment pressure in colon cancer drives the molecular profile of resistant circulating tumor cell clones.
The characterization of circulating tumor cells (CTCs) holds promises for precision medicine because these cells are an important clinical indicator of treatment efficacy. We established the first and still only nine permanent colon CTC lines from peripheral blood samples of a patient with metastatic colon cancer collected at different time points during treatment and cancer progression. The study objectives were (i) to compare the gene expression profiles of these CTC lines, and (ii) to determine the main features acquired during treatment. The number of upregulated genes was higher in the CTC lines obtained after treatment, indicating that they acquired properties to escape treatment pressure. Among these upregulated genes, some are involved in the mTOR and PI3K/AKT signaling pathways. Moreover, cytidine deaminase expression was significantly increased in the CTC lines obtained after failure of the first- and second-line 5-fluorouracile-based treatments, suggesting that these CTCs can eliminate this specific drug and resist to therapy. Several enzymes involved in xenobiotic metabolism also were upregulated after treatment, suggesting the activation of detoxification mechanisms in response to chemotherapy. Finally, the significant higher expression of aldolase B in four of the six CTC lines obtained after treatment withdrawal and cancer progression indicated that these clones originated from liver metastases. In conclusion, these CTC lines generated at different time points during treatment of metastatic colon cancer in a single patient are characterized by the deregulation of different genes that promote (i) drug resistance, (ii) xenobiotic and energy metabolism, and (iii) stem cell properties and plasticity.
Main text
Liquid biopsy-based strategies may transform oncology in the near future [1]. Many studies analyzed circulating tumor cells (CTCs) as a real-time liquid biopsy in epithelial tumors (i.e. breast, prostate, and colon cancer) [2] and showed that their study contributes to the prognostic evaluation, patient stratification, and real-time monitoring of treatment efficacy, as well as to the identification of therapeutic targets and tumor resistance mechanisms. However, the low CTC concentration in blood is a crucial limiting factor for the identification of CTCs that may initiate a new tumor at a distant site (i.e. “metastasis-initiator CTCs” or “metastasis-competent CTCs”). Moreover, the establishment and long-term maintenance of in vitro CTC cultures are a major challenge, achieved only by few groups [3, 4].
We established the first nine permanent CTC lines from a 57-year-old patient with metastatic colon cancer (MCC). At diagnosis, he had unresectable widespread MCC with abdominal and mediastinal lymph node invasion and liver metastases. The patient was first treated with the 5-fluorouracile (5-FU)-irinotecan (FOLFIRI) combination and bevacizumab (5 cycles). The first biological progression was observed after the fifth FOLFIRI cycle, and second-line treatment was initiated with 5-FU-oxaliplatin (FOLXFOX) and bevacizumab, but was stopped after the third cycle because of disease progression (clinical and morphological). The patient died about 6 months after diagnosis due to cancer progression. We derived these CTC lines from blood samples collected before treatment initiation (CTC-MCC-41) [5], after the first- and second-line treatments (CTC-MCC-41.4), and 1 week before the patient’s death (CTC-MCC-41.5 [A-G]) [6]. Their phenotypic and molecular characterization indicated that they present common traits and all display epithelial-to-mesenchymal plasticity and stem cell-like characteristics [6, 7].
Here, we obtained and compared the transcriptomic profiles of these CTC lines to identify expression changes linked to tumor progression and treatment pressure, with the aim of identifying biomarkers and mechanisms involved in colon cancer progression.
Results and discussion
CTC selection during cancer progression and treatment pressure
The analysis of the transcriptomic profiles of the nine CTC lines using Affymetrix HG-U133P microarray chips clearly separated them in four distinct groups: CTC-MCC-41, CTC-MCC-41.4, CTC-MCC-41.5 [ABFG], and CTC-MCC-41.5 [CDE] (Fig. 1a). We then compared the transcriptomic profiles of the pre-treatment CTC-MCC-41 line and of the other eight CTC lines (CTC-MCC-41.4 and CTC-MCC-41.5[A-G]) to understand the treatment impact on CTC clonal selection (Fig. 1b and Additional file 2: Tables S1–2). The significantly higher number of upregulated genes in the eight cell lines obtained after treatment initiation (Fig. 1c) suggests that they acquired properties to adapt and resist to treatment. For instance, genes involved in the mTOR and PI3K/AKT signaling cascades, which are implicated in cancer development by coordinating cell growth, survival and proliferation, and in resistance to chemotherapy, were upregulated in the post-treatment CTC lines (Fig. 1d). Colon cancer-specific mortality is higher in patients with tumors harboring mutated PIK3CA than wild type PIK3CA [8]. All our CTC lines harbored wild type PIK3CA and AKT [6], but these signaling pathways were deregulated. Some studies demonstrated that PI3K/mTOR pathway inhibitors could be used in primary and metastatic colorectal cancer [9]. We recently reported that CTC-MCC-41 cells also respond to mTOR and AKT inhibitors, suggesting these therapies are effective even in the absence of mutations [10].
Fig. 1 Transcriptomic analysis of the nine CTC lines obtained from a patient with metastatic colon cancer at different times during disease progression. a Unsupervised 3D PCA representing the gene expression patterns of the CTC line obtained before treatment (n = 3 samples) and the eight CTC lines obtained after treatment initiation (n = 10 samples); b Hierarchical clustering of the CTC lines based on the differentially expressed transcripts (DETs) in CTC-MCC-41 (before treatment) and the other eight lines. The color intensity indicates the transcript expression level (red for upregulated transcripts and blue for downregulated transcripts); c Volcano plots showing the distribution of gene expression fold changes and p-values using the TAC software. Transcripts upregulated in CTC-MCC-41 are indicated in green, and transcripts upregulated in the other eight CTC lines are in red. d Top enriched pathways for the DETs (ANOVA analysis), ranked in increasing order (Fisher’s exact test p-value) identified by Ingenuity® Pathway Analysis, by comparing CTC-MCC-41 (before treatment) and the other eight lines. The “EIF2 signaling”, “mTOR and “PI3K/AKT signaling” pathways were significantly deregulated. Red: genes upregulated in CTC-MCC-41 compared with the other eight CTC lines; green: genes upregulated in the eight post-treatment CTC lines; white: no overlap with the data set; Orange - log (p-value); e Volcano plots showing the distribution of gene expression fold changes and p-values using the TAC software, with transcripts upregulated in the CTC-MCC-41.5 [ABFG] subgroup (green) and in the CTC-MCC-41.5 [CDE] subgroup (red). f Top enriched pathways for the DETs based on the ANOVA analysis, ranked in increasing order (Fisher’s exact test p-values) identified by Ingenuity® Pathway Analysis, in the comparison of the seven CTC-MCC-41.5 lines obtained just before the patient’s death. Many “metabolism” pathways were significantly deregulated, including “xenobiotic metabolism signaling”. Abbreviations: TAC, Transcriptome Analysis Console; DET, differentially expressed transcripts
Conversely, we did not observe many differences between the CTC-MCC-41.4 line, obtained after the last treatment, and the seven CTC-MCC-41.5 [A-G] lines obtained before the patient’s death (Additional file 2: Table S3). This suggests that, without drug pressure, the rapid cancer worsening was not link anymore to a clonal evolution but is due to natural disease progression with the replication of the CTC clones already selected under treatment. Indeed, the seven last CTC lines seem to be already present in the pooled CTC-MCC-41.4 line and they have been selected in the in vitro culture from the last blood sample. However, we could clearly segregate the last seven CTC cell lines (CTC-MCC-41.5 [A-G]), in two groups, [ABFG] and [CDE] (Fig. 1a), with different gene expression profiles (Fig. 1e). Most of the significantly deregulated pathways were involved in metabolism signaling (Fig. 1f), including xenobiotic metabolism. This suggests that detoxification mechanisms were induced upon exposure to anti-cancer drugs, as indicated by the deregulation of the irinotecan/SN38 pathway specifically in the [CDE] group. Furthermore, lipid metabolism upregulation appeared to be more represented in the “CDE signature”. Lipid metabolism is a key function on the basis of the enrichment of different signaling cascades leading to energy metabolism. Since Warburg’s work, metabolic reprogramming is one of the main hallmarks of cancer cells and plays a critical role in the continued tumor growth and progression and is driven by a complex interplay between the tumor mutational landscape, epigenetic modifications, and microenvironmental influences [11]. This topic is actively studied and a high-throughput metabolic-based assay was developed for rapid detection of rare metabolically active disseminated tumor cells in pleural effusion of lung cancer [12].
Cytidine deaminase as a drug resistance biomarker
Besides deregulation of the irinotecan/SN38 pathway in the [CDE] group, the gene encoding cytidine deaminase (CDA) was deregulated in the post-treatment CTC lines (Additional file 2: Table S2). This finding in a patient treated with 5-FU, a pyrimidine analogue, is interesting because CDA maintains the cellular pyrimidine pool by catalyzing the hydrolytic deamination of cytidine and deoxycytidine to uridine and deoxyuridine. Some studies showed that in patients treated with direct cytidine analogues, such as gemcitabine and cytosine arabinoside, CDA overexpression might be a marker of resistance [13]. Analysis of CDA expression in colorectal cancer using publicly available data [14] indicated that it was significantly downregulated in colon adenocarcinoma compared with normal colon (Fig. 2a). However, CDA was strongly upregulated in the CTC-MCC41.4 cell line obtained directly after failure of the first- and second-line 5-FU-based treatments (RT-qPCR analysis in Fig. 2b) and also, to a lower extent, in the CTC lines (CTC-MCC-41.5 A-G) obtained just before death, compared with the pre-treatment CTC-MCC-41 line.
Fig. 2 Major features of the aggressive colon cancer CTC clones selected after treatment. a Boxplot showing cytidine deaminase (CDA) relative expression in normal colon (n = 41) and colon adenocarcinoma (n = 286) samples using UALCAN (p-value = 1.45E-06). b RT-qPCR analysis of CDA gene expression in the nine CTC lines (mean values of triplicate experiments with standard deviation). c ELISA measurement of CDA protein level (ng/ml) in the conditioned medium from the nine CTC lines (mean values from triplicate experiments with standard deviation). Aldolase B (ALDOB) expression analysis (d) by RT-qPCR in the nine CTC lines [*significant upregulation in the CTC-MCC-41.5 [ABFG] cell lines compared with all the other CTC lines (p-value = 0.0134), and only with the CTC-MCC-41.5 [CDE] lines (p-value = 0.0466); **significantly upregulation compared with all the other CTC lines (p-value = 0.0017)], and e in tissue samples (normal colon, normal liver, primary colorectal tumor, liver metastases of colon cancer) (n = 5/tissue). f Representation of the cancer hallmarks of the CTC lines resistant to treatment: (i) Stemness and Plasticity: metastasis-competent potential, (ii) Drug resistance: different molecules and pathways involved in treatment resistance and drug detoxification, such as the CDA enzyme implicated in pyrimidine analogue metabolism (e.g. for 5-FU), (iii) Metabolism: xenobiotic metabolism linked to therapy resistance, energy metabolism linked to mitochondrial activity, and ALDOB activity that gave information also on the liver metastasis origin of the CTC41.5[ABFG] lines. Abbreviation: EMT, epithelial-mesenchymal transition
As CDA is secreted in the extracellular compartment (https://www.uniprot.org/uniprot/P32320) and can be detected in blood, we quantified CDA concentration by ELISA in conditioned medium from the nine CTC-MCC lines. As observed for the CDA gene, CDA protein level was highest in CTC-MCC-41.4 cells (Fig. 2c). These findings suggest that in this patient, CDA was directly produced and secreted by resistant and aggressive CTCs in response to 5-FU-based chemotherapy. Therefore, CDA might represent a candidate plasmatic biomarker to monitor 5-FU efficacy and resistance development.
Aldolase B as a marker to identify CTCs released only by liver metastases
Comparison of the signatures of the two CTC-MCC-41.5 sub-groups ([ABFG] and [CDE]) (Additional file 2: Tables S4–5) highlighted ALDOB upregulation in the [ABFG] group (Fig. 2d). This gene encodes the aldolase B enzyme (fructose-bisphosphate aldolase B or liver-type aldolase), one of three isoenzymes (A, B, and C) of the class I fructose 1,6-bisphosphate aldolase enzyme (EC 4.1.2.1) that plays a key role in glycolysis and gluconeogenesis. This enzyme is preferentially expressed in the liver and at lower extend in the kidney and the small intestine. ALDOB downregulation correlates with poor overall survival in liver and gastric cancer [15, 16], whereas ALDOB overexpression in colorectal cancer has been associated with poor overall survival and epithelial-to-mesenchymal transition promotion [17]. Colorectal cancer is known to preferentially metastasize (∼70% patients) to the liver [18], which is the main organ for glycogenesis and gluconeogenesis. In addition, this specific patient had liver metastases. Comparison of ALDOB expression in different tissues using publicly available data showed that: (i) ALDOB was strongly expressed in normal liver compared with normal colon, (ii) ALDOB expression was comparable in primary colon adenocarcinoma and normal colon samples, and (iii) ALDOB was upregulated in colon cancer liver metastases compared with primary tumors (Fig. 2e). Bu et al. showed that during liver colonization, colon cancer cells undergo metabolic reprogramming by upregulating ALDOB [19]. This enhances fructose metabolism and promotes the growth of colon cancer liver metastases. These data suggest that the [ABFG] lines were derived from CTCs released by liver metastases. It is thought that CTCs are released by the primary tumor and/or metastases; however, to our knowledge, this is the first time that this could be demonstrated in a patient.
Conclusions
From Nowell’s work in 1976, it is acknowledged that cancer is an evolutionary process and that treatments exert selective pressures that drive the tumor cell evolution, favoring the appearance of resistant clones. The present results confirm that CTC line profiling is a relevant approach to study clonal selection during disease progression and to discover new CTC biomarkers for monitoring treatment response. The transcriptomic analysis of the CTC lines obtained after treatments (CTC-MCC-41.4 and CTC-MCC-41.5[A-G]) showed the progressive deregulation of genes involved in cancer aggressiveness hallmarks: (i) drug resistance, with the upregulation of molecules and pathways implicated in drug detoxification (e.g. CDA and the irinotecan/SN38 pathway), (ii) metabolism changes, including upregulation of genes implicated in the xenobiotic metabolism, linked to therapy resistance, and energy metabolism (mitochondrial activity to provide energy to hyper-metabolic cells), and the ALDOB gene linked to liver metabolism, and (iii) stemness and plasticity, highlighting their metastasis-competent potential (Fig. 2f). This work is, however, specific of this cancer patient and the biomarkers found and highlighted in these CTC lines need now to be validated on CTCs and plasma from independent patients with colorectal cancer.
Supplementary Information
Additional file 1. Supplementary materials and methods.
Additional file 2: Table S1. List of DETs upregulated in CTC-MCC-41 vs all the other CTC lines. Table S2. List of DETs downregulated in CTC-MCC-41 vs all the other CTC lines. Table S3. List of DETs upregulated in all CTC-MCC-41.5 cell lines vs the CTC-MCC-41.4 cell line. Table S4. List of DETs upregulated in the [ABFG] subgroup vs the [CDE] subgroup of the CTC-MCC-41.5 cell lines. Table S5. List of DETs downregulated in the [ABFG] subgroup vs the [CDE] subgroup of the CTC-MCC-41.5 cell lines. Table S6. Primer sequences.
Additional file 3: Figure S1. Box-plots showing the expression level of a set of differentially expressed transcripts (DETs) in the CTC-MCC-41, CTC-MCC-41.4, and CTC-MCC-41.5 [ABFG] and [CDE] cell lines. Abbreviations: CTC-BT, CTC line derived before treatment initiation; CTC-AT, CTC lines derived after treatment initiation. Figure S2. RT-qPCR validation of the microarray data. Abbreviations: CTC-BT, CTC line derived before treatment initiation; CTC-AT, CTC lines derived after treatment initiation.
Abbreviations
5-FU5-fluorouracile
ALDOBAldolase B
CDACytidine deaminase
CTCCirculating tumor cell
EMTEpithelial to mesenchymal transition
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Acknowledgements
The authors thank Dr. Elisabetta Andermarcher for assistance with her comments and proofreading that greatly improved the manuscript.
Authors’ contributions
LC and SA analyzed and interpreted the data. LC, SA and CAP were major contributors in the conception of the study and in the writing of the manuscript. All authors red and approved the final manuscript.
Funding
This work was supported by the National Cancer Institute (INCA) and the General Direction for Caregiving (DGOS) for patient recruitment and analysis in the COLOSPOT study (NCT01596790), by SIRIC Montpellier Cancer Grant INCa_Inserm_DGOS_12553 for staff salary as well as by the MAVA Foundation, the CNRS and the ANR project TRANSCAN (ANR-18-CE35–0009).
Availability of data and materials
The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.
The 20 publicly available Affymetrix datasets on normal colon (n = 5 samples), primary tumor (n = 5 samples), liver metastases (n = 5 samples) and normal liver (n = 5 samples) are accessible at the gene expression Omnibus (GEO) repository (https://www-ncbi-nlm-nih-gov.proxy.insermbiblio.inist.fr/geo) through the accession numbers: GSM1198032, GSM1198034, GSM1198038, GSM1198047, GSM1198050, GSM1198030, GSM1198035, GSM1198037, GSM1198046, GSM1198048, GSM1198023, GSM1198031, GSM1198033, GSM1198042, GSM1198052, GSM557089, GSM557091, GSM557093, GSM557099, GSM557107.
Ethics approval and consent to participate
The patient gave his consent to participate in the COLOSPOT study to investigate CTCs in metastatic colorectal cancer. The bioethics committee gave its approval (ID-RCB 2011-A01130–41).
Consent for publication
The content of this manuscript has not been previously published and is not under consideration for publication elsewhere.
Competing interests
CAP declare to have had an honorarium from Menarini. The other authors declare that they have no competing interests. | RECEIVED 5 CYCLES ALONGSIDE FOLFIRI REGIMEN, AND 3 CYCLES ALONGSIDE FOLFOX REGIMEN | DrugDosageText | CC BY | 33557844 | 19,135,051 | 2021-02-08 |
What was the dosage of drug 'FLUOROURACIL'? | Selective treatment pressure in colon cancer drives the molecular profile of resistant circulating tumor cell clones.
The characterization of circulating tumor cells (CTCs) holds promises for precision medicine because these cells are an important clinical indicator of treatment efficacy. We established the first and still only nine permanent colon CTC lines from peripheral blood samples of a patient with metastatic colon cancer collected at different time points during treatment and cancer progression. The study objectives were (i) to compare the gene expression profiles of these CTC lines, and (ii) to determine the main features acquired during treatment. The number of upregulated genes was higher in the CTC lines obtained after treatment, indicating that they acquired properties to escape treatment pressure. Among these upregulated genes, some are involved in the mTOR and PI3K/AKT signaling pathways. Moreover, cytidine deaminase expression was significantly increased in the CTC lines obtained after failure of the first- and second-line 5-fluorouracile-based treatments, suggesting that these CTCs can eliminate this specific drug and resist to therapy. Several enzymes involved in xenobiotic metabolism also were upregulated after treatment, suggesting the activation of detoxification mechanisms in response to chemotherapy. Finally, the significant higher expression of aldolase B in four of the six CTC lines obtained after treatment withdrawal and cancer progression indicated that these clones originated from liver metastases. In conclusion, these CTC lines generated at different time points during treatment of metastatic colon cancer in a single patient are characterized by the deregulation of different genes that promote (i) drug resistance, (ii) xenobiotic and energy metabolism, and (iii) stem cell properties and plasticity.
Main text
Liquid biopsy-based strategies may transform oncology in the near future [1]. Many studies analyzed circulating tumor cells (CTCs) as a real-time liquid biopsy in epithelial tumors (i.e. breast, prostate, and colon cancer) [2] and showed that their study contributes to the prognostic evaluation, patient stratification, and real-time monitoring of treatment efficacy, as well as to the identification of therapeutic targets and tumor resistance mechanisms. However, the low CTC concentration in blood is a crucial limiting factor for the identification of CTCs that may initiate a new tumor at a distant site (i.e. “metastasis-initiator CTCs” or “metastasis-competent CTCs”). Moreover, the establishment and long-term maintenance of in vitro CTC cultures are a major challenge, achieved only by few groups [3, 4].
We established the first nine permanent CTC lines from a 57-year-old patient with metastatic colon cancer (MCC). At diagnosis, he had unresectable widespread MCC with abdominal and mediastinal lymph node invasion and liver metastases. The patient was first treated with the 5-fluorouracile (5-FU)-irinotecan (FOLFIRI) combination and bevacizumab (5 cycles). The first biological progression was observed after the fifth FOLFIRI cycle, and second-line treatment was initiated with 5-FU-oxaliplatin (FOLXFOX) and bevacizumab, but was stopped after the third cycle because of disease progression (clinical and morphological). The patient died about 6 months after diagnosis due to cancer progression. We derived these CTC lines from blood samples collected before treatment initiation (CTC-MCC-41) [5], after the first- and second-line treatments (CTC-MCC-41.4), and 1 week before the patient’s death (CTC-MCC-41.5 [A-G]) [6]. Their phenotypic and molecular characterization indicated that they present common traits and all display epithelial-to-mesenchymal plasticity and stem cell-like characteristics [6, 7].
Here, we obtained and compared the transcriptomic profiles of these CTC lines to identify expression changes linked to tumor progression and treatment pressure, with the aim of identifying biomarkers and mechanisms involved in colon cancer progression.
Results and discussion
CTC selection during cancer progression and treatment pressure
The analysis of the transcriptomic profiles of the nine CTC lines using Affymetrix HG-U133P microarray chips clearly separated them in four distinct groups: CTC-MCC-41, CTC-MCC-41.4, CTC-MCC-41.5 [ABFG], and CTC-MCC-41.5 [CDE] (Fig. 1a). We then compared the transcriptomic profiles of the pre-treatment CTC-MCC-41 line and of the other eight CTC lines (CTC-MCC-41.4 and CTC-MCC-41.5[A-G]) to understand the treatment impact on CTC clonal selection (Fig. 1b and Additional file 2: Tables S1–2). The significantly higher number of upregulated genes in the eight cell lines obtained after treatment initiation (Fig. 1c) suggests that they acquired properties to adapt and resist to treatment. For instance, genes involved in the mTOR and PI3K/AKT signaling cascades, which are implicated in cancer development by coordinating cell growth, survival and proliferation, and in resistance to chemotherapy, were upregulated in the post-treatment CTC lines (Fig. 1d). Colon cancer-specific mortality is higher in patients with tumors harboring mutated PIK3CA than wild type PIK3CA [8]. All our CTC lines harbored wild type PIK3CA and AKT [6], but these signaling pathways were deregulated. Some studies demonstrated that PI3K/mTOR pathway inhibitors could be used in primary and metastatic colorectal cancer [9]. We recently reported that CTC-MCC-41 cells also respond to mTOR and AKT inhibitors, suggesting these therapies are effective even in the absence of mutations [10].
Fig. 1 Transcriptomic analysis of the nine CTC lines obtained from a patient with metastatic colon cancer at different times during disease progression. a Unsupervised 3D PCA representing the gene expression patterns of the CTC line obtained before treatment (n = 3 samples) and the eight CTC lines obtained after treatment initiation (n = 10 samples); b Hierarchical clustering of the CTC lines based on the differentially expressed transcripts (DETs) in CTC-MCC-41 (before treatment) and the other eight lines. The color intensity indicates the transcript expression level (red for upregulated transcripts and blue for downregulated transcripts); c Volcano plots showing the distribution of gene expression fold changes and p-values using the TAC software. Transcripts upregulated in CTC-MCC-41 are indicated in green, and transcripts upregulated in the other eight CTC lines are in red. d Top enriched pathways for the DETs (ANOVA analysis), ranked in increasing order (Fisher’s exact test p-value) identified by Ingenuity® Pathway Analysis, by comparing CTC-MCC-41 (before treatment) and the other eight lines. The “EIF2 signaling”, “mTOR and “PI3K/AKT signaling” pathways were significantly deregulated. Red: genes upregulated in CTC-MCC-41 compared with the other eight CTC lines; green: genes upregulated in the eight post-treatment CTC lines; white: no overlap with the data set; Orange - log (p-value); e Volcano plots showing the distribution of gene expression fold changes and p-values using the TAC software, with transcripts upregulated in the CTC-MCC-41.5 [ABFG] subgroup (green) and in the CTC-MCC-41.5 [CDE] subgroup (red). f Top enriched pathways for the DETs based on the ANOVA analysis, ranked in increasing order (Fisher’s exact test p-values) identified by Ingenuity® Pathway Analysis, in the comparison of the seven CTC-MCC-41.5 lines obtained just before the patient’s death. Many “metabolism” pathways were significantly deregulated, including “xenobiotic metabolism signaling”. Abbreviations: TAC, Transcriptome Analysis Console; DET, differentially expressed transcripts
Conversely, we did not observe many differences between the CTC-MCC-41.4 line, obtained after the last treatment, and the seven CTC-MCC-41.5 [A-G] lines obtained before the patient’s death (Additional file 2: Table S3). This suggests that, without drug pressure, the rapid cancer worsening was not link anymore to a clonal evolution but is due to natural disease progression with the replication of the CTC clones already selected under treatment. Indeed, the seven last CTC lines seem to be already present in the pooled CTC-MCC-41.4 line and they have been selected in the in vitro culture from the last blood sample. However, we could clearly segregate the last seven CTC cell lines (CTC-MCC-41.5 [A-G]), in two groups, [ABFG] and [CDE] (Fig. 1a), with different gene expression profiles (Fig. 1e). Most of the significantly deregulated pathways were involved in metabolism signaling (Fig. 1f), including xenobiotic metabolism. This suggests that detoxification mechanisms were induced upon exposure to anti-cancer drugs, as indicated by the deregulation of the irinotecan/SN38 pathway specifically in the [CDE] group. Furthermore, lipid metabolism upregulation appeared to be more represented in the “CDE signature”. Lipid metabolism is a key function on the basis of the enrichment of different signaling cascades leading to energy metabolism. Since Warburg’s work, metabolic reprogramming is one of the main hallmarks of cancer cells and plays a critical role in the continued tumor growth and progression and is driven by a complex interplay between the tumor mutational landscape, epigenetic modifications, and microenvironmental influences [11]. This topic is actively studied and a high-throughput metabolic-based assay was developed for rapid detection of rare metabolically active disseminated tumor cells in pleural effusion of lung cancer [12].
Cytidine deaminase as a drug resistance biomarker
Besides deregulation of the irinotecan/SN38 pathway in the [CDE] group, the gene encoding cytidine deaminase (CDA) was deregulated in the post-treatment CTC lines (Additional file 2: Table S2). This finding in a patient treated with 5-FU, a pyrimidine analogue, is interesting because CDA maintains the cellular pyrimidine pool by catalyzing the hydrolytic deamination of cytidine and deoxycytidine to uridine and deoxyuridine. Some studies showed that in patients treated with direct cytidine analogues, such as gemcitabine and cytosine arabinoside, CDA overexpression might be a marker of resistance [13]. Analysis of CDA expression in colorectal cancer using publicly available data [14] indicated that it was significantly downregulated in colon adenocarcinoma compared with normal colon (Fig. 2a). However, CDA was strongly upregulated in the CTC-MCC41.4 cell line obtained directly after failure of the first- and second-line 5-FU-based treatments (RT-qPCR analysis in Fig. 2b) and also, to a lower extent, in the CTC lines (CTC-MCC-41.5 A-G) obtained just before death, compared with the pre-treatment CTC-MCC-41 line.
Fig. 2 Major features of the aggressive colon cancer CTC clones selected after treatment. a Boxplot showing cytidine deaminase (CDA) relative expression in normal colon (n = 41) and colon adenocarcinoma (n = 286) samples using UALCAN (p-value = 1.45E-06). b RT-qPCR analysis of CDA gene expression in the nine CTC lines (mean values of triplicate experiments with standard deviation). c ELISA measurement of CDA protein level (ng/ml) in the conditioned medium from the nine CTC lines (mean values from triplicate experiments with standard deviation). Aldolase B (ALDOB) expression analysis (d) by RT-qPCR in the nine CTC lines [*significant upregulation in the CTC-MCC-41.5 [ABFG] cell lines compared with all the other CTC lines (p-value = 0.0134), and only with the CTC-MCC-41.5 [CDE] lines (p-value = 0.0466); **significantly upregulation compared with all the other CTC lines (p-value = 0.0017)], and e in tissue samples (normal colon, normal liver, primary colorectal tumor, liver metastases of colon cancer) (n = 5/tissue). f Representation of the cancer hallmarks of the CTC lines resistant to treatment: (i) Stemness and Plasticity: metastasis-competent potential, (ii) Drug resistance: different molecules and pathways involved in treatment resistance and drug detoxification, such as the CDA enzyme implicated in pyrimidine analogue metabolism (e.g. for 5-FU), (iii) Metabolism: xenobiotic metabolism linked to therapy resistance, energy metabolism linked to mitochondrial activity, and ALDOB activity that gave information also on the liver metastasis origin of the CTC41.5[ABFG] lines. Abbreviation: EMT, epithelial-mesenchymal transition
As CDA is secreted in the extracellular compartment (https://www.uniprot.org/uniprot/P32320) and can be detected in blood, we quantified CDA concentration by ELISA in conditioned medium from the nine CTC-MCC lines. As observed for the CDA gene, CDA protein level was highest in CTC-MCC-41.4 cells (Fig. 2c). These findings suggest that in this patient, CDA was directly produced and secreted by resistant and aggressive CTCs in response to 5-FU-based chemotherapy. Therefore, CDA might represent a candidate plasmatic biomarker to monitor 5-FU efficacy and resistance development.
Aldolase B as a marker to identify CTCs released only by liver metastases
Comparison of the signatures of the two CTC-MCC-41.5 sub-groups ([ABFG] and [CDE]) (Additional file 2: Tables S4–5) highlighted ALDOB upregulation in the [ABFG] group (Fig. 2d). This gene encodes the aldolase B enzyme (fructose-bisphosphate aldolase B or liver-type aldolase), one of three isoenzymes (A, B, and C) of the class I fructose 1,6-bisphosphate aldolase enzyme (EC 4.1.2.1) that plays a key role in glycolysis and gluconeogenesis. This enzyme is preferentially expressed in the liver and at lower extend in the kidney and the small intestine. ALDOB downregulation correlates with poor overall survival in liver and gastric cancer [15, 16], whereas ALDOB overexpression in colorectal cancer has been associated with poor overall survival and epithelial-to-mesenchymal transition promotion [17]. Colorectal cancer is known to preferentially metastasize (∼70% patients) to the liver [18], which is the main organ for glycogenesis and gluconeogenesis. In addition, this specific patient had liver metastases. Comparison of ALDOB expression in different tissues using publicly available data showed that: (i) ALDOB was strongly expressed in normal liver compared with normal colon, (ii) ALDOB expression was comparable in primary colon adenocarcinoma and normal colon samples, and (iii) ALDOB was upregulated in colon cancer liver metastases compared with primary tumors (Fig. 2e). Bu et al. showed that during liver colonization, colon cancer cells undergo metabolic reprogramming by upregulating ALDOB [19]. This enhances fructose metabolism and promotes the growth of colon cancer liver metastases. These data suggest that the [ABFG] lines were derived from CTCs released by liver metastases. It is thought that CTCs are released by the primary tumor and/or metastases; however, to our knowledge, this is the first time that this could be demonstrated in a patient.
Conclusions
From Nowell’s work in 1976, it is acknowledged that cancer is an evolutionary process and that treatments exert selective pressures that drive the tumor cell evolution, favoring the appearance of resistant clones. The present results confirm that CTC line profiling is a relevant approach to study clonal selection during disease progression and to discover new CTC biomarkers for monitoring treatment response. The transcriptomic analysis of the CTC lines obtained after treatments (CTC-MCC-41.4 and CTC-MCC-41.5[A-G]) showed the progressive deregulation of genes involved in cancer aggressiveness hallmarks: (i) drug resistance, with the upregulation of molecules and pathways implicated in drug detoxification (e.g. CDA and the irinotecan/SN38 pathway), (ii) metabolism changes, including upregulation of genes implicated in the xenobiotic metabolism, linked to therapy resistance, and energy metabolism (mitochondrial activity to provide energy to hyper-metabolic cells), and the ALDOB gene linked to liver metabolism, and (iii) stemness and plasticity, highlighting their metastasis-competent potential (Fig. 2f). This work is, however, specific of this cancer patient and the biomarkers found and highlighted in these CTC lines need now to be validated on CTCs and plasma from independent patients with colorectal cancer.
Supplementary Information
Additional file 1. Supplementary materials and methods.
Additional file 2: Table S1. List of DETs upregulated in CTC-MCC-41 vs all the other CTC lines. Table S2. List of DETs downregulated in CTC-MCC-41 vs all the other CTC lines. Table S3. List of DETs upregulated in all CTC-MCC-41.5 cell lines vs the CTC-MCC-41.4 cell line. Table S4. List of DETs upregulated in the [ABFG] subgroup vs the [CDE] subgroup of the CTC-MCC-41.5 cell lines. Table S5. List of DETs downregulated in the [ABFG] subgroup vs the [CDE] subgroup of the CTC-MCC-41.5 cell lines. Table S6. Primer sequences.
Additional file 3: Figure S1. Box-plots showing the expression level of a set of differentially expressed transcripts (DETs) in the CTC-MCC-41, CTC-MCC-41.4, and CTC-MCC-41.5 [ABFG] and [CDE] cell lines. Abbreviations: CTC-BT, CTC line derived before treatment initiation; CTC-AT, CTC lines derived after treatment initiation. Figure S2. RT-qPCR validation of the microarray data. Abbreviations: CTC-BT, CTC line derived before treatment initiation; CTC-AT, CTC lines derived after treatment initiation.
Abbreviations
5-FU5-fluorouracile
ALDOBAldolase B
CDACytidine deaminase
CTCCirculating tumor cell
EMTEpithelial to mesenchymal transition
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Acknowledgements
The authors thank Dr. Elisabetta Andermarcher for assistance with her comments and proofreading that greatly improved the manuscript.
Authors’ contributions
LC and SA analyzed and interpreted the data. LC, SA and CAP were major contributors in the conception of the study and in the writing of the manuscript. All authors red and approved the final manuscript.
Funding
This work was supported by the National Cancer Institute (INCA) and the General Direction for Caregiving (DGOS) for patient recruitment and analysis in the COLOSPOT study (NCT01596790), by SIRIC Montpellier Cancer Grant INCa_Inserm_DGOS_12553 for staff salary as well as by the MAVA Foundation, the CNRS and the ANR project TRANSCAN (ANR-18-CE35–0009).
Availability of data and materials
The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.
The 20 publicly available Affymetrix datasets on normal colon (n = 5 samples), primary tumor (n = 5 samples), liver metastases (n = 5 samples) and normal liver (n = 5 samples) are accessible at the gene expression Omnibus (GEO) repository (https://www-ncbi-nlm-nih-gov.proxy.insermbiblio.inist.fr/geo) through the accession numbers: GSM1198032, GSM1198034, GSM1198038, GSM1198047, GSM1198050, GSM1198030, GSM1198035, GSM1198037, GSM1198046, GSM1198048, GSM1198023, GSM1198031, GSM1198033, GSM1198042, GSM1198052, GSM557089, GSM557091, GSM557093, GSM557099, GSM557107.
Ethics approval and consent to participate
The patient gave his consent to participate in the COLOSPOT study to investigate CTCs in metastatic colorectal cancer. The bioethics committee gave its approval (ID-RCB 2011-A01130–41).
Consent for publication
The content of this manuscript has not been previously published and is not under consideration for publication elsewhere.
Competing interests
CAP declare to have had an honorarium from Menarini. The other authors declare that they have no competing interests. | RECEIVED 5 CYCLES AS PART OF THE FOLFIRI REGIMEN, AND 3 CYCLES AS PART OF THE FOLFOX REGIMEN | DrugDosageText | CC BY | 33557844 | 19,135,051 | 2021-02-08 |
What was the dosage of drug 'IRINOTECAN'? | Selective treatment pressure in colon cancer drives the molecular profile of resistant circulating tumor cell clones.
The characterization of circulating tumor cells (CTCs) holds promises for precision medicine because these cells are an important clinical indicator of treatment efficacy. We established the first and still only nine permanent colon CTC lines from peripheral blood samples of a patient with metastatic colon cancer collected at different time points during treatment and cancer progression. The study objectives were (i) to compare the gene expression profiles of these CTC lines, and (ii) to determine the main features acquired during treatment. The number of upregulated genes was higher in the CTC lines obtained after treatment, indicating that they acquired properties to escape treatment pressure. Among these upregulated genes, some are involved in the mTOR and PI3K/AKT signaling pathways. Moreover, cytidine deaminase expression was significantly increased in the CTC lines obtained after failure of the first- and second-line 5-fluorouracile-based treatments, suggesting that these CTCs can eliminate this specific drug and resist to therapy. Several enzymes involved in xenobiotic metabolism also were upregulated after treatment, suggesting the activation of detoxification mechanisms in response to chemotherapy. Finally, the significant higher expression of aldolase B in four of the six CTC lines obtained after treatment withdrawal and cancer progression indicated that these clones originated from liver metastases. In conclusion, these CTC lines generated at different time points during treatment of metastatic colon cancer in a single patient are characterized by the deregulation of different genes that promote (i) drug resistance, (ii) xenobiotic and energy metabolism, and (iii) stem cell properties and plasticity.
Main text
Liquid biopsy-based strategies may transform oncology in the near future [1]. Many studies analyzed circulating tumor cells (CTCs) as a real-time liquid biopsy in epithelial tumors (i.e. breast, prostate, and colon cancer) [2] and showed that their study contributes to the prognostic evaluation, patient stratification, and real-time monitoring of treatment efficacy, as well as to the identification of therapeutic targets and tumor resistance mechanisms. However, the low CTC concentration in blood is a crucial limiting factor for the identification of CTCs that may initiate a new tumor at a distant site (i.e. “metastasis-initiator CTCs” or “metastasis-competent CTCs”). Moreover, the establishment and long-term maintenance of in vitro CTC cultures are a major challenge, achieved only by few groups [3, 4].
We established the first nine permanent CTC lines from a 57-year-old patient with metastatic colon cancer (MCC). At diagnosis, he had unresectable widespread MCC with abdominal and mediastinal lymph node invasion and liver metastases. The patient was first treated with the 5-fluorouracile (5-FU)-irinotecan (FOLFIRI) combination and bevacizumab (5 cycles). The first biological progression was observed after the fifth FOLFIRI cycle, and second-line treatment was initiated with 5-FU-oxaliplatin (FOLXFOX) and bevacizumab, but was stopped after the third cycle because of disease progression (clinical and morphological). The patient died about 6 months after diagnosis due to cancer progression. We derived these CTC lines from blood samples collected before treatment initiation (CTC-MCC-41) [5], after the first- and second-line treatments (CTC-MCC-41.4), and 1 week before the patient’s death (CTC-MCC-41.5 [A-G]) [6]. Their phenotypic and molecular characterization indicated that they present common traits and all display epithelial-to-mesenchymal plasticity and stem cell-like characteristics [6, 7].
Here, we obtained and compared the transcriptomic profiles of these CTC lines to identify expression changes linked to tumor progression and treatment pressure, with the aim of identifying biomarkers and mechanisms involved in colon cancer progression.
Results and discussion
CTC selection during cancer progression and treatment pressure
The analysis of the transcriptomic profiles of the nine CTC lines using Affymetrix HG-U133P microarray chips clearly separated them in four distinct groups: CTC-MCC-41, CTC-MCC-41.4, CTC-MCC-41.5 [ABFG], and CTC-MCC-41.5 [CDE] (Fig. 1a). We then compared the transcriptomic profiles of the pre-treatment CTC-MCC-41 line and of the other eight CTC lines (CTC-MCC-41.4 and CTC-MCC-41.5[A-G]) to understand the treatment impact on CTC clonal selection (Fig. 1b and Additional file 2: Tables S1–2). The significantly higher number of upregulated genes in the eight cell lines obtained after treatment initiation (Fig. 1c) suggests that they acquired properties to adapt and resist to treatment. For instance, genes involved in the mTOR and PI3K/AKT signaling cascades, which are implicated in cancer development by coordinating cell growth, survival and proliferation, and in resistance to chemotherapy, were upregulated in the post-treatment CTC lines (Fig. 1d). Colon cancer-specific mortality is higher in patients with tumors harboring mutated PIK3CA than wild type PIK3CA [8]. All our CTC lines harbored wild type PIK3CA and AKT [6], but these signaling pathways were deregulated. Some studies demonstrated that PI3K/mTOR pathway inhibitors could be used in primary and metastatic colorectal cancer [9]. We recently reported that CTC-MCC-41 cells also respond to mTOR and AKT inhibitors, suggesting these therapies are effective even in the absence of mutations [10].
Fig. 1 Transcriptomic analysis of the nine CTC lines obtained from a patient with metastatic colon cancer at different times during disease progression. a Unsupervised 3D PCA representing the gene expression patterns of the CTC line obtained before treatment (n = 3 samples) and the eight CTC lines obtained after treatment initiation (n = 10 samples); b Hierarchical clustering of the CTC lines based on the differentially expressed transcripts (DETs) in CTC-MCC-41 (before treatment) and the other eight lines. The color intensity indicates the transcript expression level (red for upregulated transcripts and blue for downregulated transcripts); c Volcano plots showing the distribution of gene expression fold changes and p-values using the TAC software. Transcripts upregulated in CTC-MCC-41 are indicated in green, and transcripts upregulated in the other eight CTC lines are in red. d Top enriched pathways for the DETs (ANOVA analysis), ranked in increasing order (Fisher’s exact test p-value) identified by Ingenuity® Pathway Analysis, by comparing CTC-MCC-41 (before treatment) and the other eight lines. The “EIF2 signaling”, “mTOR and “PI3K/AKT signaling” pathways were significantly deregulated. Red: genes upregulated in CTC-MCC-41 compared with the other eight CTC lines; green: genes upregulated in the eight post-treatment CTC lines; white: no overlap with the data set; Orange - log (p-value); e Volcano plots showing the distribution of gene expression fold changes and p-values using the TAC software, with transcripts upregulated in the CTC-MCC-41.5 [ABFG] subgroup (green) and in the CTC-MCC-41.5 [CDE] subgroup (red). f Top enriched pathways for the DETs based on the ANOVA analysis, ranked in increasing order (Fisher’s exact test p-values) identified by Ingenuity® Pathway Analysis, in the comparison of the seven CTC-MCC-41.5 lines obtained just before the patient’s death. Many “metabolism” pathways were significantly deregulated, including “xenobiotic metabolism signaling”. Abbreviations: TAC, Transcriptome Analysis Console; DET, differentially expressed transcripts
Conversely, we did not observe many differences between the CTC-MCC-41.4 line, obtained after the last treatment, and the seven CTC-MCC-41.5 [A-G] lines obtained before the patient’s death (Additional file 2: Table S3). This suggests that, without drug pressure, the rapid cancer worsening was not link anymore to a clonal evolution but is due to natural disease progression with the replication of the CTC clones already selected under treatment. Indeed, the seven last CTC lines seem to be already present in the pooled CTC-MCC-41.4 line and they have been selected in the in vitro culture from the last blood sample. However, we could clearly segregate the last seven CTC cell lines (CTC-MCC-41.5 [A-G]), in two groups, [ABFG] and [CDE] (Fig. 1a), with different gene expression profiles (Fig. 1e). Most of the significantly deregulated pathways were involved in metabolism signaling (Fig. 1f), including xenobiotic metabolism. This suggests that detoxification mechanisms were induced upon exposure to anti-cancer drugs, as indicated by the deregulation of the irinotecan/SN38 pathway specifically in the [CDE] group. Furthermore, lipid metabolism upregulation appeared to be more represented in the “CDE signature”. Lipid metabolism is a key function on the basis of the enrichment of different signaling cascades leading to energy metabolism. Since Warburg’s work, metabolic reprogramming is one of the main hallmarks of cancer cells and plays a critical role in the continued tumor growth and progression and is driven by a complex interplay between the tumor mutational landscape, epigenetic modifications, and microenvironmental influences [11]. This topic is actively studied and a high-throughput metabolic-based assay was developed for rapid detection of rare metabolically active disseminated tumor cells in pleural effusion of lung cancer [12].
Cytidine deaminase as a drug resistance biomarker
Besides deregulation of the irinotecan/SN38 pathway in the [CDE] group, the gene encoding cytidine deaminase (CDA) was deregulated in the post-treatment CTC lines (Additional file 2: Table S2). This finding in a patient treated with 5-FU, a pyrimidine analogue, is interesting because CDA maintains the cellular pyrimidine pool by catalyzing the hydrolytic deamination of cytidine and deoxycytidine to uridine and deoxyuridine. Some studies showed that in patients treated with direct cytidine analogues, such as gemcitabine and cytosine arabinoside, CDA overexpression might be a marker of resistance [13]. Analysis of CDA expression in colorectal cancer using publicly available data [14] indicated that it was significantly downregulated in colon adenocarcinoma compared with normal colon (Fig. 2a). However, CDA was strongly upregulated in the CTC-MCC41.4 cell line obtained directly after failure of the first- and second-line 5-FU-based treatments (RT-qPCR analysis in Fig. 2b) and also, to a lower extent, in the CTC lines (CTC-MCC-41.5 A-G) obtained just before death, compared with the pre-treatment CTC-MCC-41 line.
Fig. 2 Major features of the aggressive colon cancer CTC clones selected after treatment. a Boxplot showing cytidine deaminase (CDA) relative expression in normal colon (n = 41) and colon adenocarcinoma (n = 286) samples using UALCAN (p-value = 1.45E-06). b RT-qPCR analysis of CDA gene expression in the nine CTC lines (mean values of triplicate experiments with standard deviation). c ELISA measurement of CDA protein level (ng/ml) in the conditioned medium from the nine CTC lines (mean values from triplicate experiments with standard deviation). Aldolase B (ALDOB) expression analysis (d) by RT-qPCR in the nine CTC lines [*significant upregulation in the CTC-MCC-41.5 [ABFG] cell lines compared with all the other CTC lines (p-value = 0.0134), and only with the CTC-MCC-41.5 [CDE] lines (p-value = 0.0466); **significantly upregulation compared with all the other CTC lines (p-value = 0.0017)], and e in tissue samples (normal colon, normal liver, primary colorectal tumor, liver metastases of colon cancer) (n = 5/tissue). f Representation of the cancer hallmarks of the CTC lines resistant to treatment: (i) Stemness and Plasticity: metastasis-competent potential, (ii) Drug resistance: different molecules and pathways involved in treatment resistance and drug detoxification, such as the CDA enzyme implicated in pyrimidine analogue metabolism (e.g. for 5-FU), (iii) Metabolism: xenobiotic metabolism linked to therapy resistance, energy metabolism linked to mitochondrial activity, and ALDOB activity that gave information also on the liver metastasis origin of the CTC41.5[ABFG] lines. Abbreviation: EMT, epithelial-mesenchymal transition
As CDA is secreted in the extracellular compartment (https://www.uniprot.org/uniprot/P32320) and can be detected in blood, we quantified CDA concentration by ELISA in conditioned medium from the nine CTC-MCC lines. As observed for the CDA gene, CDA protein level was highest in CTC-MCC-41.4 cells (Fig. 2c). These findings suggest that in this patient, CDA was directly produced and secreted by resistant and aggressive CTCs in response to 5-FU-based chemotherapy. Therefore, CDA might represent a candidate plasmatic biomarker to monitor 5-FU efficacy and resistance development.
Aldolase B as a marker to identify CTCs released only by liver metastases
Comparison of the signatures of the two CTC-MCC-41.5 sub-groups ([ABFG] and [CDE]) (Additional file 2: Tables S4–5) highlighted ALDOB upregulation in the [ABFG] group (Fig. 2d). This gene encodes the aldolase B enzyme (fructose-bisphosphate aldolase B or liver-type aldolase), one of three isoenzymes (A, B, and C) of the class I fructose 1,6-bisphosphate aldolase enzyme (EC 4.1.2.1) that plays a key role in glycolysis and gluconeogenesis. This enzyme is preferentially expressed in the liver and at lower extend in the kidney and the small intestine. ALDOB downregulation correlates with poor overall survival in liver and gastric cancer [15, 16], whereas ALDOB overexpression in colorectal cancer has been associated with poor overall survival and epithelial-to-mesenchymal transition promotion [17]. Colorectal cancer is known to preferentially metastasize (∼70% patients) to the liver [18], which is the main organ for glycogenesis and gluconeogenesis. In addition, this specific patient had liver metastases. Comparison of ALDOB expression in different tissues using publicly available data showed that: (i) ALDOB was strongly expressed in normal liver compared with normal colon, (ii) ALDOB expression was comparable in primary colon adenocarcinoma and normal colon samples, and (iii) ALDOB was upregulated in colon cancer liver metastases compared with primary tumors (Fig. 2e). Bu et al. showed that during liver colonization, colon cancer cells undergo metabolic reprogramming by upregulating ALDOB [19]. This enhances fructose metabolism and promotes the growth of colon cancer liver metastases. These data suggest that the [ABFG] lines were derived from CTCs released by liver metastases. It is thought that CTCs are released by the primary tumor and/or metastases; however, to our knowledge, this is the first time that this could be demonstrated in a patient.
Conclusions
From Nowell’s work in 1976, it is acknowledged that cancer is an evolutionary process and that treatments exert selective pressures that drive the tumor cell evolution, favoring the appearance of resistant clones. The present results confirm that CTC line profiling is a relevant approach to study clonal selection during disease progression and to discover new CTC biomarkers for monitoring treatment response. The transcriptomic analysis of the CTC lines obtained after treatments (CTC-MCC-41.4 and CTC-MCC-41.5[A-G]) showed the progressive deregulation of genes involved in cancer aggressiveness hallmarks: (i) drug resistance, with the upregulation of molecules and pathways implicated in drug detoxification (e.g. CDA and the irinotecan/SN38 pathway), (ii) metabolism changes, including upregulation of genes implicated in the xenobiotic metabolism, linked to therapy resistance, and energy metabolism (mitochondrial activity to provide energy to hyper-metabolic cells), and the ALDOB gene linked to liver metabolism, and (iii) stemness and plasticity, highlighting their metastasis-competent potential (Fig. 2f). This work is, however, specific of this cancer patient and the biomarkers found and highlighted in these CTC lines need now to be validated on CTCs and plasma from independent patients with colorectal cancer.
Supplementary Information
Additional file 1. Supplementary materials and methods.
Additional file 2: Table S1. List of DETs upregulated in CTC-MCC-41 vs all the other CTC lines. Table S2. List of DETs downregulated in CTC-MCC-41 vs all the other CTC lines. Table S3. List of DETs upregulated in all CTC-MCC-41.5 cell lines vs the CTC-MCC-41.4 cell line. Table S4. List of DETs upregulated in the [ABFG] subgroup vs the [CDE] subgroup of the CTC-MCC-41.5 cell lines. Table S5. List of DETs downregulated in the [ABFG] subgroup vs the [CDE] subgroup of the CTC-MCC-41.5 cell lines. Table S6. Primer sequences.
Additional file 3: Figure S1. Box-plots showing the expression level of a set of differentially expressed transcripts (DETs) in the CTC-MCC-41, CTC-MCC-41.4, and CTC-MCC-41.5 [ABFG] and [CDE] cell lines. Abbreviations: CTC-BT, CTC line derived before treatment initiation; CTC-AT, CTC lines derived after treatment initiation. Figure S2. RT-qPCR validation of the microarray data. Abbreviations: CTC-BT, CTC line derived before treatment initiation; CTC-AT, CTC lines derived after treatment initiation.
Abbreviations
5-FU5-fluorouracile
ALDOBAldolase B
CDACytidine deaminase
CTCCirculating tumor cell
EMTEpithelial to mesenchymal transition
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Acknowledgements
The authors thank Dr. Elisabetta Andermarcher for assistance with her comments and proofreading that greatly improved the manuscript.
Authors’ contributions
LC and SA analyzed and interpreted the data. LC, SA and CAP were major contributors in the conception of the study and in the writing of the manuscript. All authors red and approved the final manuscript.
Funding
This work was supported by the National Cancer Institute (INCA) and the General Direction for Caregiving (DGOS) for patient recruitment and analysis in the COLOSPOT study (NCT01596790), by SIRIC Montpellier Cancer Grant INCa_Inserm_DGOS_12553 for staff salary as well as by the MAVA Foundation, the CNRS and the ANR project TRANSCAN (ANR-18-CE35–0009).
Availability of data and materials
The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.
The 20 publicly available Affymetrix datasets on normal colon (n = 5 samples), primary tumor (n = 5 samples), liver metastases (n = 5 samples) and normal liver (n = 5 samples) are accessible at the gene expression Omnibus (GEO) repository (https://www-ncbi-nlm-nih-gov.proxy.insermbiblio.inist.fr/geo) through the accession numbers: GSM1198032, GSM1198034, GSM1198038, GSM1198047, GSM1198050, GSM1198030, GSM1198035, GSM1198037, GSM1198046, GSM1198048, GSM1198023, GSM1198031, GSM1198033, GSM1198042, GSM1198052, GSM557089, GSM557091, GSM557093, GSM557099, GSM557107.
Ethics approval and consent to participate
The patient gave his consent to participate in the COLOSPOT study to investigate CTCs in metastatic colorectal cancer. The bioethics committee gave its approval (ID-RCB 2011-A01130–41).
Consent for publication
The content of this manuscript has not been previously published and is not under consideration for publication elsewhere.
Competing interests
CAP declare to have had an honorarium from Menarini. The other authors declare that they have no competing interests. | RECEIVED 5 CYCLES AS PART OF THE FOLFIRI REGIMEN | DrugDosageText | CC BY | 33557844 | 19,135,051 | 2021-02-08 |
What was the dosage of drug 'OXALIPLATIN'? | Selective treatment pressure in colon cancer drives the molecular profile of resistant circulating tumor cell clones.
The characterization of circulating tumor cells (CTCs) holds promises for precision medicine because these cells are an important clinical indicator of treatment efficacy. We established the first and still only nine permanent colon CTC lines from peripheral blood samples of a patient with metastatic colon cancer collected at different time points during treatment and cancer progression. The study objectives were (i) to compare the gene expression profiles of these CTC lines, and (ii) to determine the main features acquired during treatment. The number of upregulated genes was higher in the CTC lines obtained after treatment, indicating that they acquired properties to escape treatment pressure. Among these upregulated genes, some are involved in the mTOR and PI3K/AKT signaling pathways. Moreover, cytidine deaminase expression was significantly increased in the CTC lines obtained after failure of the first- and second-line 5-fluorouracile-based treatments, suggesting that these CTCs can eliminate this specific drug and resist to therapy. Several enzymes involved in xenobiotic metabolism also were upregulated after treatment, suggesting the activation of detoxification mechanisms in response to chemotherapy. Finally, the significant higher expression of aldolase B in four of the six CTC lines obtained after treatment withdrawal and cancer progression indicated that these clones originated from liver metastases. In conclusion, these CTC lines generated at different time points during treatment of metastatic colon cancer in a single patient are characterized by the deregulation of different genes that promote (i) drug resistance, (ii) xenobiotic and energy metabolism, and (iii) stem cell properties and plasticity.
Main text
Liquid biopsy-based strategies may transform oncology in the near future [1]. Many studies analyzed circulating tumor cells (CTCs) as a real-time liquid biopsy in epithelial tumors (i.e. breast, prostate, and colon cancer) [2] and showed that their study contributes to the prognostic evaluation, patient stratification, and real-time monitoring of treatment efficacy, as well as to the identification of therapeutic targets and tumor resistance mechanisms. However, the low CTC concentration in blood is a crucial limiting factor for the identification of CTCs that may initiate a new tumor at a distant site (i.e. “metastasis-initiator CTCs” or “metastasis-competent CTCs”). Moreover, the establishment and long-term maintenance of in vitro CTC cultures are a major challenge, achieved only by few groups [3, 4].
We established the first nine permanent CTC lines from a 57-year-old patient with metastatic colon cancer (MCC). At diagnosis, he had unresectable widespread MCC with abdominal and mediastinal lymph node invasion and liver metastases. The patient was first treated with the 5-fluorouracile (5-FU)-irinotecan (FOLFIRI) combination and bevacizumab (5 cycles). The first biological progression was observed after the fifth FOLFIRI cycle, and second-line treatment was initiated with 5-FU-oxaliplatin (FOLXFOX) and bevacizumab, but was stopped after the third cycle because of disease progression (clinical and morphological). The patient died about 6 months after diagnosis due to cancer progression. We derived these CTC lines from blood samples collected before treatment initiation (CTC-MCC-41) [5], after the first- and second-line treatments (CTC-MCC-41.4), and 1 week before the patient’s death (CTC-MCC-41.5 [A-G]) [6]. Their phenotypic and molecular characterization indicated that they present common traits and all display epithelial-to-mesenchymal plasticity and stem cell-like characteristics [6, 7].
Here, we obtained and compared the transcriptomic profiles of these CTC lines to identify expression changes linked to tumor progression and treatment pressure, with the aim of identifying biomarkers and mechanisms involved in colon cancer progression.
Results and discussion
CTC selection during cancer progression and treatment pressure
The analysis of the transcriptomic profiles of the nine CTC lines using Affymetrix HG-U133P microarray chips clearly separated them in four distinct groups: CTC-MCC-41, CTC-MCC-41.4, CTC-MCC-41.5 [ABFG], and CTC-MCC-41.5 [CDE] (Fig. 1a). We then compared the transcriptomic profiles of the pre-treatment CTC-MCC-41 line and of the other eight CTC lines (CTC-MCC-41.4 and CTC-MCC-41.5[A-G]) to understand the treatment impact on CTC clonal selection (Fig. 1b and Additional file 2: Tables S1–2). The significantly higher number of upregulated genes in the eight cell lines obtained after treatment initiation (Fig. 1c) suggests that they acquired properties to adapt and resist to treatment. For instance, genes involved in the mTOR and PI3K/AKT signaling cascades, which are implicated in cancer development by coordinating cell growth, survival and proliferation, and in resistance to chemotherapy, were upregulated in the post-treatment CTC lines (Fig. 1d). Colon cancer-specific mortality is higher in patients with tumors harboring mutated PIK3CA than wild type PIK3CA [8]. All our CTC lines harbored wild type PIK3CA and AKT [6], but these signaling pathways were deregulated. Some studies demonstrated that PI3K/mTOR pathway inhibitors could be used in primary and metastatic colorectal cancer [9]. We recently reported that CTC-MCC-41 cells also respond to mTOR and AKT inhibitors, suggesting these therapies are effective even in the absence of mutations [10].
Fig. 1 Transcriptomic analysis of the nine CTC lines obtained from a patient with metastatic colon cancer at different times during disease progression. a Unsupervised 3D PCA representing the gene expression patterns of the CTC line obtained before treatment (n = 3 samples) and the eight CTC lines obtained after treatment initiation (n = 10 samples); b Hierarchical clustering of the CTC lines based on the differentially expressed transcripts (DETs) in CTC-MCC-41 (before treatment) and the other eight lines. The color intensity indicates the transcript expression level (red for upregulated transcripts and blue for downregulated transcripts); c Volcano plots showing the distribution of gene expression fold changes and p-values using the TAC software. Transcripts upregulated in CTC-MCC-41 are indicated in green, and transcripts upregulated in the other eight CTC lines are in red. d Top enriched pathways for the DETs (ANOVA analysis), ranked in increasing order (Fisher’s exact test p-value) identified by Ingenuity® Pathway Analysis, by comparing CTC-MCC-41 (before treatment) and the other eight lines. The “EIF2 signaling”, “mTOR and “PI3K/AKT signaling” pathways were significantly deregulated. Red: genes upregulated in CTC-MCC-41 compared with the other eight CTC lines; green: genes upregulated in the eight post-treatment CTC lines; white: no overlap with the data set; Orange - log (p-value); e Volcano plots showing the distribution of gene expression fold changes and p-values using the TAC software, with transcripts upregulated in the CTC-MCC-41.5 [ABFG] subgroup (green) and in the CTC-MCC-41.5 [CDE] subgroup (red). f Top enriched pathways for the DETs based on the ANOVA analysis, ranked in increasing order (Fisher’s exact test p-values) identified by Ingenuity® Pathway Analysis, in the comparison of the seven CTC-MCC-41.5 lines obtained just before the patient’s death. Many “metabolism” pathways were significantly deregulated, including “xenobiotic metabolism signaling”. Abbreviations: TAC, Transcriptome Analysis Console; DET, differentially expressed transcripts
Conversely, we did not observe many differences between the CTC-MCC-41.4 line, obtained after the last treatment, and the seven CTC-MCC-41.5 [A-G] lines obtained before the patient’s death (Additional file 2: Table S3). This suggests that, without drug pressure, the rapid cancer worsening was not link anymore to a clonal evolution but is due to natural disease progression with the replication of the CTC clones already selected under treatment. Indeed, the seven last CTC lines seem to be already present in the pooled CTC-MCC-41.4 line and they have been selected in the in vitro culture from the last blood sample. However, we could clearly segregate the last seven CTC cell lines (CTC-MCC-41.5 [A-G]), in two groups, [ABFG] and [CDE] (Fig. 1a), with different gene expression profiles (Fig. 1e). Most of the significantly deregulated pathways were involved in metabolism signaling (Fig. 1f), including xenobiotic metabolism. This suggests that detoxification mechanisms were induced upon exposure to anti-cancer drugs, as indicated by the deregulation of the irinotecan/SN38 pathway specifically in the [CDE] group. Furthermore, lipid metabolism upregulation appeared to be more represented in the “CDE signature”. Lipid metabolism is a key function on the basis of the enrichment of different signaling cascades leading to energy metabolism. Since Warburg’s work, metabolic reprogramming is one of the main hallmarks of cancer cells and plays a critical role in the continued tumor growth and progression and is driven by a complex interplay between the tumor mutational landscape, epigenetic modifications, and microenvironmental influences [11]. This topic is actively studied and a high-throughput metabolic-based assay was developed for rapid detection of rare metabolically active disseminated tumor cells in pleural effusion of lung cancer [12].
Cytidine deaminase as a drug resistance biomarker
Besides deregulation of the irinotecan/SN38 pathway in the [CDE] group, the gene encoding cytidine deaminase (CDA) was deregulated in the post-treatment CTC lines (Additional file 2: Table S2). This finding in a patient treated with 5-FU, a pyrimidine analogue, is interesting because CDA maintains the cellular pyrimidine pool by catalyzing the hydrolytic deamination of cytidine and deoxycytidine to uridine and deoxyuridine. Some studies showed that in patients treated with direct cytidine analogues, such as gemcitabine and cytosine arabinoside, CDA overexpression might be a marker of resistance [13]. Analysis of CDA expression in colorectal cancer using publicly available data [14] indicated that it was significantly downregulated in colon adenocarcinoma compared with normal colon (Fig. 2a). However, CDA was strongly upregulated in the CTC-MCC41.4 cell line obtained directly after failure of the first- and second-line 5-FU-based treatments (RT-qPCR analysis in Fig. 2b) and also, to a lower extent, in the CTC lines (CTC-MCC-41.5 A-G) obtained just before death, compared with the pre-treatment CTC-MCC-41 line.
Fig. 2 Major features of the aggressive colon cancer CTC clones selected after treatment. a Boxplot showing cytidine deaminase (CDA) relative expression in normal colon (n = 41) and colon adenocarcinoma (n = 286) samples using UALCAN (p-value = 1.45E-06). b RT-qPCR analysis of CDA gene expression in the nine CTC lines (mean values of triplicate experiments with standard deviation). c ELISA measurement of CDA protein level (ng/ml) in the conditioned medium from the nine CTC lines (mean values from triplicate experiments with standard deviation). Aldolase B (ALDOB) expression analysis (d) by RT-qPCR in the nine CTC lines [*significant upregulation in the CTC-MCC-41.5 [ABFG] cell lines compared with all the other CTC lines (p-value = 0.0134), and only with the CTC-MCC-41.5 [CDE] lines (p-value = 0.0466); **significantly upregulation compared with all the other CTC lines (p-value = 0.0017)], and e in tissue samples (normal colon, normal liver, primary colorectal tumor, liver metastases of colon cancer) (n = 5/tissue). f Representation of the cancer hallmarks of the CTC lines resistant to treatment: (i) Stemness and Plasticity: metastasis-competent potential, (ii) Drug resistance: different molecules and pathways involved in treatment resistance and drug detoxification, such as the CDA enzyme implicated in pyrimidine analogue metabolism (e.g. for 5-FU), (iii) Metabolism: xenobiotic metabolism linked to therapy resistance, energy metabolism linked to mitochondrial activity, and ALDOB activity that gave information also on the liver metastasis origin of the CTC41.5[ABFG] lines. Abbreviation: EMT, epithelial-mesenchymal transition
As CDA is secreted in the extracellular compartment (https://www.uniprot.org/uniprot/P32320) and can be detected in blood, we quantified CDA concentration by ELISA in conditioned medium from the nine CTC-MCC lines. As observed for the CDA gene, CDA protein level was highest in CTC-MCC-41.4 cells (Fig. 2c). These findings suggest that in this patient, CDA was directly produced and secreted by resistant and aggressive CTCs in response to 5-FU-based chemotherapy. Therefore, CDA might represent a candidate plasmatic biomarker to monitor 5-FU efficacy and resistance development.
Aldolase B as a marker to identify CTCs released only by liver metastases
Comparison of the signatures of the two CTC-MCC-41.5 sub-groups ([ABFG] and [CDE]) (Additional file 2: Tables S4–5) highlighted ALDOB upregulation in the [ABFG] group (Fig. 2d). This gene encodes the aldolase B enzyme (fructose-bisphosphate aldolase B or liver-type aldolase), one of three isoenzymes (A, B, and C) of the class I fructose 1,6-bisphosphate aldolase enzyme (EC 4.1.2.1) that plays a key role in glycolysis and gluconeogenesis. This enzyme is preferentially expressed in the liver and at lower extend in the kidney and the small intestine. ALDOB downregulation correlates with poor overall survival in liver and gastric cancer [15, 16], whereas ALDOB overexpression in colorectal cancer has been associated with poor overall survival and epithelial-to-mesenchymal transition promotion [17]. Colorectal cancer is known to preferentially metastasize (∼70% patients) to the liver [18], which is the main organ for glycogenesis and gluconeogenesis. In addition, this specific patient had liver metastases. Comparison of ALDOB expression in different tissues using publicly available data showed that: (i) ALDOB was strongly expressed in normal liver compared with normal colon, (ii) ALDOB expression was comparable in primary colon adenocarcinoma and normal colon samples, and (iii) ALDOB was upregulated in colon cancer liver metastases compared with primary tumors (Fig. 2e). Bu et al. showed that during liver colonization, colon cancer cells undergo metabolic reprogramming by upregulating ALDOB [19]. This enhances fructose metabolism and promotes the growth of colon cancer liver metastases. These data suggest that the [ABFG] lines were derived from CTCs released by liver metastases. It is thought that CTCs are released by the primary tumor and/or metastases; however, to our knowledge, this is the first time that this could be demonstrated in a patient.
Conclusions
From Nowell’s work in 1976, it is acknowledged that cancer is an evolutionary process and that treatments exert selective pressures that drive the tumor cell evolution, favoring the appearance of resistant clones. The present results confirm that CTC line profiling is a relevant approach to study clonal selection during disease progression and to discover new CTC biomarkers for monitoring treatment response. The transcriptomic analysis of the CTC lines obtained after treatments (CTC-MCC-41.4 and CTC-MCC-41.5[A-G]) showed the progressive deregulation of genes involved in cancer aggressiveness hallmarks: (i) drug resistance, with the upregulation of molecules and pathways implicated in drug detoxification (e.g. CDA and the irinotecan/SN38 pathway), (ii) metabolism changes, including upregulation of genes implicated in the xenobiotic metabolism, linked to therapy resistance, and energy metabolism (mitochondrial activity to provide energy to hyper-metabolic cells), and the ALDOB gene linked to liver metabolism, and (iii) stemness and plasticity, highlighting their metastasis-competent potential (Fig. 2f). This work is, however, specific of this cancer patient and the biomarkers found and highlighted in these CTC lines need now to be validated on CTCs and plasma from independent patients with colorectal cancer.
Supplementary Information
Additional file 1. Supplementary materials and methods.
Additional file 2: Table S1. List of DETs upregulated in CTC-MCC-41 vs all the other CTC lines. Table S2. List of DETs downregulated in CTC-MCC-41 vs all the other CTC lines. Table S3. List of DETs upregulated in all CTC-MCC-41.5 cell lines vs the CTC-MCC-41.4 cell line. Table S4. List of DETs upregulated in the [ABFG] subgroup vs the [CDE] subgroup of the CTC-MCC-41.5 cell lines. Table S5. List of DETs downregulated in the [ABFG] subgroup vs the [CDE] subgroup of the CTC-MCC-41.5 cell lines. Table S6. Primer sequences.
Additional file 3: Figure S1. Box-plots showing the expression level of a set of differentially expressed transcripts (DETs) in the CTC-MCC-41, CTC-MCC-41.4, and CTC-MCC-41.5 [ABFG] and [CDE] cell lines. Abbreviations: CTC-BT, CTC line derived before treatment initiation; CTC-AT, CTC lines derived after treatment initiation. Figure S2. RT-qPCR validation of the microarray data. Abbreviations: CTC-BT, CTC line derived before treatment initiation; CTC-AT, CTC lines derived after treatment initiation.
Abbreviations
5-FU5-fluorouracile
ALDOBAldolase B
CDACytidine deaminase
CTCCirculating tumor cell
EMTEpithelial to mesenchymal transition
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Acknowledgements
The authors thank Dr. Elisabetta Andermarcher for assistance with her comments and proofreading that greatly improved the manuscript.
Authors’ contributions
LC and SA analyzed and interpreted the data. LC, SA and CAP were major contributors in the conception of the study and in the writing of the manuscript. All authors red and approved the final manuscript.
Funding
This work was supported by the National Cancer Institute (INCA) and the General Direction for Caregiving (DGOS) for patient recruitment and analysis in the COLOSPOT study (NCT01596790), by SIRIC Montpellier Cancer Grant INCa_Inserm_DGOS_12553 for staff salary as well as by the MAVA Foundation, the CNRS and the ANR project TRANSCAN (ANR-18-CE35–0009).
Availability of data and materials
The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.
The 20 publicly available Affymetrix datasets on normal colon (n = 5 samples), primary tumor (n = 5 samples), liver metastases (n = 5 samples) and normal liver (n = 5 samples) are accessible at the gene expression Omnibus (GEO) repository (https://www-ncbi-nlm-nih-gov.proxy.insermbiblio.inist.fr/geo) through the accession numbers: GSM1198032, GSM1198034, GSM1198038, GSM1198047, GSM1198050, GSM1198030, GSM1198035, GSM1198037, GSM1198046, GSM1198048, GSM1198023, GSM1198031, GSM1198033, GSM1198042, GSM1198052, GSM557089, GSM557091, GSM557093, GSM557099, GSM557107.
Ethics approval and consent to participate
The patient gave his consent to participate in the COLOSPOT study to investigate CTCs in metastatic colorectal cancer. The bioethics committee gave its approval (ID-RCB 2011-A01130–41).
Consent for publication
The content of this manuscript has not been previously published and is not under consideration for publication elsewhere.
Competing interests
CAP declare to have had an honorarium from Menarini. The other authors declare that they have no competing interests. | RECEIVED 3 CYCLES AS PART OF THE FOLFOX REGIMEN | DrugDosageText | CC BY | 33557844 | 19,135,051 | 2021-02-08 |
Give an alphabetized list of all active substances of drugs taken by the patient who experienced 'Drug reaction with eosinophilia and systemic symptoms'. | An unusual case of piperacillin-tazobactam-induced fever, eosinophilia, thrombocytopenia and liver damage.
Piperacillin-tazobactam is a broad-spectrum antimicrobial agent that is commonly used in clinical practice. The development of delayed drug hypersensitivity reaction (DHR) has been reported in several cases previously. Here we describe an unusual case of non-immediate DHR due to a prolonged course of piperacillin-tazobactam. We report a 22-year-old man who developed fever, eosinophilia, thrombocytopenia and elevated hepatic enzymes following 17 days of piperacillin-tazobactam for methicillin-sensitive Staphylococcus aureus (MSSA) pneumonia. These adverse reactions were reversed immediately after antibiotic cessation. Our case highlights that clinicians should be aware of delayed adverse effects in patients receiving long-term piperacillin-tazobactam treatment.
pmcBackground
Piperacillin-tazobactam is a combination formulation of an ureidopenicillin and a beta-lactamase inhibitor with a broad spectrum of antibacterial activity.1 2 It is effective for the treatment of patients with polymicrobial infection caused by many Gram-negative, Gram-positive and beta-lactamase-producing bacteria, such as complicated nosocomial and intra-abdominal infections, and also is regarded as empiric therapy for patients who present with fever and neutropenia.3
As a typical antibiotic, piperacillin-tazobactam is considered safe and well tolerated. However, some adverse reactions have been reported. The most frequent complications include diarrhoea and hepatic dysfunction.4 Eosinophilia with fever and haematological abnormality have been described as severe adverse effects of piperacillin-tazobactam, and are also characteristically regarded as part of the non-immediate drug hypersensitivity reactions (DHRs).5 6 Non-immediate DHRs tend to occur in patients receiving piperacillin-tazobactam therapy over 10 days.7 Here we report an unusual case of a non-immediate DHR reaction to piperacillin-tazobactam.
Case presentation
A previously healthy 22-year-old man presented at our emergency room in January 2020 with high fever (up to 40℃) for a week, accompanied with cough and expectoration. He had 3- year history of smoking without intravenous drug abuse. Physical examination revealed: body temperature 39.5℃; blood pressure 101/54 mmHg and tachypnea of 28 breaths/minute. There were no signs of wounds or skin abscesses. No obvious rhonchi was heard at bilateral lungs and no murmurs were audible in the cardiac valve areas. Initial laboratory tests in the emergency room included: white blood cell count 30.45×109/L, neutrophils 26.95×109/L, platelets 469×109/L, C-reactive protein (CRP) 78 mg/L (normal range 0–8 mg/L) and lactate dehydrogenase (LDH) 657 U/L. Computed tomography (CT) of the chest indicated multiple patchy opacities with cavities. The patient was admitted for further investigation and treatment.
Cardiac ultrasound indicated no signs of bacterial endocarditis. Methicillin-sensitive Staphylococcus aureus (MSSA) was isolated from sputum. Repeated blood cultures were negative. HIV and hepatitis B virus tests were negative. Tests for active and latent tuberculosis, including mycobacterium cultures of sputum samples and the interferon-γ release test for tuberculosis infection, were negative. Chest CT showed multiple dense consolidation with cavities at both side of the lungs and also indicated some cavities with gas-liquid level formation inside pulmonary abscesses (figure 1). A small quantity of pleural effusion presented on the scan. No obvious abnormality was found on abdominal CT. A diagnosis was made of S. aureus pneumonia, complicated by pulmonary abscess. Initially the patient empirically received intravenous vancomycin, 1 g twice daily, and imipenem 1 g every 6 hours. Three days later the patient’s body temperature had markedly decreased. Give the presence of MSSA and abnormality of liver function, antimicrobial therapy was switched to intravenous piperacillin-tazobactam 4.5 g every 8 hours per day.
Figure 1 Computed tomography (CT) images of a 22-year-old patient admitted with Staphylococcus aureus pneumonia in January 2020. CT showed multiple patchy opacities with cavities, some of which had gas-liquid level formation inside in the emergency room (A) and after admission (B). During the initiation of vancomycin and imipenem, slightly absorbed parts of inflammatory lesions were revealed on CT (C). Piperacillin-tazobactam treatment improved the CT findings on day 6 following administration (D). No indication of new infection was found after drug-induced fever. (E). No obvious focus was seen on CT scan 3 months after discharge (F).
Intravenous piperacillin-tazobactam apparently further improved the patient's symptoms and CT appearance. His body temperature remained normal for 10 days. However, 17 days after continuous treatment with piperacillin-tazobactam, the patient suddenly developed a high fever with a body temperature of 38.5℃ and did not complain of any other symptoms. Detailed physical examination did not reveal any abnormal findings. Blood samples were taken for culture. Repeated chest CT did not show any deterioration or was suggestive of a new infection for the recurrence of fever. Laboratory analysis indicated reduced platelets (66×109/L) compared with the initial level (figure 2). On the following days, the patient also had eosinophilia (1.36×109/L) and liver function abnormality (alanine aminotransferase (ALT) 78 U/L, aspartate aminotransferase (AST) 223 U/L). Potential viral infection of the upper respiratory tract was excluded.
Figure 2 The development of eosinophilia, thrombocytopenia and liver function test abnormality during the course of piperacillin-tazobactam treatment with normal values for white cell count. Blood counts of eosinophils and platelets returned to normal levels after cessation of piperacillin-tazobactam on day 14 following initiation. Liver parameters returned to normal after 1 week following cessation of piperacillin-tazobactam treatment. PCT, procalcitonin.
The piperacillin-tazobactam was suspected to be the most likely cause of the recurrent fever, eosinophilia, thrombocytopenia and hepatic abnormalities, and hence was stopped. The fever quickly resolved within 24 hours following the termination of piperacillin-tazobactam treatment and did not recur afterwards. Platelet and eosinophil counts normalised on day 3 and day 7 after cessation of piperacillin-tazobactam, respectively. The parameters of hepatic function declined nearly to normal levels after a week following piperacillin-tazobactam cessation. The patient did not receive any additional medication (including antibiotic therapy) for the recurrent fever until discharge, and underwent supportive treatment without any complications.
Investigations
This is an uncommon case of adverse drug response caused by piperacillin-tazobactam. Previous reports have revealed several cases of haematological abnormalities that were suspected as probably being piperacillin-tazobactam-induced side effects, including neutropenia, thrombocytopenia or anaemia.8 9 Other reports showed that eosinophilia with systemic symptoms are regarded as kinds of adverse effects caused by the antibiotics.5 10 In our work, we found a special case of delayed thrombocytopenia and eosinophilia that occurred simultaneously after the use of piperacillin-tazobactam for the treatment of S. aureus pneumonia. The patient’s laboratory and clinical factors did not show evidence of latent infection in other locations. The possibile involvement of the upper respiratory tract was excluded.
Treatment
The patient' diagnosis was S. aureus pneumonia, complicated by pulmonary abscesses. The use of intravenous piperacillin-tazobactam apparently improved the patient's symptoms and CT appearance. Although the patient developed fever, eosinophilia, thrombocytopenia and liver damage caused by the treatment, the unusual syndromes gradually disappeared after cessation of piperacillin-tazobactama.
Outcome and follow-up
The fever resolved within 24 hours after stopping piperacillin-tazobactam treatment. The platelet and eosinophil counts both returned to normal after the cessation of piperacillin-tazobactam. The parameters of hepatic function also declined nearly to normal levels following treatment termination.
Discussion
In the present case, the patient started to show the side effects of fever, thrombocytopenia and eosinophilia after 17 days of piperacillin-tazobactam treatment. This is similar to previous reports in which drug induced-fever and associated adverse effects occurred from 11 to 17 days after the initiation of piperacillin-tazobactam administration. We have experienced this several times and have described this as the ‘dangerous period’ for piperacillin-tazobactam-induced fever. Consequently we stopped piperacillin-tazobactam therapy immediately without starting any other antibiotics or medication. Fortunately, this patient's fever disappeared within 24 hours of the piperacillin-tazobactam therapy being discontinued. Although the patient's blood CRP and procalcitonin increased in tandem with the fever, they soon declined on day 3 after the termination of piperacillin-tazobactam therapy. Based on the evidence, we believe there is a correlation between the described side effects and piperacillin-tazobactam therapy.
It has been reported in some cases that piperacillin-tazobactam-induced fever is regarded as a hypersensitivity reaction. Fever, eosinophilia, thrombocytopenia and liver damage are all part of the drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome.5 DRESS syndrome is a life-threatening, rare adverse effect that frequently develops following exposure to antibiotics or antiepileptics, which is characterised by fever, rash, elevated liver enzyme levels, and leukocytosis with eosinophilia.11 The RegiSCAR (European Register of Severe Cutaneous Adverse Reactions) is a scoring system which is most commonly used to categorise cases of DRESS into four groups: no case, possible case, probable case and definite case. Our patient presented several of the described features including fever, eosinophilia and elevated liver enzymes. Typical rash and enlarged lymph nodes were not detected in our patient. Use of the RegiSCAR indicated a possible relationship (score of 3) between our patient’s manifestation of DRESS syndrome and treatment with piperacillin-tazobactam.12
Our patient’s presentation of a fever and an elevated CRP lasting for a transient period evoked a suspicion of latent viral and haematological infection probably after prolonged use of piperacillin-tazobactam. However, no other probable aetiology of eosinophilia could be identified, and the eosinophil abnormality associated with administration of piperacillin-tazobactam resolved soon after the termination of antibiotic therapy. We reasoned that the eosinophilia was probably related to piperacillin-tazobactam as a non-immediate DHR. The mechanism of piperacillin-tazobactam-induced eosinophilia is not entirely understood, but one theory is that activation of interleukin-5 (IL-5) on accumulation of toxic metabolites could cause activation of eosinophils and inflammatory cascades.13 Although there is no accurate diagnostic test or pathognomonic sign, the diagnosis of DRESS syndrome should be considered after exposure to piperacillin-tazobactam for longer than 2 weeks.
Bone marrow suppression is a rare and serious adverse effect of piperacillin-tazobactam, and it has been reported that abnormalities occurred after 2 weeks of prolonged antibiotic use.8 The most common abnormality is neutropenia that is often accompanied with thrombocytopenia. Thrombocytopenia rarely develops alone. Thus, we demonstrate an unusual isolated thrombocytopenia after a long course of piperacillin-tazobactam. To our knowledge, isolated thrombocytopenia is thought likely to be due to an immune-mediated reaction induced by drug administration that occurs suddenly and precipitously. Bose et al described a case of abrupt and severe thrombocytopenia within 2 days of piperacillin-tazobactam administration.14 The patient had a positive test for immunoglobulin G (IgG) antiplatelet antibodies to piperacillin-tazobactam therapy, supporting the speculation of immune-related thrombocytopenia. Alzahrani et al reported two cases of possible immune thrombocytopenia that developed rapidly and severely in association with re-exposure to piperacillin-tazobactam.15 Also the platelet count in peripheral blood improved after the discontinuation of piperacillin-tazobactam and the initiation of corticosteroid therapy, suggesting the possibility of immune-mediated thrombocytopenia.
In our case, the patient developed wild thrombocytopenia without any positive results of auto-immune antibodies or change in complement C3. Since we stopped piperacillin-tazobactam immediately after the side effect occurred, the thrombocytopenia quickly resolved without corticosteroid therapy. It has been suggested that this later-onset thrombocytopenia is dependent on a delayed-type hypersensitivity. Among antibiotics, the beta-lactam antibiotics are a common cause of immune thrombocytopenia, while a beta-lactam-beta-lactamase inhibitor combination, such as piperacillin-tazobactam, has rarely been reported to induce immune-mediated thrombocytopenia. The aetiology of drug-induced immune thrombocytopenia is complex and the mechanism of piperacillin-related thrombocytopenia is possibly associated with hapten-induced antibodies. Some studies have suggested that small molecules like drugs might induce an immune response when linked to macromolecules such as proteins. The combination acts as a hapten and triggers a humoral immune response. On re-exposure to the drug, this leads to platelet destruction and this mechanism may explain the haemolytic anaemia.16 Another report revealed that piperacillin can induce hapten-specific antibodies that are reactive with piperacillin-coated blood cells.17 This similar mechanism may account for the thrombocytopenia that is rarely seen in patients after treatment with piperacillin, but this still needs further confirmation experimentally. An explanation whereby the later-onset thrombocytopenia caused by piperacillin-tazobactam likely occurs as a result of direct toxicity of myeloid precursors should not be excluded.
Moreover, our patient also manifested liver dysfunction, having previously had normal liver function, while the haematological abnormality appeared after the onset of drug-induced fever, and the hepatic value returned to the normal level 1 week after drug cessation. Although hepatic dysfunction has been reported previously in patients on piperacillin-tazobactam therapy, there is no apparent relationship with mortality or progression. Saloojee et al showed that among 225 critically ill patients enrolled in a retrospective study, piperacillin-tazobactam was found to be associated with hepatic dysfunction18. McDonald et al showed there were no significant differences between the high-dose and licensed dose of piperacillin-tazobactam therapy in terms of hepatotoxicity.19 Another report indicates that the beta-lactamantibiotics may induce leucopenia in sever liver dysfunction.20 In the present case, there was no other explanation for this complication except for the exposure to piperacillin-tazobactam as there was no evidence of sepsis, or other responsible drugs. We speculated that the hepatic dysfunction was associated with antibiotic use.
In conclusion, this is the first description of an unusual case of fever, eosinophilia, thrombocytopenia and liver damage induced by piperacillin-tazobactam. The antibiotic-induced fever may precede bone marrow suppression. Eosinophilia is a rare adverse effect of piperacillin-tazobactam and caution is needed regarding the DRESS syndrome in patients with long duration of piperacillin-tazobactam treatment.
Learning points
This is an unusual case of adverse effects induced by long-term use of piperacillin-tazobactam that has not been observed previously for methicillin-sensitive Staphylococcus aureus.
Eosinophilia is rarely seen following piperacillin-tazobactam treatment, especially accompanying other adverse effects simultaneously.
Clinicians should be aware of possible adverse effects in patients receiving long-term antibiotic treatment.
Data availability statement
All data relevant to the study are included in the article.
Ethics statements
Patient consent for publication
Parental/guardian consent obtained.
Contributors: JL: overall manuscript writing and interpretation. GW and FZ: interpretation of results. XS: manuscript modification and submission.
Funding: This study was funded by National Natural Science Foundation of China (82070011, 81670073), Jiangsu Commission of Health (K2019004) and "333 project" of Jiangsu Province (BRA2019339).
Competing interests: None declared.
Provenance and peer review: Not commissioned; externally peer reviewed. | PIPERACILLIN SODIUM\TAZOBACTAM SODIUM | DrugsGivenReaction | CC BY-NC | 33558219 | 18,987,367 | 2021-02-08 |
Give an alphabetized list of all active substances of drugs taken by the patient who experienced 'Eosinophilia'. | An unusual case of piperacillin-tazobactam-induced fever, eosinophilia, thrombocytopenia and liver damage.
Piperacillin-tazobactam is a broad-spectrum antimicrobial agent that is commonly used in clinical practice. The development of delayed drug hypersensitivity reaction (DHR) has been reported in several cases previously. Here we describe an unusual case of non-immediate DHR due to a prolonged course of piperacillin-tazobactam. We report a 22-year-old man who developed fever, eosinophilia, thrombocytopenia and elevated hepatic enzymes following 17 days of piperacillin-tazobactam for methicillin-sensitive Staphylococcus aureus (MSSA) pneumonia. These adverse reactions were reversed immediately after antibiotic cessation. Our case highlights that clinicians should be aware of delayed adverse effects in patients receiving long-term piperacillin-tazobactam treatment.
pmcBackground
Piperacillin-tazobactam is a combination formulation of an ureidopenicillin and a beta-lactamase inhibitor with a broad spectrum of antibacterial activity.1 2 It is effective for the treatment of patients with polymicrobial infection caused by many Gram-negative, Gram-positive and beta-lactamase-producing bacteria, such as complicated nosocomial and intra-abdominal infections, and also is regarded as empiric therapy for patients who present with fever and neutropenia.3
As a typical antibiotic, piperacillin-tazobactam is considered safe and well tolerated. However, some adverse reactions have been reported. The most frequent complications include diarrhoea and hepatic dysfunction.4 Eosinophilia with fever and haematological abnormality have been described as severe adverse effects of piperacillin-tazobactam, and are also characteristically regarded as part of the non-immediate drug hypersensitivity reactions (DHRs).5 6 Non-immediate DHRs tend to occur in patients receiving piperacillin-tazobactam therapy over 10 days.7 Here we report an unusual case of a non-immediate DHR reaction to piperacillin-tazobactam.
Case presentation
A previously healthy 22-year-old man presented at our emergency room in January 2020 with high fever (up to 40℃) for a week, accompanied with cough and expectoration. He had 3- year history of smoking without intravenous drug abuse. Physical examination revealed: body temperature 39.5℃; blood pressure 101/54 mmHg and tachypnea of 28 breaths/minute. There were no signs of wounds or skin abscesses. No obvious rhonchi was heard at bilateral lungs and no murmurs were audible in the cardiac valve areas. Initial laboratory tests in the emergency room included: white blood cell count 30.45×109/L, neutrophils 26.95×109/L, platelets 469×109/L, C-reactive protein (CRP) 78 mg/L (normal range 0–8 mg/L) and lactate dehydrogenase (LDH) 657 U/L. Computed tomography (CT) of the chest indicated multiple patchy opacities with cavities. The patient was admitted for further investigation and treatment.
Cardiac ultrasound indicated no signs of bacterial endocarditis. Methicillin-sensitive Staphylococcus aureus (MSSA) was isolated from sputum. Repeated blood cultures were negative. HIV and hepatitis B virus tests were negative. Tests for active and latent tuberculosis, including mycobacterium cultures of sputum samples and the interferon-γ release test for tuberculosis infection, were negative. Chest CT showed multiple dense consolidation with cavities at both side of the lungs and also indicated some cavities with gas-liquid level formation inside pulmonary abscesses (figure 1). A small quantity of pleural effusion presented on the scan. No obvious abnormality was found on abdominal CT. A diagnosis was made of S. aureus pneumonia, complicated by pulmonary abscess. Initially the patient empirically received intravenous vancomycin, 1 g twice daily, and imipenem 1 g every 6 hours. Three days later the patient’s body temperature had markedly decreased. Give the presence of MSSA and abnormality of liver function, antimicrobial therapy was switched to intravenous piperacillin-tazobactam 4.5 g every 8 hours per day.
Figure 1 Computed tomography (CT) images of a 22-year-old patient admitted with Staphylococcus aureus pneumonia in January 2020. CT showed multiple patchy opacities with cavities, some of which had gas-liquid level formation inside in the emergency room (A) and after admission (B). During the initiation of vancomycin and imipenem, slightly absorbed parts of inflammatory lesions were revealed on CT (C). Piperacillin-tazobactam treatment improved the CT findings on day 6 following administration (D). No indication of new infection was found after drug-induced fever. (E). No obvious focus was seen on CT scan 3 months after discharge (F).
Intravenous piperacillin-tazobactam apparently further improved the patient's symptoms and CT appearance. His body temperature remained normal for 10 days. However, 17 days after continuous treatment with piperacillin-tazobactam, the patient suddenly developed a high fever with a body temperature of 38.5℃ and did not complain of any other symptoms. Detailed physical examination did not reveal any abnormal findings. Blood samples were taken for culture. Repeated chest CT did not show any deterioration or was suggestive of a new infection for the recurrence of fever. Laboratory analysis indicated reduced platelets (66×109/L) compared with the initial level (figure 2). On the following days, the patient also had eosinophilia (1.36×109/L) and liver function abnormality (alanine aminotransferase (ALT) 78 U/L, aspartate aminotransferase (AST) 223 U/L). Potential viral infection of the upper respiratory tract was excluded.
Figure 2 The development of eosinophilia, thrombocytopenia and liver function test abnormality during the course of piperacillin-tazobactam treatment with normal values for white cell count. Blood counts of eosinophils and platelets returned to normal levels after cessation of piperacillin-tazobactam on day 14 following initiation. Liver parameters returned to normal after 1 week following cessation of piperacillin-tazobactam treatment. PCT, procalcitonin.
The piperacillin-tazobactam was suspected to be the most likely cause of the recurrent fever, eosinophilia, thrombocytopenia and hepatic abnormalities, and hence was stopped. The fever quickly resolved within 24 hours following the termination of piperacillin-tazobactam treatment and did not recur afterwards. Platelet and eosinophil counts normalised on day 3 and day 7 after cessation of piperacillin-tazobactam, respectively. The parameters of hepatic function declined nearly to normal levels after a week following piperacillin-tazobactam cessation. The patient did not receive any additional medication (including antibiotic therapy) for the recurrent fever until discharge, and underwent supportive treatment without any complications.
Investigations
This is an uncommon case of adverse drug response caused by piperacillin-tazobactam. Previous reports have revealed several cases of haematological abnormalities that were suspected as probably being piperacillin-tazobactam-induced side effects, including neutropenia, thrombocytopenia or anaemia.8 9 Other reports showed that eosinophilia with systemic symptoms are regarded as kinds of adverse effects caused by the antibiotics.5 10 In our work, we found a special case of delayed thrombocytopenia and eosinophilia that occurred simultaneously after the use of piperacillin-tazobactam for the treatment of S. aureus pneumonia. The patient’s laboratory and clinical factors did not show evidence of latent infection in other locations. The possibile involvement of the upper respiratory tract was excluded.
Treatment
The patient' diagnosis was S. aureus pneumonia, complicated by pulmonary abscesses. The use of intravenous piperacillin-tazobactam apparently improved the patient's symptoms and CT appearance. Although the patient developed fever, eosinophilia, thrombocytopenia and liver damage caused by the treatment, the unusual syndromes gradually disappeared after cessation of piperacillin-tazobactama.
Outcome and follow-up
The fever resolved within 24 hours after stopping piperacillin-tazobactam treatment. The platelet and eosinophil counts both returned to normal after the cessation of piperacillin-tazobactam. The parameters of hepatic function also declined nearly to normal levels following treatment termination.
Discussion
In the present case, the patient started to show the side effects of fever, thrombocytopenia and eosinophilia after 17 days of piperacillin-tazobactam treatment. This is similar to previous reports in which drug induced-fever and associated adverse effects occurred from 11 to 17 days after the initiation of piperacillin-tazobactam administration. We have experienced this several times and have described this as the ‘dangerous period’ for piperacillin-tazobactam-induced fever. Consequently we stopped piperacillin-tazobactam therapy immediately without starting any other antibiotics or medication. Fortunately, this patient's fever disappeared within 24 hours of the piperacillin-tazobactam therapy being discontinued. Although the patient's blood CRP and procalcitonin increased in tandem with the fever, they soon declined on day 3 after the termination of piperacillin-tazobactam therapy. Based on the evidence, we believe there is a correlation between the described side effects and piperacillin-tazobactam therapy.
It has been reported in some cases that piperacillin-tazobactam-induced fever is regarded as a hypersensitivity reaction. Fever, eosinophilia, thrombocytopenia and liver damage are all part of the drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome.5 DRESS syndrome is a life-threatening, rare adverse effect that frequently develops following exposure to antibiotics or antiepileptics, which is characterised by fever, rash, elevated liver enzyme levels, and leukocytosis with eosinophilia.11 The RegiSCAR (European Register of Severe Cutaneous Adverse Reactions) is a scoring system which is most commonly used to categorise cases of DRESS into four groups: no case, possible case, probable case and definite case. Our patient presented several of the described features including fever, eosinophilia and elevated liver enzymes. Typical rash and enlarged lymph nodes were not detected in our patient. Use of the RegiSCAR indicated a possible relationship (score of 3) between our patient’s manifestation of DRESS syndrome and treatment with piperacillin-tazobactam.12
Our patient’s presentation of a fever and an elevated CRP lasting for a transient period evoked a suspicion of latent viral and haematological infection probably after prolonged use of piperacillin-tazobactam. However, no other probable aetiology of eosinophilia could be identified, and the eosinophil abnormality associated with administration of piperacillin-tazobactam resolved soon after the termination of antibiotic therapy. We reasoned that the eosinophilia was probably related to piperacillin-tazobactam as a non-immediate DHR. The mechanism of piperacillin-tazobactam-induced eosinophilia is not entirely understood, but one theory is that activation of interleukin-5 (IL-5) on accumulation of toxic metabolites could cause activation of eosinophils and inflammatory cascades.13 Although there is no accurate diagnostic test or pathognomonic sign, the diagnosis of DRESS syndrome should be considered after exposure to piperacillin-tazobactam for longer than 2 weeks.
Bone marrow suppression is a rare and serious adverse effect of piperacillin-tazobactam, and it has been reported that abnormalities occurred after 2 weeks of prolonged antibiotic use.8 The most common abnormality is neutropenia that is often accompanied with thrombocytopenia. Thrombocytopenia rarely develops alone. Thus, we demonstrate an unusual isolated thrombocytopenia after a long course of piperacillin-tazobactam. To our knowledge, isolated thrombocytopenia is thought likely to be due to an immune-mediated reaction induced by drug administration that occurs suddenly and precipitously. Bose et al described a case of abrupt and severe thrombocytopenia within 2 days of piperacillin-tazobactam administration.14 The patient had a positive test for immunoglobulin G (IgG) antiplatelet antibodies to piperacillin-tazobactam therapy, supporting the speculation of immune-related thrombocytopenia. Alzahrani et al reported two cases of possible immune thrombocytopenia that developed rapidly and severely in association with re-exposure to piperacillin-tazobactam.15 Also the platelet count in peripheral blood improved after the discontinuation of piperacillin-tazobactam and the initiation of corticosteroid therapy, suggesting the possibility of immune-mediated thrombocytopenia.
In our case, the patient developed wild thrombocytopenia without any positive results of auto-immune antibodies or change in complement C3. Since we stopped piperacillin-tazobactam immediately after the side effect occurred, the thrombocytopenia quickly resolved without corticosteroid therapy. It has been suggested that this later-onset thrombocytopenia is dependent on a delayed-type hypersensitivity. Among antibiotics, the beta-lactam antibiotics are a common cause of immune thrombocytopenia, while a beta-lactam-beta-lactamase inhibitor combination, such as piperacillin-tazobactam, has rarely been reported to induce immune-mediated thrombocytopenia. The aetiology of drug-induced immune thrombocytopenia is complex and the mechanism of piperacillin-related thrombocytopenia is possibly associated with hapten-induced antibodies. Some studies have suggested that small molecules like drugs might induce an immune response when linked to macromolecules such as proteins. The combination acts as a hapten and triggers a humoral immune response. On re-exposure to the drug, this leads to platelet destruction and this mechanism may explain the haemolytic anaemia.16 Another report revealed that piperacillin can induce hapten-specific antibodies that are reactive with piperacillin-coated blood cells.17 This similar mechanism may account for the thrombocytopenia that is rarely seen in patients after treatment with piperacillin, but this still needs further confirmation experimentally. An explanation whereby the later-onset thrombocytopenia caused by piperacillin-tazobactam likely occurs as a result of direct toxicity of myeloid precursors should not be excluded.
Moreover, our patient also manifested liver dysfunction, having previously had normal liver function, while the haematological abnormality appeared after the onset of drug-induced fever, and the hepatic value returned to the normal level 1 week after drug cessation. Although hepatic dysfunction has been reported previously in patients on piperacillin-tazobactam therapy, there is no apparent relationship with mortality or progression. Saloojee et al showed that among 225 critically ill patients enrolled in a retrospective study, piperacillin-tazobactam was found to be associated with hepatic dysfunction18. McDonald et al showed there were no significant differences between the high-dose and licensed dose of piperacillin-tazobactam therapy in terms of hepatotoxicity.19 Another report indicates that the beta-lactamantibiotics may induce leucopenia in sever liver dysfunction.20 In the present case, there was no other explanation for this complication except for the exposure to piperacillin-tazobactam as there was no evidence of sepsis, or other responsible drugs. We speculated that the hepatic dysfunction was associated with antibiotic use.
In conclusion, this is the first description of an unusual case of fever, eosinophilia, thrombocytopenia and liver damage induced by piperacillin-tazobactam. The antibiotic-induced fever may precede bone marrow suppression. Eosinophilia is a rare adverse effect of piperacillin-tazobactam and caution is needed regarding the DRESS syndrome in patients with long duration of piperacillin-tazobactam treatment.
Learning points
This is an unusual case of adverse effects induced by long-term use of piperacillin-tazobactam that has not been observed previously for methicillin-sensitive Staphylococcus aureus.
Eosinophilia is rarely seen following piperacillin-tazobactam treatment, especially accompanying other adverse effects simultaneously.
Clinicians should be aware of possible adverse effects in patients receiving long-term antibiotic treatment.
Data availability statement
All data relevant to the study are included in the article.
Ethics statements
Patient consent for publication
Parental/guardian consent obtained.
Contributors: JL: overall manuscript writing and interpretation. GW and FZ: interpretation of results. XS: manuscript modification and submission.
Funding: This study was funded by National Natural Science Foundation of China (82070011, 81670073), Jiangsu Commission of Health (K2019004) and "333 project" of Jiangsu Province (BRA2019339).
Competing interests: None declared.
Provenance and peer review: Not commissioned; externally peer reviewed. | PIPERACILLIN SODIUM\TAZOBACTAM SODIUM | DrugsGivenReaction | CC BY-NC | 33558219 | 18,987,367 | 2021-02-08 |
Give an alphabetized list of all active substances of drugs taken by the patient who experienced 'Hepatic enzyme increased'. | An unusual case of piperacillin-tazobactam-induced fever, eosinophilia, thrombocytopenia and liver damage.
Piperacillin-tazobactam is a broad-spectrum antimicrobial agent that is commonly used in clinical practice. The development of delayed drug hypersensitivity reaction (DHR) has been reported in several cases previously. Here we describe an unusual case of non-immediate DHR due to a prolonged course of piperacillin-tazobactam. We report a 22-year-old man who developed fever, eosinophilia, thrombocytopenia and elevated hepatic enzymes following 17 days of piperacillin-tazobactam for methicillin-sensitive Staphylococcus aureus (MSSA) pneumonia. These adverse reactions were reversed immediately after antibiotic cessation. Our case highlights that clinicians should be aware of delayed adverse effects in patients receiving long-term piperacillin-tazobactam treatment.
pmcBackground
Piperacillin-tazobactam is a combination formulation of an ureidopenicillin and a beta-lactamase inhibitor with a broad spectrum of antibacterial activity.1 2 It is effective for the treatment of patients with polymicrobial infection caused by many Gram-negative, Gram-positive and beta-lactamase-producing bacteria, such as complicated nosocomial and intra-abdominal infections, and also is regarded as empiric therapy for patients who present with fever and neutropenia.3
As a typical antibiotic, piperacillin-tazobactam is considered safe and well tolerated. However, some adverse reactions have been reported. The most frequent complications include diarrhoea and hepatic dysfunction.4 Eosinophilia with fever and haematological abnormality have been described as severe adverse effects of piperacillin-tazobactam, and are also characteristically regarded as part of the non-immediate drug hypersensitivity reactions (DHRs).5 6 Non-immediate DHRs tend to occur in patients receiving piperacillin-tazobactam therapy over 10 days.7 Here we report an unusual case of a non-immediate DHR reaction to piperacillin-tazobactam.
Case presentation
A previously healthy 22-year-old man presented at our emergency room in January 2020 with high fever (up to 40℃) for a week, accompanied with cough and expectoration. He had 3- year history of smoking without intravenous drug abuse. Physical examination revealed: body temperature 39.5℃; blood pressure 101/54 mmHg and tachypnea of 28 breaths/minute. There were no signs of wounds or skin abscesses. No obvious rhonchi was heard at bilateral lungs and no murmurs were audible in the cardiac valve areas. Initial laboratory tests in the emergency room included: white blood cell count 30.45×109/L, neutrophils 26.95×109/L, platelets 469×109/L, C-reactive protein (CRP) 78 mg/L (normal range 0–8 mg/L) and lactate dehydrogenase (LDH) 657 U/L. Computed tomography (CT) of the chest indicated multiple patchy opacities with cavities. The patient was admitted for further investigation and treatment.
Cardiac ultrasound indicated no signs of bacterial endocarditis. Methicillin-sensitive Staphylococcus aureus (MSSA) was isolated from sputum. Repeated blood cultures were negative. HIV and hepatitis B virus tests were negative. Tests for active and latent tuberculosis, including mycobacterium cultures of sputum samples and the interferon-γ release test for tuberculosis infection, were negative. Chest CT showed multiple dense consolidation with cavities at both side of the lungs and also indicated some cavities with gas-liquid level formation inside pulmonary abscesses (figure 1). A small quantity of pleural effusion presented on the scan. No obvious abnormality was found on abdominal CT. A diagnosis was made of S. aureus pneumonia, complicated by pulmonary abscess. Initially the patient empirically received intravenous vancomycin, 1 g twice daily, and imipenem 1 g every 6 hours. Three days later the patient’s body temperature had markedly decreased. Give the presence of MSSA and abnormality of liver function, antimicrobial therapy was switched to intravenous piperacillin-tazobactam 4.5 g every 8 hours per day.
Figure 1 Computed tomography (CT) images of a 22-year-old patient admitted with Staphylococcus aureus pneumonia in January 2020. CT showed multiple patchy opacities with cavities, some of which had gas-liquid level formation inside in the emergency room (A) and after admission (B). During the initiation of vancomycin and imipenem, slightly absorbed parts of inflammatory lesions were revealed on CT (C). Piperacillin-tazobactam treatment improved the CT findings on day 6 following administration (D). No indication of new infection was found after drug-induced fever. (E). No obvious focus was seen on CT scan 3 months after discharge (F).
Intravenous piperacillin-tazobactam apparently further improved the patient's symptoms and CT appearance. His body temperature remained normal for 10 days. However, 17 days after continuous treatment with piperacillin-tazobactam, the patient suddenly developed a high fever with a body temperature of 38.5℃ and did not complain of any other symptoms. Detailed physical examination did not reveal any abnormal findings. Blood samples were taken for culture. Repeated chest CT did not show any deterioration or was suggestive of a new infection for the recurrence of fever. Laboratory analysis indicated reduced platelets (66×109/L) compared with the initial level (figure 2). On the following days, the patient also had eosinophilia (1.36×109/L) and liver function abnormality (alanine aminotransferase (ALT) 78 U/L, aspartate aminotransferase (AST) 223 U/L). Potential viral infection of the upper respiratory tract was excluded.
Figure 2 The development of eosinophilia, thrombocytopenia and liver function test abnormality during the course of piperacillin-tazobactam treatment with normal values for white cell count. Blood counts of eosinophils and platelets returned to normal levels after cessation of piperacillin-tazobactam on day 14 following initiation. Liver parameters returned to normal after 1 week following cessation of piperacillin-tazobactam treatment. PCT, procalcitonin.
The piperacillin-tazobactam was suspected to be the most likely cause of the recurrent fever, eosinophilia, thrombocytopenia and hepatic abnormalities, and hence was stopped. The fever quickly resolved within 24 hours following the termination of piperacillin-tazobactam treatment and did not recur afterwards. Platelet and eosinophil counts normalised on day 3 and day 7 after cessation of piperacillin-tazobactam, respectively. The parameters of hepatic function declined nearly to normal levels after a week following piperacillin-tazobactam cessation. The patient did not receive any additional medication (including antibiotic therapy) for the recurrent fever until discharge, and underwent supportive treatment without any complications.
Investigations
This is an uncommon case of adverse drug response caused by piperacillin-tazobactam. Previous reports have revealed several cases of haematological abnormalities that were suspected as probably being piperacillin-tazobactam-induced side effects, including neutropenia, thrombocytopenia or anaemia.8 9 Other reports showed that eosinophilia with systemic symptoms are regarded as kinds of adverse effects caused by the antibiotics.5 10 In our work, we found a special case of delayed thrombocytopenia and eosinophilia that occurred simultaneously after the use of piperacillin-tazobactam for the treatment of S. aureus pneumonia. The patient’s laboratory and clinical factors did not show evidence of latent infection in other locations. The possibile involvement of the upper respiratory tract was excluded.
Treatment
The patient' diagnosis was S. aureus pneumonia, complicated by pulmonary abscesses. The use of intravenous piperacillin-tazobactam apparently improved the patient's symptoms and CT appearance. Although the patient developed fever, eosinophilia, thrombocytopenia and liver damage caused by the treatment, the unusual syndromes gradually disappeared after cessation of piperacillin-tazobactama.
Outcome and follow-up
The fever resolved within 24 hours after stopping piperacillin-tazobactam treatment. The platelet and eosinophil counts both returned to normal after the cessation of piperacillin-tazobactam. The parameters of hepatic function also declined nearly to normal levels following treatment termination.
Discussion
In the present case, the patient started to show the side effects of fever, thrombocytopenia and eosinophilia after 17 days of piperacillin-tazobactam treatment. This is similar to previous reports in which drug induced-fever and associated adverse effects occurred from 11 to 17 days after the initiation of piperacillin-tazobactam administration. We have experienced this several times and have described this as the ‘dangerous period’ for piperacillin-tazobactam-induced fever. Consequently we stopped piperacillin-tazobactam therapy immediately without starting any other antibiotics or medication. Fortunately, this patient's fever disappeared within 24 hours of the piperacillin-tazobactam therapy being discontinued. Although the patient's blood CRP and procalcitonin increased in tandem with the fever, they soon declined on day 3 after the termination of piperacillin-tazobactam therapy. Based on the evidence, we believe there is a correlation between the described side effects and piperacillin-tazobactam therapy.
It has been reported in some cases that piperacillin-tazobactam-induced fever is regarded as a hypersensitivity reaction. Fever, eosinophilia, thrombocytopenia and liver damage are all part of the drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome.5 DRESS syndrome is a life-threatening, rare adverse effect that frequently develops following exposure to antibiotics or antiepileptics, which is characterised by fever, rash, elevated liver enzyme levels, and leukocytosis with eosinophilia.11 The RegiSCAR (European Register of Severe Cutaneous Adverse Reactions) is a scoring system which is most commonly used to categorise cases of DRESS into four groups: no case, possible case, probable case and definite case. Our patient presented several of the described features including fever, eosinophilia and elevated liver enzymes. Typical rash and enlarged lymph nodes were not detected in our patient. Use of the RegiSCAR indicated a possible relationship (score of 3) between our patient’s manifestation of DRESS syndrome and treatment with piperacillin-tazobactam.12
Our patient’s presentation of a fever and an elevated CRP lasting for a transient period evoked a suspicion of latent viral and haematological infection probably after prolonged use of piperacillin-tazobactam. However, no other probable aetiology of eosinophilia could be identified, and the eosinophil abnormality associated with administration of piperacillin-tazobactam resolved soon after the termination of antibiotic therapy. We reasoned that the eosinophilia was probably related to piperacillin-tazobactam as a non-immediate DHR. The mechanism of piperacillin-tazobactam-induced eosinophilia is not entirely understood, but one theory is that activation of interleukin-5 (IL-5) on accumulation of toxic metabolites could cause activation of eosinophils and inflammatory cascades.13 Although there is no accurate diagnostic test or pathognomonic sign, the diagnosis of DRESS syndrome should be considered after exposure to piperacillin-tazobactam for longer than 2 weeks.
Bone marrow suppression is a rare and serious adverse effect of piperacillin-tazobactam, and it has been reported that abnormalities occurred after 2 weeks of prolonged antibiotic use.8 The most common abnormality is neutropenia that is often accompanied with thrombocytopenia. Thrombocytopenia rarely develops alone. Thus, we demonstrate an unusual isolated thrombocytopenia after a long course of piperacillin-tazobactam. To our knowledge, isolated thrombocytopenia is thought likely to be due to an immune-mediated reaction induced by drug administration that occurs suddenly and precipitously. Bose et al described a case of abrupt and severe thrombocytopenia within 2 days of piperacillin-tazobactam administration.14 The patient had a positive test for immunoglobulin G (IgG) antiplatelet antibodies to piperacillin-tazobactam therapy, supporting the speculation of immune-related thrombocytopenia. Alzahrani et al reported two cases of possible immune thrombocytopenia that developed rapidly and severely in association with re-exposure to piperacillin-tazobactam.15 Also the platelet count in peripheral blood improved after the discontinuation of piperacillin-tazobactam and the initiation of corticosteroid therapy, suggesting the possibility of immune-mediated thrombocytopenia.
In our case, the patient developed wild thrombocytopenia without any positive results of auto-immune antibodies or change in complement C3. Since we stopped piperacillin-tazobactam immediately after the side effect occurred, the thrombocytopenia quickly resolved without corticosteroid therapy. It has been suggested that this later-onset thrombocytopenia is dependent on a delayed-type hypersensitivity. Among antibiotics, the beta-lactam antibiotics are a common cause of immune thrombocytopenia, while a beta-lactam-beta-lactamase inhibitor combination, such as piperacillin-tazobactam, has rarely been reported to induce immune-mediated thrombocytopenia. The aetiology of drug-induced immune thrombocytopenia is complex and the mechanism of piperacillin-related thrombocytopenia is possibly associated with hapten-induced antibodies. Some studies have suggested that small molecules like drugs might induce an immune response when linked to macromolecules such as proteins. The combination acts as a hapten and triggers a humoral immune response. On re-exposure to the drug, this leads to platelet destruction and this mechanism may explain the haemolytic anaemia.16 Another report revealed that piperacillin can induce hapten-specific antibodies that are reactive with piperacillin-coated blood cells.17 This similar mechanism may account for the thrombocytopenia that is rarely seen in patients after treatment with piperacillin, but this still needs further confirmation experimentally. An explanation whereby the later-onset thrombocytopenia caused by piperacillin-tazobactam likely occurs as a result of direct toxicity of myeloid precursors should not be excluded.
Moreover, our patient also manifested liver dysfunction, having previously had normal liver function, while the haematological abnormality appeared after the onset of drug-induced fever, and the hepatic value returned to the normal level 1 week after drug cessation. Although hepatic dysfunction has been reported previously in patients on piperacillin-tazobactam therapy, there is no apparent relationship with mortality or progression. Saloojee et al showed that among 225 critically ill patients enrolled in a retrospective study, piperacillin-tazobactam was found to be associated with hepatic dysfunction18. McDonald et al showed there were no significant differences between the high-dose and licensed dose of piperacillin-tazobactam therapy in terms of hepatotoxicity.19 Another report indicates that the beta-lactamantibiotics may induce leucopenia in sever liver dysfunction.20 In the present case, there was no other explanation for this complication except for the exposure to piperacillin-tazobactam as there was no evidence of sepsis, or other responsible drugs. We speculated that the hepatic dysfunction was associated with antibiotic use.
In conclusion, this is the first description of an unusual case of fever, eosinophilia, thrombocytopenia and liver damage induced by piperacillin-tazobactam. The antibiotic-induced fever may precede bone marrow suppression. Eosinophilia is a rare adverse effect of piperacillin-tazobactam and caution is needed regarding the DRESS syndrome in patients with long duration of piperacillin-tazobactam treatment.
Learning points
This is an unusual case of adverse effects induced by long-term use of piperacillin-tazobactam that has not been observed previously for methicillin-sensitive Staphylococcus aureus.
Eosinophilia is rarely seen following piperacillin-tazobactam treatment, especially accompanying other adverse effects simultaneously.
Clinicians should be aware of possible adverse effects in patients receiving long-term antibiotic treatment.
Data availability statement
All data relevant to the study are included in the article.
Ethics statements
Patient consent for publication
Parental/guardian consent obtained.
Contributors: JL: overall manuscript writing and interpretation. GW and FZ: interpretation of results. XS: manuscript modification and submission.
Funding: This study was funded by National Natural Science Foundation of China (82070011, 81670073), Jiangsu Commission of Health (K2019004) and "333 project" of Jiangsu Province (BRA2019339).
Competing interests: None declared.
Provenance and peer review: Not commissioned; externally peer reviewed. | PIPERACILLIN SODIUM\TAZOBACTAM SODIUM | DrugsGivenReaction | CC BY-NC | 33558219 | 18,987,367 | 2021-02-08 |
Give an alphabetized list of all active substances of drugs taken by the patient who experienced 'Liver injury'. | An unusual case of piperacillin-tazobactam-induced fever, eosinophilia, thrombocytopenia and liver damage.
Piperacillin-tazobactam is a broad-spectrum antimicrobial agent that is commonly used in clinical practice. The development of delayed drug hypersensitivity reaction (DHR) has been reported in several cases previously. Here we describe an unusual case of non-immediate DHR due to a prolonged course of piperacillin-tazobactam. We report a 22-year-old man who developed fever, eosinophilia, thrombocytopenia and elevated hepatic enzymes following 17 days of piperacillin-tazobactam for methicillin-sensitive Staphylococcus aureus (MSSA) pneumonia. These adverse reactions were reversed immediately after antibiotic cessation. Our case highlights that clinicians should be aware of delayed adverse effects in patients receiving long-term piperacillin-tazobactam treatment.
pmcBackground
Piperacillin-tazobactam is a combination formulation of an ureidopenicillin and a beta-lactamase inhibitor with a broad spectrum of antibacterial activity.1 2 It is effective for the treatment of patients with polymicrobial infection caused by many Gram-negative, Gram-positive and beta-lactamase-producing bacteria, such as complicated nosocomial and intra-abdominal infections, and also is regarded as empiric therapy for patients who present with fever and neutropenia.3
As a typical antibiotic, piperacillin-tazobactam is considered safe and well tolerated. However, some adverse reactions have been reported. The most frequent complications include diarrhoea and hepatic dysfunction.4 Eosinophilia with fever and haematological abnormality have been described as severe adverse effects of piperacillin-tazobactam, and are also characteristically regarded as part of the non-immediate drug hypersensitivity reactions (DHRs).5 6 Non-immediate DHRs tend to occur in patients receiving piperacillin-tazobactam therapy over 10 days.7 Here we report an unusual case of a non-immediate DHR reaction to piperacillin-tazobactam.
Case presentation
A previously healthy 22-year-old man presented at our emergency room in January 2020 with high fever (up to 40℃) for a week, accompanied with cough and expectoration. He had 3- year history of smoking without intravenous drug abuse. Physical examination revealed: body temperature 39.5℃; blood pressure 101/54 mmHg and tachypnea of 28 breaths/minute. There were no signs of wounds or skin abscesses. No obvious rhonchi was heard at bilateral lungs and no murmurs were audible in the cardiac valve areas. Initial laboratory tests in the emergency room included: white blood cell count 30.45×109/L, neutrophils 26.95×109/L, platelets 469×109/L, C-reactive protein (CRP) 78 mg/L (normal range 0–8 mg/L) and lactate dehydrogenase (LDH) 657 U/L. Computed tomography (CT) of the chest indicated multiple patchy opacities with cavities. The patient was admitted for further investigation and treatment.
Cardiac ultrasound indicated no signs of bacterial endocarditis. Methicillin-sensitive Staphylococcus aureus (MSSA) was isolated from sputum. Repeated blood cultures were negative. HIV and hepatitis B virus tests were negative. Tests for active and latent tuberculosis, including mycobacterium cultures of sputum samples and the interferon-γ release test for tuberculosis infection, were negative. Chest CT showed multiple dense consolidation with cavities at both side of the lungs and also indicated some cavities with gas-liquid level formation inside pulmonary abscesses (figure 1). A small quantity of pleural effusion presented on the scan. No obvious abnormality was found on abdominal CT. A diagnosis was made of S. aureus pneumonia, complicated by pulmonary abscess. Initially the patient empirically received intravenous vancomycin, 1 g twice daily, and imipenem 1 g every 6 hours. Three days later the patient’s body temperature had markedly decreased. Give the presence of MSSA and abnormality of liver function, antimicrobial therapy was switched to intravenous piperacillin-tazobactam 4.5 g every 8 hours per day.
Figure 1 Computed tomography (CT) images of a 22-year-old patient admitted with Staphylococcus aureus pneumonia in January 2020. CT showed multiple patchy opacities with cavities, some of which had gas-liquid level formation inside in the emergency room (A) and after admission (B). During the initiation of vancomycin and imipenem, slightly absorbed parts of inflammatory lesions were revealed on CT (C). Piperacillin-tazobactam treatment improved the CT findings on day 6 following administration (D). No indication of new infection was found after drug-induced fever. (E). No obvious focus was seen on CT scan 3 months after discharge (F).
Intravenous piperacillin-tazobactam apparently further improved the patient's symptoms and CT appearance. His body temperature remained normal for 10 days. However, 17 days after continuous treatment with piperacillin-tazobactam, the patient suddenly developed a high fever with a body temperature of 38.5℃ and did not complain of any other symptoms. Detailed physical examination did not reveal any abnormal findings. Blood samples were taken for culture. Repeated chest CT did not show any deterioration or was suggestive of a new infection for the recurrence of fever. Laboratory analysis indicated reduced platelets (66×109/L) compared with the initial level (figure 2). On the following days, the patient also had eosinophilia (1.36×109/L) and liver function abnormality (alanine aminotransferase (ALT) 78 U/L, aspartate aminotransferase (AST) 223 U/L). Potential viral infection of the upper respiratory tract was excluded.
Figure 2 The development of eosinophilia, thrombocytopenia and liver function test abnormality during the course of piperacillin-tazobactam treatment with normal values for white cell count. Blood counts of eosinophils and platelets returned to normal levels after cessation of piperacillin-tazobactam on day 14 following initiation. Liver parameters returned to normal after 1 week following cessation of piperacillin-tazobactam treatment. PCT, procalcitonin.
The piperacillin-tazobactam was suspected to be the most likely cause of the recurrent fever, eosinophilia, thrombocytopenia and hepatic abnormalities, and hence was stopped. The fever quickly resolved within 24 hours following the termination of piperacillin-tazobactam treatment and did not recur afterwards. Platelet and eosinophil counts normalised on day 3 and day 7 after cessation of piperacillin-tazobactam, respectively. The parameters of hepatic function declined nearly to normal levels after a week following piperacillin-tazobactam cessation. The patient did not receive any additional medication (including antibiotic therapy) for the recurrent fever until discharge, and underwent supportive treatment without any complications.
Investigations
This is an uncommon case of adverse drug response caused by piperacillin-tazobactam. Previous reports have revealed several cases of haematological abnormalities that were suspected as probably being piperacillin-tazobactam-induced side effects, including neutropenia, thrombocytopenia or anaemia.8 9 Other reports showed that eosinophilia with systemic symptoms are regarded as kinds of adverse effects caused by the antibiotics.5 10 In our work, we found a special case of delayed thrombocytopenia and eosinophilia that occurred simultaneously after the use of piperacillin-tazobactam for the treatment of S. aureus pneumonia. The patient’s laboratory and clinical factors did not show evidence of latent infection in other locations. The possibile involvement of the upper respiratory tract was excluded.
Treatment
The patient' diagnosis was S. aureus pneumonia, complicated by pulmonary abscesses. The use of intravenous piperacillin-tazobactam apparently improved the patient's symptoms and CT appearance. Although the patient developed fever, eosinophilia, thrombocytopenia and liver damage caused by the treatment, the unusual syndromes gradually disappeared after cessation of piperacillin-tazobactama.
Outcome and follow-up
The fever resolved within 24 hours after stopping piperacillin-tazobactam treatment. The platelet and eosinophil counts both returned to normal after the cessation of piperacillin-tazobactam. The parameters of hepatic function also declined nearly to normal levels following treatment termination.
Discussion
In the present case, the patient started to show the side effects of fever, thrombocytopenia and eosinophilia after 17 days of piperacillin-tazobactam treatment. This is similar to previous reports in which drug induced-fever and associated adverse effects occurred from 11 to 17 days after the initiation of piperacillin-tazobactam administration. We have experienced this several times and have described this as the ‘dangerous period’ for piperacillin-tazobactam-induced fever. Consequently we stopped piperacillin-tazobactam therapy immediately without starting any other antibiotics or medication. Fortunately, this patient's fever disappeared within 24 hours of the piperacillin-tazobactam therapy being discontinued. Although the patient's blood CRP and procalcitonin increased in tandem with the fever, they soon declined on day 3 after the termination of piperacillin-tazobactam therapy. Based on the evidence, we believe there is a correlation between the described side effects and piperacillin-tazobactam therapy.
It has been reported in some cases that piperacillin-tazobactam-induced fever is regarded as a hypersensitivity reaction. Fever, eosinophilia, thrombocytopenia and liver damage are all part of the drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome.5 DRESS syndrome is a life-threatening, rare adverse effect that frequently develops following exposure to antibiotics or antiepileptics, which is characterised by fever, rash, elevated liver enzyme levels, and leukocytosis with eosinophilia.11 The RegiSCAR (European Register of Severe Cutaneous Adverse Reactions) is a scoring system which is most commonly used to categorise cases of DRESS into four groups: no case, possible case, probable case and definite case. Our patient presented several of the described features including fever, eosinophilia and elevated liver enzymes. Typical rash and enlarged lymph nodes were not detected in our patient. Use of the RegiSCAR indicated a possible relationship (score of 3) between our patient’s manifestation of DRESS syndrome and treatment with piperacillin-tazobactam.12
Our patient’s presentation of a fever and an elevated CRP lasting for a transient period evoked a suspicion of latent viral and haematological infection probably after prolonged use of piperacillin-tazobactam. However, no other probable aetiology of eosinophilia could be identified, and the eosinophil abnormality associated with administration of piperacillin-tazobactam resolved soon after the termination of antibiotic therapy. We reasoned that the eosinophilia was probably related to piperacillin-tazobactam as a non-immediate DHR. The mechanism of piperacillin-tazobactam-induced eosinophilia is not entirely understood, but one theory is that activation of interleukin-5 (IL-5) on accumulation of toxic metabolites could cause activation of eosinophils and inflammatory cascades.13 Although there is no accurate diagnostic test or pathognomonic sign, the diagnosis of DRESS syndrome should be considered after exposure to piperacillin-tazobactam for longer than 2 weeks.
Bone marrow suppression is a rare and serious adverse effect of piperacillin-tazobactam, and it has been reported that abnormalities occurred after 2 weeks of prolonged antibiotic use.8 The most common abnormality is neutropenia that is often accompanied with thrombocytopenia. Thrombocytopenia rarely develops alone. Thus, we demonstrate an unusual isolated thrombocytopenia after a long course of piperacillin-tazobactam. To our knowledge, isolated thrombocytopenia is thought likely to be due to an immune-mediated reaction induced by drug administration that occurs suddenly and precipitously. Bose et al described a case of abrupt and severe thrombocytopenia within 2 days of piperacillin-tazobactam administration.14 The patient had a positive test for immunoglobulin G (IgG) antiplatelet antibodies to piperacillin-tazobactam therapy, supporting the speculation of immune-related thrombocytopenia. Alzahrani et al reported two cases of possible immune thrombocytopenia that developed rapidly and severely in association with re-exposure to piperacillin-tazobactam.15 Also the platelet count in peripheral blood improved after the discontinuation of piperacillin-tazobactam and the initiation of corticosteroid therapy, suggesting the possibility of immune-mediated thrombocytopenia.
In our case, the patient developed wild thrombocytopenia without any positive results of auto-immune antibodies or change in complement C3. Since we stopped piperacillin-tazobactam immediately after the side effect occurred, the thrombocytopenia quickly resolved without corticosteroid therapy. It has been suggested that this later-onset thrombocytopenia is dependent on a delayed-type hypersensitivity. Among antibiotics, the beta-lactam antibiotics are a common cause of immune thrombocytopenia, while a beta-lactam-beta-lactamase inhibitor combination, such as piperacillin-tazobactam, has rarely been reported to induce immune-mediated thrombocytopenia. The aetiology of drug-induced immune thrombocytopenia is complex and the mechanism of piperacillin-related thrombocytopenia is possibly associated with hapten-induced antibodies. Some studies have suggested that small molecules like drugs might induce an immune response when linked to macromolecules such as proteins. The combination acts as a hapten and triggers a humoral immune response. On re-exposure to the drug, this leads to platelet destruction and this mechanism may explain the haemolytic anaemia.16 Another report revealed that piperacillin can induce hapten-specific antibodies that are reactive with piperacillin-coated blood cells.17 This similar mechanism may account for the thrombocytopenia that is rarely seen in patients after treatment with piperacillin, but this still needs further confirmation experimentally. An explanation whereby the later-onset thrombocytopenia caused by piperacillin-tazobactam likely occurs as a result of direct toxicity of myeloid precursors should not be excluded.
Moreover, our patient also manifested liver dysfunction, having previously had normal liver function, while the haematological abnormality appeared after the onset of drug-induced fever, and the hepatic value returned to the normal level 1 week after drug cessation. Although hepatic dysfunction has been reported previously in patients on piperacillin-tazobactam therapy, there is no apparent relationship with mortality or progression. Saloojee et al showed that among 225 critically ill patients enrolled in a retrospective study, piperacillin-tazobactam was found to be associated with hepatic dysfunction18. McDonald et al showed there were no significant differences between the high-dose and licensed dose of piperacillin-tazobactam therapy in terms of hepatotoxicity.19 Another report indicates that the beta-lactamantibiotics may induce leucopenia in sever liver dysfunction.20 In the present case, there was no other explanation for this complication except for the exposure to piperacillin-tazobactam as there was no evidence of sepsis, or other responsible drugs. We speculated that the hepatic dysfunction was associated with antibiotic use.
In conclusion, this is the first description of an unusual case of fever, eosinophilia, thrombocytopenia and liver damage induced by piperacillin-tazobactam. The antibiotic-induced fever may precede bone marrow suppression. Eosinophilia is a rare adverse effect of piperacillin-tazobactam and caution is needed regarding the DRESS syndrome in patients with long duration of piperacillin-tazobactam treatment.
Learning points
This is an unusual case of adverse effects induced by long-term use of piperacillin-tazobactam that has not been observed previously for methicillin-sensitive Staphylococcus aureus.
Eosinophilia is rarely seen following piperacillin-tazobactam treatment, especially accompanying other adverse effects simultaneously.
Clinicians should be aware of possible adverse effects in patients receiving long-term antibiotic treatment.
Data availability statement
All data relevant to the study are included in the article.
Ethics statements
Patient consent for publication
Parental/guardian consent obtained.
Contributors: JL: overall manuscript writing and interpretation. GW and FZ: interpretation of results. XS: manuscript modification and submission.
Funding: This study was funded by National Natural Science Foundation of China (82070011, 81670073), Jiangsu Commission of Health (K2019004) and "333 project" of Jiangsu Province (BRA2019339).
Competing interests: None declared.
Provenance and peer review: Not commissioned; externally peer reviewed. | PIPERACILLIN SODIUM\TAZOBACTAM SODIUM | DrugsGivenReaction | CC BY-NC | 33558219 | 18,952,530 | 2021-02-08 |
Give an alphabetized list of all active substances of drugs taken by the patient who experienced 'Pyrexia'. | An unusual case of piperacillin-tazobactam-induced fever, eosinophilia, thrombocytopenia and liver damage.
Piperacillin-tazobactam is a broad-spectrum antimicrobial agent that is commonly used in clinical practice. The development of delayed drug hypersensitivity reaction (DHR) has been reported in several cases previously. Here we describe an unusual case of non-immediate DHR due to a prolonged course of piperacillin-tazobactam. We report a 22-year-old man who developed fever, eosinophilia, thrombocytopenia and elevated hepatic enzymes following 17 days of piperacillin-tazobactam for methicillin-sensitive Staphylococcus aureus (MSSA) pneumonia. These adverse reactions were reversed immediately after antibiotic cessation. Our case highlights that clinicians should be aware of delayed adverse effects in patients receiving long-term piperacillin-tazobactam treatment.
pmcBackground
Piperacillin-tazobactam is a combination formulation of an ureidopenicillin and a beta-lactamase inhibitor with a broad spectrum of antibacterial activity.1 2 It is effective for the treatment of patients with polymicrobial infection caused by many Gram-negative, Gram-positive and beta-lactamase-producing bacteria, such as complicated nosocomial and intra-abdominal infections, and also is regarded as empiric therapy for patients who present with fever and neutropenia.3
As a typical antibiotic, piperacillin-tazobactam is considered safe and well tolerated. However, some adverse reactions have been reported. The most frequent complications include diarrhoea and hepatic dysfunction.4 Eosinophilia with fever and haematological abnormality have been described as severe adverse effects of piperacillin-tazobactam, and are also characteristically regarded as part of the non-immediate drug hypersensitivity reactions (DHRs).5 6 Non-immediate DHRs tend to occur in patients receiving piperacillin-tazobactam therapy over 10 days.7 Here we report an unusual case of a non-immediate DHR reaction to piperacillin-tazobactam.
Case presentation
A previously healthy 22-year-old man presented at our emergency room in January 2020 with high fever (up to 40℃) for a week, accompanied with cough and expectoration. He had 3- year history of smoking without intravenous drug abuse. Physical examination revealed: body temperature 39.5℃; blood pressure 101/54 mmHg and tachypnea of 28 breaths/minute. There were no signs of wounds or skin abscesses. No obvious rhonchi was heard at bilateral lungs and no murmurs were audible in the cardiac valve areas. Initial laboratory tests in the emergency room included: white blood cell count 30.45×109/L, neutrophils 26.95×109/L, platelets 469×109/L, C-reactive protein (CRP) 78 mg/L (normal range 0–8 mg/L) and lactate dehydrogenase (LDH) 657 U/L. Computed tomography (CT) of the chest indicated multiple patchy opacities with cavities. The patient was admitted for further investigation and treatment.
Cardiac ultrasound indicated no signs of bacterial endocarditis. Methicillin-sensitive Staphylococcus aureus (MSSA) was isolated from sputum. Repeated blood cultures were negative. HIV and hepatitis B virus tests were negative. Tests for active and latent tuberculosis, including mycobacterium cultures of sputum samples and the interferon-γ release test for tuberculosis infection, were negative. Chest CT showed multiple dense consolidation with cavities at both side of the lungs and also indicated some cavities with gas-liquid level formation inside pulmonary abscesses (figure 1). A small quantity of pleural effusion presented on the scan. No obvious abnormality was found on abdominal CT. A diagnosis was made of S. aureus pneumonia, complicated by pulmonary abscess. Initially the patient empirically received intravenous vancomycin, 1 g twice daily, and imipenem 1 g every 6 hours. Three days later the patient’s body temperature had markedly decreased. Give the presence of MSSA and abnormality of liver function, antimicrobial therapy was switched to intravenous piperacillin-tazobactam 4.5 g every 8 hours per day.
Figure 1 Computed tomography (CT) images of a 22-year-old patient admitted with Staphylococcus aureus pneumonia in January 2020. CT showed multiple patchy opacities with cavities, some of which had gas-liquid level formation inside in the emergency room (A) and after admission (B). During the initiation of vancomycin and imipenem, slightly absorbed parts of inflammatory lesions were revealed on CT (C). Piperacillin-tazobactam treatment improved the CT findings on day 6 following administration (D). No indication of new infection was found after drug-induced fever. (E). No obvious focus was seen on CT scan 3 months after discharge (F).
Intravenous piperacillin-tazobactam apparently further improved the patient's symptoms and CT appearance. His body temperature remained normal for 10 days. However, 17 days after continuous treatment with piperacillin-tazobactam, the patient suddenly developed a high fever with a body temperature of 38.5℃ and did not complain of any other symptoms. Detailed physical examination did not reveal any abnormal findings. Blood samples were taken for culture. Repeated chest CT did not show any deterioration or was suggestive of a new infection for the recurrence of fever. Laboratory analysis indicated reduced platelets (66×109/L) compared with the initial level (figure 2). On the following days, the patient also had eosinophilia (1.36×109/L) and liver function abnormality (alanine aminotransferase (ALT) 78 U/L, aspartate aminotransferase (AST) 223 U/L). Potential viral infection of the upper respiratory tract was excluded.
Figure 2 The development of eosinophilia, thrombocytopenia and liver function test abnormality during the course of piperacillin-tazobactam treatment with normal values for white cell count. Blood counts of eosinophils and platelets returned to normal levels after cessation of piperacillin-tazobactam on day 14 following initiation. Liver parameters returned to normal after 1 week following cessation of piperacillin-tazobactam treatment. PCT, procalcitonin.
The piperacillin-tazobactam was suspected to be the most likely cause of the recurrent fever, eosinophilia, thrombocytopenia and hepatic abnormalities, and hence was stopped. The fever quickly resolved within 24 hours following the termination of piperacillin-tazobactam treatment and did not recur afterwards. Platelet and eosinophil counts normalised on day 3 and day 7 after cessation of piperacillin-tazobactam, respectively. The parameters of hepatic function declined nearly to normal levels after a week following piperacillin-tazobactam cessation. The patient did not receive any additional medication (including antibiotic therapy) for the recurrent fever until discharge, and underwent supportive treatment without any complications.
Investigations
This is an uncommon case of adverse drug response caused by piperacillin-tazobactam. Previous reports have revealed several cases of haematological abnormalities that were suspected as probably being piperacillin-tazobactam-induced side effects, including neutropenia, thrombocytopenia or anaemia.8 9 Other reports showed that eosinophilia with systemic symptoms are regarded as kinds of adverse effects caused by the antibiotics.5 10 In our work, we found a special case of delayed thrombocytopenia and eosinophilia that occurred simultaneously after the use of piperacillin-tazobactam for the treatment of S. aureus pneumonia. The patient’s laboratory and clinical factors did not show evidence of latent infection in other locations. The possibile involvement of the upper respiratory tract was excluded.
Treatment
The patient' diagnosis was S. aureus pneumonia, complicated by pulmonary abscesses. The use of intravenous piperacillin-tazobactam apparently improved the patient's symptoms and CT appearance. Although the patient developed fever, eosinophilia, thrombocytopenia and liver damage caused by the treatment, the unusual syndromes gradually disappeared after cessation of piperacillin-tazobactama.
Outcome and follow-up
The fever resolved within 24 hours after stopping piperacillin-tazobactam treatment. The platelet and eosinophil counts both returned to normal after the cessation of piperacillin-tazobactam. The parameters of hepatic function also declined nearly to normal levels following treatment termination.
Discussion
In the present case, the patient started to show the side effects of fever, thrombocytopenia and eosinophilia after 17 days of piperacillin-tazobactam treatment. This is similar to previous reports in which drug induced-fever and associated adverse effects occurred from 11 to 17 days after the initiation of piperacillin-tazobactam administration. We have experienced this several times and have described this as the ‘dangerous period’ for piperacillin-tazobactam-induced fever. Consequently we stopped piperacillin-tazobactam therapy immediately without starting any other antibiotics or medication. Fortunately, this patient's fever disappeared within 24 hours of the piperacillin-tazobactam therapy being discontinued. Although the patient's blood CRP and procalcitonin increased in tandem with the fever, they soon declined on day 3 after the termination of piperacillin-tazobactam therapy. Based on the evidence, we believe there is a correlation between the described side effects and piperacillin-tazobactam therapy.
It has been reported in some cases that piperacillin-tazobactam-induced fever is regarded as a hypersensitivity reaction. Fever, eosinophilia, thrombocytopenia and liver damage are all part of the drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome.5 DRESS syndrome is a life-threatening, rare adverse effect that frequently develops following exposure to antibiotics or antiepileptics, which is characterised by fever, rash, elevated liver enzyme levels, and leukocytosis with eosinophilia.11 The RegiSCAR (European Register of Severe Cutaneous Adverse Reactions) is a scoring system which is most commonly used to categorise cases of DRESS into four groups: no case, possible case, probable case and definite case. Our patient presented several of the described features including fever, eosinophilia and elevated liver enzymes. Typical rash and enlarged lymph nodes were not detected in our patient. Use of the RegiSCAR indicated a possible relationship (score of 3) between our patient’s manifestation of DRESS syndrome and treatment with piperacillin-tazobactam.12
Our patient’s presentation of a fever and an elevated CRP lasting for a transient period evoked a suspicion of latent viral and haematological infection probably after prolonged use of piperacillin-tazobactam. However, no other probable aetiology of eosinophilia could be identified, and the eosinophil abnormality associated with administration of piperacillin-tazobactam resolved soon after the termination of antibiotic therapy. We reasoned that the eosinophilia was probably related to piperacillin-tazobactam as a non-immediate DHR. The mechanism of piperacillin-tazobactam-induced eosinophilia is not entirely understood, but one theory is that activation of interleukin-5 (IL-5) on accumulation of toxic metabolites could cause activation of eosinophils and inflammatory cascades.13 Although there is no accurate diagnostic test or pathognomonic sign, the diagnosis of DRESS syndrome should be considered after exposure to piperacillin-tazobactam for longer than 2 weeks.
Bone marrow suppression is a rare and serious adverse effect of piperacillin-tazobactam, and it has been reported that abnormalities occurred after 2 weeks of prolonged antibiotic use.8 The most common abnormality is neutropenia that is often accompanied with thrombocytopenia. Thrombocytopenia rarely develops alone. Thus, we demonstrate an unusual isolated thrombocytopenia after a long course of piperacillin-tazobactam. To our knowledge, isolated thrombocytopenia is thought likely to be due to an immune-mediated reaction induced by drug administration that occurs suddenly and precipitously. Bose et al described a case of abrupt and severe thrombocytopenia within 2 days of piperacillin-tazobactam administration.14 The patient had a positive test for immunoglobulin G (IgG) antiplatelet antibodies to piperacillin-tazobactam therapy, supporting the speculation of immune-related thrombocytopenia. Alzahrani et al reported two cases of possible immune thrombocytopenia that developed rapidly and severely in association with re-exposure to piperacillin-tazobactam.15 Also the platelet count in peripheral blood improved after the discontinuation of piperacillin-tazobactam and the initiation of corticosteroid therapy, suggesting the possibility of immune-mediated thrombocytopenia.
In our case, the patient developed wild thrombocytopenia without any positive results of auto-immune antibodies or change in complement C3. Since we stopped piperacillin-tazobactam immediately after the side effect occurred, the thrombocytopenia quickly resolved without corticosteroid therapy. It has been suggested that this later-onset thrombocytopenia is dependent on a delayed-type hypersensitivity. Among antibiotics, the beta-lactam antibiotics are a common cause of immune thrombocytopenia, while a beta-lactam-beta-lactamase inhibitor combination, such as piperacillin-tazobactam, has rarely been reported to induce immune-mediated thrombocytopenia. The aetiology of drug-induced immune thrombocytopenia is complex and the mechanism of piperacillin-related thrombocytopenia is possibly associated with hapten-induced antibodies. Some studies have suggested that small molecules like drugs might induce an immune response when linked to macromolecules such as proteins. The combination acts as a hapten and triggers a humoral immune response. On re-exposure to the drug, this leads to platelet destruction and this mechanism may explain the haemolytic anaemia.16 Another report revealed that piperacillin can induce hapten-specific antibodies that are reactive with piperacillin-coated blood cells.17 This similar mechanism may account for the thrombocytopenia that is rarely seen in patients after treatment with piperacillin, but this still needs further confirmation experimentally. An explanation whereby the later-onset thrombocytopenia caused by piperacillin-tazobactam likely occurs as a result of direct toxicity of myeloid precursors should not be excluded.
Moreover, our patient also manifested liver dysfunction, having previously had normal liver function, while the haematological abnormality appeared after the onset of drug-induced fever, and the hepatic value returned to the normal level 1 week after drug cessation. Although hepatic dysfunction has been reported previously in patients on piperacillin-tazobactam therapy, there is no apparent relationship with mortality or progression. Saloojee et al showed that among 225 critically ill patients enrolled in a retrospective study, piperacillin-tazobactam was found to be associated with hepatic dysfunction18. McDonald et al showed there were no significant differences between the high-dose and licensed dose of piperacillin-tazobactam therapy in terms of hepatotoxicity.19 Another report indicates that the beta-lactamantibiotics may induce leucopenia in sever liver dysfunction.20 In the present case, there was no other explanation for this complication except for the exposure to piperacillin-tazobactam as there was no evidence of sepsis, or other responsible drugs. We speculated that the hepatic dysfunction was associated with antibiotic use.
In conclusion, this is the first description of an unusual case of fever, eosinophilia, thrombocytopenia and liver damage induced by piperacillin-tazobactam. The antibiotic-induced fever may precede bone marrow suppression. Eosinophilia is a rare adverse effect of piperacillin-tazobactam and caution is needed regarding the DRESS syndrome in patients with long duration of piperacillin-tazobactam treatment.
Learning points
This is an unusual case of adverse effects induced by long-term use of piperacillin-tazobactam that has not been observed previously for methicillin-sensitive Staphylococcus aureus.
Eosinophilia is rarely seen following piperacillin-tazobactam treatment, especially accompanying other adverse effects simultaneously.
Clinicians should be aware of possible adverse effects in patients receiving long-term antibiotic treatment.
Data availability statement
All data relevant to the study are included in the article.
Ethics statements
Patient consent for publication
Parental/guardian consent obtained.
Contributors: JL: overall manuscript writing and interpretation. GW and FZ: interpretation of results. XS: manuscript modification and submission.
Funding: This study was funded by National Natural Science Foundation of China (82070011, 81670073), Jiangsu Commission of Health (K2019004) and "333 project" of Jiangsu Province (BRA2019339).
Competing interests: None declared.
Provenance and peer review: Not commissioned; externally peer reviewed. | PIPERACILLIN SODIUM\TAZOBACTAM SODIUM | DrugsGivenReaction | CC BY-NC | 33558219 | 18,987,367 | 2021-02-08 |
Give an alphabetized list of all active substances of drugs taken by the patient who experienced 'Thrombocytopenia'. | An unusual case of piperacillin-tazobactam-induced fever, eosinophilia, thrombocytopenia and liver damage.
Piperacillin-tazobactam is a broad-spectrum antimicrobial agent that is commonly used in clinical practice. The development of delayed drug hypersensitivity reaction (DHR) has been reported in several cases previously. Here we describe an unusual case of non-immediate DHR due to a prolonged course of piperacillin-tazobactam. We report a 22-year-old man who developed fever, eosinophilia, thrombocytopenia and elevated hepatic enzymes following 17 days of piperacillin-tazobactam for methicillin-sensitive Staphylococcus aureus (MSSA) pneumonia. These adverse reactions were reversed immediately after antibiotic cessation. Our case highlights that clinicians should be aware of delayed adverse effects in patients receiving long-term piperacillin-tazobactam treatment.
pmcBackground
Piperacillin-tazobactam is a combination formulation of an ureidopenicillin and a beta-lactamase inhibitor with a broad spectrum of antibacterial activity.1 2 It is effective for the treatment of patients with polymicrobial infection caused by many Gram-negative, Gram-positive and beta-lactamase-producing bacteria, such as complicated nosocomial and intra-abdominal infections, and also is regarded as empiric therapy for patients who present with fever and neutropenia.3
As a typical antibiotic, piperacillin-tazobactam is considered safe and well tolerated. However, some adverse reactions have been reported. The most frequent complications include diarrhoea and hepatic dysfunction.4 Eosinophilia with fever and haematological abnormality have been described as severe adverse effects of piperacillin-tazobactam, and are also characteristically regarded as part of the non-immediate drug hypersensitivity reactions (DHRs).5 6 Non-immediate DHRs tend to occur in patients receiving piperacillin-tazobactam therapy over 10 days.7 Here we report an unusual case of a non-immediate DHR reaction to piperacillin-tazobactam.
Case presentation
A previously healthy 22-year-old man presented at our emergency room in January 2020 with high fever (up to 40℃) for a week, accompanied with cough and expectoration. He had 3- year history of smoking without intravenous drug abuse. Physical examination revealed: body temperature 39.5℃; blood pressure 101/54 mmHg and tachypnea of 28 breaths/minute. There were no signs of wounds or skin abscesses. No obvious rhonchi was heard at bilateral lungs and no murmurs were audible in the cardiac valve areas. Initial laboratory tests in the emergency room included: white blood cell count 30.45×109/L, neutrophils 26.95×109/L, platelets 469×109/L, C-reactive protein (CRP) 78 mg/L (normal range 0–8 mg/L) and lactate dehydrogenase (LDH) 657 U/L. Computed tomography (CT) of the chest indicated multiple patchy opacities with cavities. The patient was admitted for further investigation and treatment.
Cardiac ultrasound indicated no signs of bacterial endocarditis. Methicillin-sensitive Staphylococcus aureus (MSSA) was isolated from sputum. Repeated blood cultures were negative. HIV and hepatitis B virus tests were negative. Tests for active and latent tuberculosis, including mycobacterium cultures of sputum samples and the interferon-γ release test for tuberculosis infection, were negative. Chest CT showed multiple dense consolidation with cavities at both side of the lungs and also indicated some cavities with gas-liquid level formation inside pulmonary abscesses (figure 1). A small quantity of pleural effusion presented on the scan. No obvious abnormality was found on abdominal CT. A diagnosis was made of S. aureus pneumonia, complicated by pulmonary abscess. Initially the patient empirically received intravenous vancomycin, 1 g twice daily, and imipenem 1 g every 6 hours. Three days later the patient’s body temperature had markedly decreased. Give the presence of MSSA and abnormality of liver function, antimicrobial therapy was switched to intravenous piperacillin-tazobactam 4.5 g every 8 hours per day.
Figure 1 Computed tomography (CT) images of a 22-year-old patient admitted with Staphylococcus aureus pneumonia in January 2020. CT showed multiple patchy opacities with cavities, some of which had gas-liquid level formation inside in the emergency room (A) and after admission (B). During the initiation of vancomycin and imipenem, slightly absorbed parts of inflammatory lesions were revealed on CT (C). Piperacillin-tazobactam treatment improved the CT findings on day 6 following administration (D). No indication of new infection was found after drug-induced fever. (E). No obvious focus was seen on CT scan 3 months after discharge (F).
Intravenous piperacillin-tazobactam apparently further improved the patient's symptoms and CT appearance. His body temperature remained normal for 10 days. However, 17 days after continuous treatment with piperacillin-tazobactam, the patient suddenly developed a high fever with a body temperature of 38.5℃ and did not complain of any other symptoms. Detailed physical examination did not reveal any abnormal findings. Blood samples were taken for culture. Repeated chest CT did not show any deterioration or was suggestive of a new infection for the recurrence of fever. Laboratory analysis indicated reduced platelets (66×109/L) compared with the initial level (figure 2). On the following days, the patient also had eosinophilia (1.36×109/L) and liver function abnormality (alanine aminotransferase (ALT) 78 U/L, aspartate aminotransferase (AST) 223 U/L). Potential viral infection of the upper respiratory tract was excluded.
Figure 2 The development of eosinophilia, thrombocytopenia and liver function test abnormality during the course of piperacillin-tazobactam treatment with normal values for white cell count. Blood counts of eosinophils and platelets returned to normal levels after cessation of piperacillin-tazobactam on day 14 following initiation. Liver parameters returned to normal after 1 week following cessation of piperacillin-tazobactam treatment. PCT, procalcitonin.
The piperacillin-tazobactam was suspected to be the most likely cause of the recurrent fever, eosinophilia, thrombocytopenia and hepatic abnormalities, and hence was stopped. The fever quickly resolved within 24 hours following the termination of piperacillin-tazobactam treatment and did not recur afterwards. Platelet and eosinophil counts normalised on day 3 and day 7 after cessation of piperacillin-tazobactam, respectively. The parameters of hepatic function declined nearly to normal levels after a week following piperacillin-tazobactam cessation. The patient did not receive any additional medication (including antibiotic therapy) for the recurrent fever until discharge, and underwent supportive treatment without any complications.
Investigations
This is an uncommon case of adverse drug response caused by piperacillin-tazobactam. Previous reports have revealed several cases of haematological abnormalities that were suspected as probably being piperacillin-tazobactam-induced side effects, including neutropenia, thrombocytopenia or anaemia.8 9 Other reports showed that eosinophilia with systemic symptoms are regarded as kinds of adverse effects caused by the antibiotics.5 10 In our work, we found a special case of delayed thrombocytopenia and eosinophilia that occurred simultaneously after the use of piperacillin-tazobactam for the treatment of S. aureus pneumonia. The patient’s laboratory and clinical factors did not show evidence of latent infection in other locations. The possibile involvement of the upper respiratory tract was excluded.
Treatment
The patient' diagnosis was S. aureus pneumonia, complicated by pulmonary abscesses. The use of intravenous piperacillin-tazobactam apparently improved the patient's symptoms and CT appearance. Although the patient developed fever, eosinophilia, thrombocytopenia and liver damage caused by the treatment, the unusual syndromes gradually disappeared after cessation of piperacillin-tazobactama.
Outcome and follow-up
The fever resolved within 24 hours after stopping piperacillin-tazobactam treatment. The platelet and eosinophil counts both returned to normal after the cessation of piperacillin-tazobactam. The parameters of hepatic function also declined nearly to normal levels following treatment termination.
Discussion
In the present case, the patient started to show the side effects of fever, thrombocytopenia and eosinophilia after 17 days of piperacillin-tazobactam treatment. This is similar to previous reports in which drug induced-fever and associated adverse effects occurred from 11 to 17 days after the initiation of piperacillin-tazobactam administration. We have experienced this several times and have described this as the ‘dangerous period’ for piperacillin-tazobactam-induced fever. Consequently we stopped piperacillin-tazobactam therapy immediately without starting any other antibiotics or medication. Fortunately, this patient's fever disappeared within 24 hours of the piperacillin-tazobactam therapy being discontinued. Although the patient's blood CRP and procalcitonin increased in tandem with the fever, they soon declined on day 3 after the termination of piperacillin-tazobactam therapy. Based on the evidence, we believe there is a correlation between the described side effects and piperacillin-tazobactam therapy.
It has been reported in some cases that piperacillin-tazobactam-induced fever is regarded as a hypersensitivity reaction. Fever, eosinophilia, thrombocytopenia and liver damage are all part of the drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome.5 DRESS syndrome is a life-threatening, rare adverse effect that frequently develops following exposure to antibiotics or antiepileptics, which is characterised by fever, rash, elevated liver enzyme levels, and leukocytosis with eosinophilia.11 The RegiSCAR (European Register of Severe Cutaneous Adverse Reactions) is a scoring system which is most commonly used to categorise cases of DRESS into four groups: no case, possible case, probable case and definite case. Our patient presented several of the described features including fever, eosinophilia and elevated liver enzymes. Typical rash and enlarged lymph nodes were not detected in our patient. Use of the RegiSCAR indicated a possible relationship (score of 3) between our patient’s manifestation of DRESS syndrome and treatment with piperacillin-tazobactam.12
Our patient’s presentation of a fever and an elevated CRP lasting for a transient period evoked a suspicion of latent viral and haematological infection probably after prolonged use of piperacillin-tazobactam. However, no other probable aetiology of eosinophilia could be identified, and the eosinophil abnormality associated with administration of piperacillin-tazobactam resolved soon after the termination of antibiotic therapy. We reasoned that the eosinophilia was probably related to piperacillin-tazobactam as a non-immediate DHR. The mechanism of piperacillin-tazobactam-induced eosinophilia is not entirely understood, but one theory is that activation of interleukin-5 (IL-5) on accumulation of toxic metabolites could cause activation of eosinophils and inflammatory cascades.13 Although there is no accurate diagnostic test or pathognomonic sign, the diagnosis of DRESS syndrome should be considered after exposure to piperacillin-tazobactam for longer than 2 weeks.
Bone marrow suppression is a rare and serious adverse effect of piperacillin-tazobactam, and it has been reported that abnormalities occurred after 2 weeks of prolonged antibiotic use.8 The most common abnormality is neutropenia that is often accompanied with thrombocytopenia. Thrombocytopenia rarely develops alone. Thus, we demonstrate an unusual isolated thrombocytopenia after a long course of piperacillin-tazobactam. To our knowledge, isolated thrombocytopenia is thought likely to be due to an immune-mediated reaction induced by drug administration that occurs suddenly and precipitously. Bose et al described a case of abrupt and severe thrombocytopenia within 2 days of piperacillin-tazobactam administration.14 The patient had a positive test for immunoglobulin G (IgG) antiplatelet antibodies to piperacillin-tazobactam therapy, supporting the speculation of immune-related thrombocytopenia. Alzahrani et al reported two cases of possible immune thrombocytopenia that developed rapidly and severely in association with re-exposure to piperacillin-tazobactam.15 Also the platelet count in peripheral blood improved after the discontinuation of piperacillin-tazobactam and the initiation of corticosteroid therapy, suggesting the possibility of immune-mediated thrombocytopenia.
In our case, the patient developed wild thrombocytopenia without any positive results of auto-immune antibodies or change in complement C3. Since we stopped piperacillin-tazobactam immediately after the side effect occurred, the thrombocytopenia quickly resolved without corticosteroid therapy. It has been suggested that this later-onset thrombocytopenia is dependent on a delayed-type hypersensitivity. Among antibiotics, the beta-lactam antibiotics are a common cause of immune thrombocytopenia, while a beta-lactam-beta-lactamase inhibitor combination, such as piperacillin-tazobactam, has rarely been reported to induce immune-mediated thrombocytopenia. The aetiology of drug-induced immune thrombocytopenia is complex and the mechanism of piperacillin-related thrombocytopenia is possibly associated with hapten-induced antibodies. Some studies have suggested that small molecules like drugs might induce an immune response when linked to macromolecules such as proteins. The combination acts as a hapten and triggers a humoral immune response. On re-exposure to the drug, this leads to platelet destruction and this mechanism may explain the haemolytic anaemia.16 Another report revealed that piperacillin can induce hapten-specific antibodies that are reactive with piperacillin-coated blood cells.17 This similar mechanism may account for the thrombocytopenia that is rarely seen in patients after treatment with piperacillin, but this still needs further confirmation experimentally. An explanation whereby the later-onset thrombocytopenia caused by piperacillin-tazobactam likely occurs as a result of direct toxicity of myeloid precursors should not be excluded.
Moreover, our patient also manifested liver dysfunction, having previously had normal liver function, while the haematological abnormality appeared after the onset of drug-induced fever, and the hepatic value returned to the normal level 1 week after drug cessation. Although hepatic dysfunction has been reported previously in patients on piperacillin-tazobactam therapy, there is no apparent relationship with mortality or progression. Saloojee et al showed that among 225 critically ill patients enrolled in a retrospective study, piperacillin-tazobactam was found to be associated with hepatic dysfunction18. McDonald et al showed there were no significant differences between the high-dose and licensed dose of piperacillin-tazobactam therapy in terms of hepatotoxicity.19 Another report indicates that the beta-lactamantibiotics may induce leucopenia in sever liver dysfunction.20 In the present case, there was no other explanation for this complication except for the exposure to piperacillin-tazobactam as there was no evidence of sepsis, or other responsible drugs. We speculated that the hepatic dysfunction was associated with antibiotic use.
In conclusion, this is the first description of an unusual case of fever, eosinophilia, thrombocytopenia and liver damage induced by piperacillin-tazobactam. The antibiotic-induced fever may precede bone marrow suppression. Eosinophilia is a rare adverse effect of piperacillin-tazobactam and caution is needed regarding the DRESS syndrome in patients with long duration of piperacillin-tazobactam treatment.
Learning points
This is an unusual case of adverse effects induced by long-term use of piperacillin-tazobactam that has not been observed previously for methicillin-sensitive Staphylococcus aureus.
Eosinophilia is rarely seen following piperacillin-tazobactam treatment, especially accompanying other adverse effects simultaneously.
Clinicians should be aware of possible adverse effects in patients receiving long-term antibiotic treatment.
Data availability statement
All data relevant to the study are included in the article.
Ethics statements
Patient consent for publication
Parental/guardian consent obtained.
Contributors: JL: overall manuscript writing and interpretation. GW and FZ: interpretation of results. XS: manuscript modification and submission.
Funding: This study was funded by National Natural Science Foundation of China (82070011, 81670073), Jiangsu Commission of Health (K2019004) and "333 project" of Jiangsu Province (BRA2019339).
Competing interests: None declared.
Provenance and peer review: Not commissioned; externally peer reviewed. | PIPERACILLIN SODIUM\TAZOBACTAM SODIUM | DrugsGivenReaction | CC BY-NC | 33558219 | 18,987,367 | 2021-02-08 |
Give an alphabetized list of all active substances of drugs taken by the patient who experienced 'Type IV hypersensitivity reaction'. | An unusual case of piperacillin-tazobactam-induced fever, eosinophilia, thrombocytopenia and liver damage.
Piperacillin-tazobactam is a broad-spectrum antimicrobial agent that is commonly used in clinical practice. The development of delayed drug hypersensitivity reaction (DHR) has been reported in several cases previously. Here we describe an unusual case of non-immediate DHR due to a prolonged course of piperacillin-tazobactam. We report a 22-year-old man who developed fever, eosinophilia, thrombocytopenia and elevated hepatic enzymes following 17 days of piperacillin-tazobactam for methicillin-sensitive Staphylococcus aureus (MSSA) pneumonia. These adverse reactions were reversed immediately after antibiotic cessation. Our case highlights that clinicians should be aware of delayed adverse effects in patients receiving long-term piperacillin-tazobactam treatment.
pmcBackground
Piperacillin-tazobactam is a combination formulation of an ureidopenicillin and a beta-lactamase inhibitor with a broad spectrum of antibacterial activity.1 2 It is effective for the treatment of patients with polymicrobial infection caused by many Gram-negative, Gram-positive and beta-lactamase-producing bacteria, such as complicated nosocomial and intra-abdominal infections, and also is regarded as empiric therapy for patients who present with fever and neutropenia.3
As a typical antibiotic, piperacillin-tazobactam is considered safe and well tolerated. However, some adverse reactions have been reported. The most frequent complications include diarrhoea and hepatic dysfunction.4 Eosinophilia with fever and haematological abnormality have been described as severe adverse effects of piperacillin-tazobactam, and are also characteristically regarded as part of the non-immediate drug hypersensitivity reactions (DHRs).5 6 Non-immediate DHRs tend to occur in patients receiving piperacillin-tazobactam therapy over 10 days.7 Here we report an unusual case of a non-immediate DHR reaction to piperacillin-tazobactam.
Case presentation
A previously healthy 22-year-old man presented at our emergency room in January 2020 with high fever (up to 40℃) for a week, accompanied with cough and expectoration. He had 3- year history of smoking without intravenous drug abuse. Physical examination revealed: body temperature 39.5℃; blood pressure 101/54 mmHg and tachypnea of 28 breaths/minute. There were no signs of wounds or skin abscesses. No obvious rhonchi was heard at bilateral lungs and no murmurs were audible in the cardiac valve areas. Initial laboratory tests in the emergency room included: white blood cell count 30.45×109/L, neutrophils 26.95×109/L, platelets 469×109/L, C-reactive protein (CRP) 78 mg/L (normal range 0–8 mg/L) and lactate dehydrogenase (LDH) 657 U/L. Computed tomography (CT) of the chest indicated multiple patchy opacities with cavities. The patient was admitted for further investigation and treatment.
Cardiac ultrasound indicated no signs of bacterial endocarditis. Methicillin-sensitive Staphylococcus aureus (MSSA) was isolated from sputum. Repeated blood cultures were negative. HIV and hepatitis B virus tests were negative. Tests for active and latent tuberculosis, including mycobacterium cultures of sputum samples and the interferon-γ release test for tuberculosis infection, were negative. Chest CT showed multiple dense consolidation with cavities at both side of the lungs and also indicated some cavities with gas-liquid level formation inside pulmonary abscesses (figure 1). A small quantity of pleural effusion presented on the scan. No obvious abnormality was found on abdominal CT. A diagnosis was made of S. aureus pneumonia, complicated by pulmonary abscess. Initially the patient empirically received intravenous vancomycin, 1 g twice daily, and imipenem 1 g every 6 hours. Three days later the patient’s body temperature had markedly decreased. Give the presence of MSSA and abnormality of liver function, antimicrobial therapy was switched to intravenous piperacillin-tazobactam 4.5 g every 8 hours per day.
Figure 1 Computed tomography (CT) images of a 22-year-old patient admitted with Staphylococcus aureus pneumonia in January 2020. CT showed multiple patchy opacities with cavities, some of which had gas-liquid level formation inside in the emergency room (A) and after admission (B). During the initiation of vancomycin and imipenem, slightly absorbed parts of inflammatory lesions were revealed on CT (C). Piperacillin-tazobactam treatment improved the CT findings on day 6 following administration (D). No indication of new infection was found after drug-induced fever. (E). No obvious focus was seen on CT scan 3 months after discharge (F).
Intravenous piperacillin-tazobactam apparently further improved the patient's symptoms and CT appearance. His body temperature remained normal for 10 days. However, 17 days after continuous treatment with piperacillin-tazobactam, the patient suddenly developed a high fever with a body temperature of 38.5℃ and did not complain of any other symptoms. Detailed physical examination did not reveal any abnormal findings. Blood samples were taken for culture. Repeated chest CT did not show any deterioration or was suggestive of a new infection for the recurrence of fever. Laboratory analysis indicated reduced platelets (66×109/L) compared with the initial level (figure 2). On the following days, the patient also had eosinophilia (1.36×109/L) and liver function abnormality (alanine aminotransferase (ALT) 78 U/L, aspartate aminotransferase (AST) 223 U/L). Potential viral infection of the upper respiratory tract was excluded.
Figure 2 The development of eosinophilia, thrombocytopenia and liver function test abnormality during the course of piperacillin-tazobactam treatment with normal values for white cell count. Blood counts of eosinophils and platelets returned to normal levels after cessation of piperacillin-tazobactam on day 14 following initiation. Liver parameters returned to normal after 1 week following cessation of piperacillin-tazobactam treatment. PCT, procalcitonin.
The piperacillin-tazobactam was suspected to be the most likely cause of the recurrent fever, eosinophilia, thrombocytopenia and hepatic abnormalities, and hence was stopped. The fever quickly resolved within 24 hours following the termination of piperacillin-tazobactam treatment and did not recur afterwards. Platelet and eosinophil counts normalised on day 3 and day 7 after cessation of piperacillin-tazobactam, respectively. The parameters of hepatic function declined nearly to normal levels after a week following piperacillin-tazobactam cessation. The patient did not receive any additional medication (including antibiotic therapy) for the recurrent fever until discharge, and underwent supportive treatment without any complications.
Investigations
This is an uncommon case of adverse drug response caused by piperacillin-tazobactam. Previous reports have revealed several cases of haematological abnormalities that were suspected as probably being piperacillin-tazobactam-induced side effects, including neutropenia, thrombocytopenia or anaemia.8 9 Other reports showed that eosinophilia with systemic symptoms are regarded as kinds of adverse effects caused by the antibiotics.5 10 In our work, we found a special case of delayed thrombocytopenia and eosinophilia that occurred simultaneously after the use of piperacillin-tazobactam for the treatment of S. aureus pneumonia. The patient’s laboratory and clinical factors did not show evidence of latent infection in other locations. The possibile involvement of the upper respiratory tract was excluded.
Treatment
The patient' diagnosis was S. aureus pneumonia, complicated by pulmonary abscesses. The use of intravenous piperacillin-tazobactam apparently improved the patient's symptoms and CT appearance. Although the patient developed fever, eosinophilia, thrombocytopenia and liver damage caused by the treatment, the unusual syndromes gradually disappeared after cessation of piperacillin-tazobactama.
Outcome and follow-up
The fever resolved within 24 hours after stopping piperacillin-tazobactam treatment. The platelet and eosinophil counts both returned to normal after the cessation of piperacillin-tazobactam. The parameters of hepatic function also declined nearly to normal levels following treatment termination.
Discussion
In the present case, the patient started to show the side effects of fever, thrombocytopenia and eosinophilia after 17 days of piperacillin-tazobactam treatment. This is similar to previous reports in which drug induced-fever and associated adverse effects occurred from 11 to 17 days after the initiation of piperacillin-tazobactam administration. We have experienced this several times and have described this as the ‘dangerous period’ for piperacillin-tazobactam-induced fever. Consequently we stopped piperacillin-tazobactam therapy immediately without starting any other antibiotics or medication. Fortunately, this patient's fever disappeared within 24 hours of the piperacillin-tazobactam therapy being discontinued. Although the patient's blood CRP and procalcitonin increased in tandem with the fever, they soon declined on day 3 after the termination of piperacillin-tazobactam therapy. Based on the evidence, we believe there is a correlation between the described side effects and piperacillin-tazobactam therapy.
It has been reported in some cases that piperacillin-tazobactam-induced fever is regarded as a hypersensitivity reaction. Fever, eosinophilia, thrombocytopenia and liver damage are all part of the drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome.5 DRESS syndrome is a life-threatening, rare adverse effect that frequently develops following exposure to antibiotics or antiepileptics, which is characterised by fever, rash, elevated liver enzyme levels, and leukocytosis with eosinophilia.11 The RegiSCAR (European Register of Severe Cutaneous Adverse Reactions) is a scoring system which is most commonly used to categorise cases of DRESS into four groups: no case, possible case, probable case and definite case. Our patient presented several of the described features including fever, eosinophilia and elevated liver enzymes. Typical rash and enlarged lymph nodes were not detected in our patient. Use of the RegiSCAR indicated a possible relationship (score of 3) between our patient’s manifestation of DRESS syndrome and treatment with piperacillin-tazobactam.12
Our patient’s presentation of a fever and an elevated CRP lasting for a transient period evoked a suspicion of latent viral and haematological infection probably after prolonged use of piperacillin-tazobactam. However, no other probable aetiology of eosinophilia could be identified, and the eosinophil abnormality associated with administration of piperacillin-tazobactam resolved soon after the termination of antibiotic therapy. We reasoned that the eosinophilia was probably related to piperacillin-tazobactam as a non-immediate DHR. The mechanism of piperacillin-tazobactam-induced eosinophilia is not entirely understood, but one theory is that activation of interleukin-5 (IL-5) on accumulation of toxic metabolites could cause activation of eosinophils and inflammatory cascades.13 Although there is no accurate diagnostic test or pathognomonic sign, the diagnosis of DRESS syndrome should be considered after exposure to piperacillin-tazobactam for longer than 2 weeks.
Bone marrow suppression is a rare and serious adverse effect of piperacillin-tazobactam, and it has been reported that abnormalities occurred after 2 weeks of prolonged antibiotic use.8 The most common abnormality is neutropenia that is often accompanied with thrombocytopenia. Thrombocytopenia rarely develops alone. Thus, we demonstrate an unusual isolated thrombocytopenia after a long course of piperacillin-tazobactam. To our knowledge, isolated thrombocytopenia is thought likely to be due to an immune-mediated reaction induced by drug administration that occurs suddenly and precipitously. Bose et al described a case of abrupt and severe thrombocytopenia within 2 days of piperacillin-tazobactam administration.14 The patient had a positive test for immunoglobulin G (IgG) antiplatelet antibodies to piperacillin-tazobactam therapy, supporting the speculation of immune-related thrombocytopenia. Alzahrani et al reported two cases of possible immune thrombocytopenia that developed rapidly and severely in association with re-exposure to piperacillin-tazobactam.15 Also the platelet count in peripheral blood improved after the discontinuation of piperacillin-tazobactam and the initiation of corticosteroid therapy, suggesting the possibility of immune-mediated thrombocytopenia.
In our case, the patient developed wild thrombocytopenia without any positive results of auto-immune antibodies or change in complement C3. Since we stopped piperacillin-tazobactam immediately after the side effect occurred, the thrombocytopenia quickly resolved without corticosteroid therapy. It has been suggested that this later-onset thrombocytopenia is dependent on a delayed-type hypersensitivity. Among antibiotics, the beta-lactam antibiotics are a common cause of immune thrombocytopenia, while a beta-lactam-beta-lactamase inhibitor combination, such as piperacillin-tazobactam, has rarely been reported to induce immune-mediated thrombocytopenia. The aetiology of drug-induced immune thrombocytopenia is complex and the mechanism of piperacillin-related thrombocytopenia is possibly associated with hapten-induced antibodies. Some studies have suggested that small molecules like drugs might induce an immune response when linked to macromolecules such as proteins. The combination acts as a hapten and triggers a humoral immune response. On re-exposure to the drug, this leads to platelet destruction and this mechanism may explain the haemolytic anaemia.16 Another report revealed that piperacillin can induce hapten-specific antibodies that are reactive with piperacillin-coated blood cells.17 This similar mechanism may account for the thrombocytopenia that is rarely seen in patients after treatment with piperacillin, but this still needs further confirmation experimentally. An explanation whereby the later-onset thrombocytopenia caused by piperacillin-tazobactam likely occurs as a result of direct toxicity of myeloid precursors should not be excluded.
Moreover, our patient also manifested liver dysfunction, having previously had normal liver function, while the haematological abnormality appeared after the onset of drug-induced fever, and the hepatic value returned to the normal level 1 week after drug cessation. Although hepatic dysfunction has been reported previously in patients on piperacillin-tazobactam therapy, there is no apparent relationship with mortality or progression. Saloojee et al showed that among 225 critically ill patients enrolled in a retrospective study, piperacillin-tazobactam was found to be associated with hepatic dysfunction18. McDonald et al showed there were no significant differences between the high-dose and licensed dose of piperacillin-tazobactam therapy in terms of hepatotoxicity.19 Another report indicates that the beta-lactamantibiotics may induce leucopenia in sever liver dysfunction.20 In the present case, there was no other explanation for this complication except for the exposure to piperacillin-tazobactam as there was no evidence of sepsis, or other responsible drugs. We speculated that the hepatic dysfunction was associated with antibiotic use.
In conclusion, this is the first description of an unusual case of fever, eosinophilia, thrombocytopenia and liver damage induced by piperacillin-tazobactam. The antibiotic-induced fever may precede bone marrow suppression. Eosinophilia is a rare adverse effect of piperacillin-tazobactam and caution is needed regarding the DRESS syndrome in patients with long duration of piperacillin-tazobactam treatment.
Learning points
This is an unusual case of adverse effects induced by long-term use of piperacillin-tazobactam that has not been observed previously for methicillin-sensitive Staphylococcus aureus.
Eosinophilia is rarely seen following piperacillin-tazobactam treatment, especially accompanying other adverse effects simultaneously.
Clinicians should be aware of possible adverse effects in patients receiving long-term antibiotic treatment.
Data availability statement
All data relevant to the study are included in the article.
Ethics statements
Patient consent for publication
Parental/guardian consent obtained.
Contributors: JL: overall manuscript writing and interpretation. GW and FZ: interpretation of results. XS: manuscript modification and submission.
Funding: This study was funded by National Natural Science Foundation of China (82070011, 81670073), Jiangsu Commission of Health (K2019004) and "333 project" of Jiangsu Province (BRA2019339).
Competing interests: None declared.
Provenance and peer review: Not commissioned; externally peer reviewed. | PIPERACILLIN SODIUM\TAZOBACTAM SODIUM | DrugsGivenReaction | CC BY-NC | 33558219 | 18,987,367 | 2021-02-08 |
What was the administration route of drug 'PIPERACILLIN SODIUM\TAZOBACTAM SODIUM'? | An unusual case of piperacillin-tazobactam-induced fever, eosinophilia, thrombocytopenia and liver damage.
Piperacillin-tazobactam is a broad-spectrum antimicrobial agent that is commonly used in clinical practice. The development of delayed drug hypersensitivity reaction (DHR) has been reported in several cases previously. Here we describe an unusual case of non-immediate DHR due to a prolonged course of piperacillin-tazobactam. We report a 22-year-old man who developed fever, eosinophilia, thrombocytopenia and elevated hepatic enzymes following 17 days of piperacillin-tazobactam for methicillin-sensitive Staphylococcus aureus (MSSA) pneumonia. These adverse reactions were reversed immediately after antibiotic cessation. Our case highlights that clinicians should be aware of delayed adverse effects in patients receiving long-term piperacillin-tazobactam treatment.
pmcBackground
Piperacillin-tazobactam is a combination formulation of an ureidopenicillin and a beta-lactamase inhibitor with a broad spectrum of antibacterial activity.1 2 It is effective for the treatment of patients with polymicrobial infection caused by many Gram-negative, Gram-positive and beta-lactamase-producing bacteria, such as complicated nosocomial and intra-abdominal infections, and also is regarded as empiric therapy for patients who present with fever and neutropenia.3
As a typical antibiotic, piperacillin-tazobactam is considered safe and well tolerated. However, some adverse reactions have been reported. The most frequent complications include diarrhoea and hepatic dysfunction.4 Eosinophilia with fever and haematological abnormality have been described as severe adverse effects of piperacillin-tazobactam, and are also characteristically regarded as part of the non-immediate drug hypersensitivity reactions (DHRs).5 6 Non-immediate DHRs tend to occur in patients receiving piperacillin-tazobactam therapy over 10 days.7 Here we report an unusual case of a non-immediate DHR reaction to piperacillin-tazobactam.
Case presentation
A previously healthy 22-year-old man presented at our emergency room in January 2020 with high fever (up to 40℃) for a week, accompanied with cough and expectoration. He had 3- year history of smoking without intravenous drug abuse. Physical examination revealed: body temperature 39.5℃; blood pressure 101/54 mmHg and tachypnea of 28 breaths/minute. There were no signs of wounds or skin abscesses. No obvious rhonchi was heard at bilateral lungs and no murmurs were audible in the cardiac valve areas. Initial laboratory tests in the emergency room included: white blood cell count 30.45×109/L, neutrophils 26.95×109/L, platelets 469×109/L, C-reactive protein (CRP) 78 mg/L (normal range 0–8 mg/L) and lactate dehydrogenase (LDH) 657 U/L. Computed tomography (CT) of the chest indicated multiple patchy opacities with cavities. The patient was admitted for further investigation and treatment.
Cardiac ultrasound indicated no signs of bacterial endocarditis. Methicillin-sensitive Staphylococcus aureus (MSSA) was isolated from sputum. Repeated blood cultures were negative. HIV and hepatitis B virus tests were negative. Tests for active and latent tuberculosis, including mycobacterium cultures of sputum samples and the interferon-γ release test for tuberculosis infection, were negative. Chest CT showed multiple dense consolidation with cavities at both side of the lungs and also indicated some cavities with gas-liquid level formation inside pulmonary abscesses (figure 1). A small quantity of pleural effusion presented on the scan. No obvious abnormality was found on abdominal CT. A diagnosis was made of S. aureus pneumonia, complicated by pulmonary abscess. Initially the patient empirically received intravenous vancomycin, 1 g twice daily, and imipenem 1 g every 6 hours. Three days later the patient’s body temperature had markedly decreased. Give the presence of MSSA and abnormality of liver function, antimicrobial therapy was switched to intravenous piperacillin-tazobactam 4.5 g every 8 hours per day.
Figure 1 Computed tomography (CT) images of a 22-year-old patient admitted with Staphylococcus aureus pneumonia in January 2020. CT showed multiple patchy opacities with cavities, some of which had gas-liquid level formation inside in the emergency room (A) and after admission (B). During the initiation of vancomycin and imipenem, slightly absorbed parts of inflammatory lesions were revealed on CT (C). Piperacillin-tazobactam treatment improved the CT findings on day 6 following administration (D). No indication of new infection was found after drug-induced fever. (E). No obvious focus was seen on CT scan 3 months after discharge (F).
Intravenous piperacillin-tazobactam apparently further improved the patient's symptoms and CT appearance. His body temperature remained normal for 10 days. However, 17 days after continuous treatment with piperacillin-tazobactam, the patient suddenly developed a high fever with a body temperature of 38.5℃ and did not complain of any other symptoms. Detailed physical examination did not reveal any abnormal findings. Blood samples were taken for culture. Repeated chest CT did not show any deterioration or was suggestive of a new infection for the recurrence of fever. Laboratory analysis indicated reduced platelets (66×109/L) compared with the initial level (figure 2). On the following days, the patient also had eosinophilia (1.36×109/L) and liver function abnormality (alanine aminotransferase (ALT) 78 U/L, aspartate aminotransferase (AST) 223 U/L). Potential viral infection of the upper respiratory tract was excluded.
Figure 2 The development of eosinophilia, thrombocytopenia and liver function test abnormality during the course of piperacillin-tazobactam treatment with normal values for white cell count. Blood counts of eosinophils and platelets returned to normal levels after cessation of piperacillin-tazobactam on day 14 following initiation. Liver parameters returned to normal after 1 week following cessation of piperacillin-tazobactam treatment. PCT, procalcitonin.
The piperacillin-tazobactam was suspected to be the most likely cause of the recurrent fever, eosinophilia, thrombocytopenia and hepatic abnormalities, and hence was stopped. The fever quickly resolved within 24 hours following the termination of piperacillin-tazobactam treatment and did not recur afterwards. Platelet and eosinophil counts normalised on day 3 and day 7 after cessation of piperacillin-tazobactam, respectively. The parameters of hepatic function declined nearly to normal levels after a week following piperacillin-tazobactam cessation. The patient did not receive any additional medication (including antibiotic therapy) for the recurrent fever until discharge, and underwent supportive treatment without any complications.
Investigations
This is an uncommon case of adverse drug response caused by piperacillin-tazobactam. Previous reports have revealed several cases of haematological abnormalities that were suspected as probably being piperacillin-tazobactam-induced side effects, including neutropenia, thrombocytopenia or anaemia.8 9 Other reports showed that eosinophilia with systemic symptoms are regarded as kinds of adverse effects caused by the antibiotics.5 10 In our work, we found a special case of delayed thrombocytopenia and eosinophilia that occurred simultaneously after the use of piperacillin-tazobactam for the treatment of S. aureus pneumonia. The patient’s laboratory and clinical factors did not show evidence of latent infection in other locations. The possibile involvement of the upper respiratory tract was excluded.
Treatment
The patient' diagnosis was S. aureus pneumonia, complicated by pulmonary abscesses. The use of intravenous piperacillin-tazobactam apparently improved the patient's symptoms and CT appearance. Although the patient developed fever, eosinophilia, thrombocytopenia and liver damage caused by the treatment, the unusual syndromes gradually disappeared after cessation of piperacillin-tazobactama.
Outcome and follow-up
The fever resolved within 24 hours after stopping piperacillin-tazobactam treatment. The platelet and eosinophil counts both returned to normal after the cessation of piperacillin-tazobactam. The parameters of hepatic function also declined nearly to normal levels following treatment termination.
Discussion
In the present case, the patient started to show the side effects of fever, thrombocytopenia and eosinophilia after 17 days of piperacillin-tazobactam treatment. This is similar to previous reports in which drug induced-fever and associated adverse effects occurred from 11 to 17 days after the initiation of piperacillin-tazobactam administration. We have experienced this several times and have described this as the ‘dangerous period’ for piperacillin-tazobactam-induced fever. Consequently we stopped piperacillin-tazobactam therapy immediately without starting any other antibiotics or medication. Fortunately, this patient's fever disappeared within 24 hours of the piperacillin-tazobactam therapy being discontinued. Although the patient's blood CRP and procalcitonin increased in tandem with the fever, they soon declined on day 3 after the termination of piperacillin-tazobactam therapy. Based on the evidence, we believe there is a correlation between the described side effects and piperacillin-tazobactam therapy.
It has been reported in some cases that piperacillin-tazobactam-induced fever is regarded as a hypersensitivity reaction. Fever, eosinophilia, thrombocytopenia and liver damage are all part of the drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome.5 DRESS syndrome is a life-threatening, rare adverse effect that frequently develops following exposure to antibiotics or antiepileptics, which is characterised by fever, rash, elevated liver enzyme levels, and leukocytosis with eosinophilia.11 The RegiSCAR (European Register of Severe Cutaneous Adverse Reactions) is a scoring system which is most commonly used to categorise cases of DRESS into four groups: no case, possible case, probable case and definite case. Our patient presented several of the described features including fever, eosinophilia and elevated liver enzymes. Typical rash and enlarged lymph nodes were not detected in our patient. Use of the RegiSCAR indicated a possible relationship (score of 3) between our patient’s manifestation of DRESS syndrome and treatment with piperacillin-tazobactam.12
Our patient’s presentation of a fever and an elevated CRP lasting for a transient period evoked a suspicion of latent viral and haematological infection probably after prolonged use of piperacillin-tazobactam. However, no other probable aetiology of eosinophilia could be identified, and the eosinophil abnormality associated with administration of piperacillin-tazobactam resolved soon after the termination of antibiotic therapy. We reasoned that the eosinophilia was probably related to piperacillin-tazobactam as a non-immediate DHR. The mechanism of piperacillin-tazobactam-induced eosinophilia is not entirely understood, but one theory is that activation of interleukin-5 (IL-5) on accumulation of toxic metabolites could cause activation of eosinophils and inflammatory cascades.13 Although there is no accurate diagnostic test or pathognomonic sign, the diagnosis of DRESS syndrome should be considered after exposure to piperacillin-tazobactam for longer than 2 weeks.
Bone marrow suppression is a rare and serious adverse effect of piperacillin-tazobactam, and it has been reported that abnormalities occurred after 2 weeks of prolonged antibiotic use.8 The most common abnormality is neutropenia that is often accompanied with thrombocytopenia. Thrombocytopenia rarely develops alone. Thus, we demonstrate an unusual isolated thrombocytopenia after a long course of piperacillin-tazobactam. To our knowledge, isolated thrombocytopenia is thought likely to be due to an immune-mediated reaction induced by drug administration that occurs suddenly and precipitously. Bose et al described a case of abrupt and severe thrombocytopenia within 2 days of piperacillin-tazobactam administration.14 The patient had a positive test for immunoglobulin G (IgG) antiplatelet antibodies to piperacillin-tazobactam therapy, supporting the speculation of immune-related thrombocytopenia. Alzahrani et al reported two cases of possible immune thrombocytopenia that developed rapidly and severely in association with re-exposure to piperacillin-tazobactam.15 Also the platelet count in peripheral blood improved after the discontinuation of piperacillin-tazobactam and the initiation of corticosteroid therapy, suggesting the possibility of immune-mediated thrombocytopenia.
In our case, the patient developed wild thrombocytopenia without any positive results of auto-immune antibodies or change in complement C3. Since we stopped piperacillin-tazobactam immediately after the side effect occurred, the thrombocytopenia quickly resolved without corticosteroid therapy. It has been suggested that this later-onset thrombocytopenia is dependent on a delayed-type hypersensitivity. Among antibiotics, the beta-lactam antibiotics are a common cause of immune thrombocytopenia, while a beta-lactam-beta-lactamase inhibitor combination, such as piperacillin-tazobactam, has rarely been reported to induce immune-mediated thrombocytopenia. The aetiology of drug-induced immune thrombocytopenia is complex and the mechanism of piperacillin-related thrombocytopenia is possibly associated with hapten-induced antibodies. Some studies have suggested that small molecules like drugs might induce an immune response when linked to macromolecules such as proteins. The combination acts as a hapten and triggers a humoral immune response. On re-exposure to the drug, this leads to platelet destruction and this mechanism may explain the haemolytic anaemia.16 Another report revealed that piperacillin can induce hapten-specific antibodies that are reactive with piperacillin-coated blood cells.17 This similar mechanism may account for the thrombocytopenia that is rarely seen in patients after treatment with piperacillin, but this still needs further confirmation experimentally. An explanation whereby the later-onset thrombocytopenia caused by piperacillin-tazobactam likely occurs as a result of direct toxicity of myeloid precursors should not be excluded.
Moreover, our patient also manifested liver dysfunction, having previously had normal liver function, while the haematological abnormality appeared after the onset of drug-induced fever, and the hepatic value returned to the normal level 1 week after drug cessation. Although hepatic dysfunction has been reported previously in patients on piperacillin-tazobactam therapy, there is no apparent relationship with mortality or progression. Saloojee et al showed that among 225 critically ill patients enrolled in a retrospective study, piperacillin-tazobactam was found to be associated with hepatic dysfunction18. McDonald et al showed there were no significant differences between the high-dose and licensed dose of piperacillin-tazobactam therapy in terms of hepatotoxicity.19 Another report indicates that the beta-lactamantibiotics may induce leucopenia in sever liver dysfunction.20 In the present case, there was no other explanation for this complication except for the exposure to piperacillin-tazobactam as there was no evidence of sepsis, or other responsible drugs. We speculated that the hepatic dysfunction was associated with antibiotic use.
In conclusion, this is the first description of an unusual case of fever, eosinophilia, thrombocytopenia and liver damage induced by piperacillin-tazobactam. The antibiotic-induced fever may precede bone marrow suppression. Eosinophilia is a rare adverse effect of piperacillin-tazobactam and caution is needed regarding the DRESS syndrome in patients with long duration of piperacillin-tazobactam treatment.
Learning points
This is an unusual case of adverse effects induced by long-term use of piperacillin-tazobactam that has not been observed previously for methicillin-sensitive Staphylococcus aureus.
Eosinophilia is rarely seen following piperacillin-tazobactam treatment, especially accompanying other adverse effects simultaneously.
Clinicians should be aware of possible adverse effects in patients receiving long-term antibiotic treatment.
Data availability statement
All data relevant to the study are included in the article.
Ethics statements
Patient consent for publication
Parental/guardian consent obtained.
Contributors: JL: overall manuscript writing and interpretation. GW and FZ: interpretation of results. XS: manuscript modification and submission.
Funding: This study was funded by National Natural Science Foundation of China (82070011, 81670073), Jiangsu Commission of Health (K2019004) and "333 project" of Jiangsu Province (BRA2019339).
Competing interests: None declared.
Provenance and peer review: Not commissioned; externally peer reviewed. | Intravenous (not otherwise specified) | DrugAdministrationRoute | CC BY-NC | 33558219 | 18,987,367 | 2021-02-08 |
What was the outcome of reaction 'Drug reaction with eosinophilia and systemic symptoms'? | An unusual case of piperacillin-tazobactam-induced fever, eosinophilia, thrombocytopenia and liver damage.
Piperacillin-tazobactam is a broad-spectrum antimicrobial agent that is commonly used in clinical practice. The development of delayed drug hypersensitivity reaction (DHR) has been reported in several cases previously. Here we describe an unusual case of non-immediate DHR due to a prolonged course of piperacillin-tazobactam. We report a 22-year-old man who developed fever, eosinophilia, thrombocytopenia and elevated hepatic enzymes following 17 days of piperacillin-tazobactam for methicillin-sensitive Staphylococcus aureus (MSSA) pneumonia. These adverse reactions were reversed immediately after antibiotic cessation. Our case highlights that clinicians should be aware of delayed adverse effects in patients receiving long-term piperacillin-tazobactam treatment.
pmcBackground
Piperacillin-tazobactam is a combination formulation of an ureidopenicillin and a beta-lactamase inhibitor with a broad spectrum of antibacterial activity.1 2 It is effective for the treatment of patients with polymicrobial infection caused by many Gram-negative, Gram-positive and beta-lactamase-producing bacteria, such as complicated nosocomial and intra-abdominal infections, and also is regarded as empiric therapy for patients who present with fever and neutropenia.3
As a typical antibiotic, piperacillin-tazobactam is considered safe and well tolerated. However, some adverse reactions have been reported. The most frequent complications include diarrhoea and hepatic dysfunction.4 Eosinophilia with fever and haematological abnormality have been described as severe adverse effects of piperacillin-tazobactam, and are also characteristically regarded as part of the non-immediate drug hypersensitivity reactions (DHRs).5 6 Non-immediate DHRs tend to occur in patients receiving piperacillin-tazobactam therapy over 10 days.7 Here we report an unusual case of a non-immediate DHR reaction to piperacillin-tazobactam.
Case presentation
A previously healthy 22-year-old man presented at our emergency room in January 2020 with high fever (up to 40℃) for a week, accompanied with cough and expectoration. He had 3- year history of smoking without intravenous drug abuse. Physical examination revealed: body temperature 39.5℃; blood pressure 101/54 mmHg and tachypnea of 28 breaths/minute. There were no signs of wounds or skin abscesses. No obvious rhonchi was heard at bilateral lungs and no murmurs were audible in the cardiac valve areas. Initial laboratory tests in the emergency room included: white blood cell count 30.45×109/L, neutrophils 26.95×109/L, platelets 469×109/L, C-reactive protein (CRP) 78 mg/L (normal range 0–8 mg/L) and lactate dehydrogenase (LDH) 657 U/L. Computed tomography (CT) of the chest indicated multiple patchy opacities with cavities. The patient was admitted for further investigation and treatment.
Cardiac ultrasound indicated no signs of bacterial endocarditis. Methicillin-sensitive Staphylococcus aureus (MSSA) was isolated from sputum. Repeated blood cultures were negative. HIV and hepatitis B virus tests were negative. Tests for active and latent tuberculosis, including mycobacterium cultures of sputum samples and the interferon-γ release test for tuberculosis infection, were negative. Chest CT showed multiple dense consolidation with cavities at both side of the lungs and also indicated some cavities with gas-liquid level formation inside pulmonary abscesses (figure 1). A small quantity of pleural effusion presented on the scan. No obvious abnormality was found on abdominal CT. A diagnosis was made of S. aureus pneumonia, complicated by pulmonary abscess. Initially the patient empirically received intravenous vancomycin, 1 g twice daily, and imipenem 1 g every 6 hours. Three days later the patient’s body temperature had markedly decreased. Give the presence of MSSA and abnormality of liver function, antimicrobial therapy was switched to intravenous piperacillin-tazobactam 4.5 g every 8 hours per day.
Figure 1 Computed tomography (CT) images of a 22-year-old patient admitted with Staphylococcus aureus pneumonia in January 2020. CT showed multiple patchy opacities with cavities, some of which had gas-liquid level formation inside in the emergency room (A) and after admission (B). During the initiation of vancomycin and imipenem, slightly absorbed parts of inflammatory lesions were revealed on CT (C). Piperacillin-tazobactam treatment improved the CT findings on day 6 following administration (D). No indication of new infection was found after drug-induced fever. (E). No obvious focus was seen on CT scan 3 months after discharge (F).
Intravenous piperacillin-tazobactam apparently further improved the patient's symptoms and CT appearance. His body temperature remained normal for 10 days. However, 17 days after continuous treatment with piperacillin-tazobactam, the patient suddenly developed a high fever with a body temperature of 38.5℃ and did not complain of any other symptoms. Detailed physical examination did not reveal any abnormal findings. Blood samples were taken for culture. Repeated chest CT did not show any deterioration or was suggestive of a new infection for the recurrence of fever. Laboratory analysis indicated reduced platelets (66×109/L) compared with the initial level (figure 2). On the following days, the patient also had eosinophilia (1.36×109/L) and liver function abnormality (alanine aminotransferase (ALT) 78 U/L, aspartate aminotransferase (AST) 223 U/L). Potential viral infection of the upper respiratory tract was excluded.
Figure 2 The development of eosinophilia, thrombocytopenia and liver function test abnormality during the course of piperacillin-tazobactam treatment with normal values for white cell count. Blood counts of eosinophils and platelets returned to normal levels after cessation of piperacillin-tazobactam on day 14 following initiation. Liver parameters returned to normal after 1 week following cessation of piperacillin-tazobactam treatment. PCT, procalcitonin.
The piperacillin-tazobactam was suspected to be the most likely cause of the recurrent fever, eosinophilia, thrombocytopenia and hepatic abnormalities, and hence was stopped. The fever quickly resolved within 24 hours following the termination of piperacillin-tazobactam treatment and did not recur afterwards. Platelet and eosinophil counts normalised on day 3 and day 7 after cessation of piperacillin-tazobactam, respectively. The parameters of hepatic function declined nearly to normal levels after a week following piperacillin-tazobactam cessation. The patient did not receive any additional medication (including antibiotic therapy) for the recurrent fever until discharge, and underwent supportive treatment without any complications.
Investigations
This is an uncommon case of adverse drug response caused by piperacillin-tazobactam. Previous reports have revealed several cases of haematological abnormalities that were suspected as probably being piperacillin-tazobactam-induced side effects, including neutropenia, thrombocytopenia or anaemia.8 9 Other reports showed that eosinophilia with systemic symptoms are regarded as kinds of adverse effects caused by the antibiotics.5 10 In our work, we found a special case of delayed thrombocytopenia and eosinophilia that occurred simultaneously after the use of piperacillin-tazobactam for the treatment of S. aureus pneumonia. The patient’s laboratory and clinical factors did not show evidence of latent infection in other locations. The possibile involvement of the upper respiratory tract was excluded.
Treatment
The patient' diagnosis was S. aureus pneumonia, complicated by pulmonary abscesses. The use of intravenous piperacillin-tazobactam apparently improved the patient's symptoms and CT appearance. Although the patient developed fever, eosinophilia, thrombocytopenia and liver damage caused by the treatment, the unusual syndromes gradually disappeared after cessation of piperacillin-tazobactama.
Outcome and follow-up
The fever resolved within 24 hours after stopping piperacillin-tazobactam treatment. The platelet and eosinophil counts both returned to normal after the cessation of piperacillin-tazobactam. The parameters of hepatic function also declined nearly to normal levels following treatment termination.
Discussion
In the present case, the patient started to show the side effects of fever, thrombocytopenia and eosinophilia after 17 days of piperacillin-tazobactam treatment. This is similar to previous reports in which drug induced-fever and associated adverse effects occurred from 11 to 17 days after the initiation of piperacillin-tazobactam administration. We have experienced this several times and have described this as the ‘dangerous period’ for piperacillin-tazobactam-induced fever. Consequently we stopped piperacillin-tazobactam therapy immediately without starting any other antibiotics or medication. Fortunately, this patient's fever disappeared within 24 hours of the piperacillin-tazobactam therapy being discontinued. Although the patient's blood CRP and procalcitonin increased in tandem with the fever, they soon declined on day 3 after the termination of piperacillin-tazobactam therapy. Based on the evidence, we believe there is a correlation between the described side effects and piperacillin-tazobactam therapy.
It has been reported in some cases that piperacillin-tazobactam-induced fever is regarded as a hypersensitivity reaction. Fever, eosinophilia, thrombocytopenia and liver damage are all part of the drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome.5 DRESS syndrome is a life-threatening, rare adverse effect that frequently develops following exposure to antibiotics or antiepileptics, which is characterised by fever, rash, elevated liver enzyme levels, and leukocytosis with eosinophilia.11 The RegiSCAR (European Register of Severe Cutaneous Adverse Reactions) is a scoring system which is most commonly used to categorise cases of DRESS into four groups: no case, possible case, probable case and definite case. Our patient presented several of the described features including fever, eosinophilia and elevated liver enzymes. Typical rash and enlarged lymph nodes were not detected in our patient. Use of the RegiSCAR indicated a possible relationship (score of 3) between our patient’s manifestation of DRESS syndrome and treatment with piperacillin-tazobactam.12
Our patient’s presentation of a fever and an elevated CRP lasting for a transient period evoked a suspicion of latent viral and haematological infection probably after prolonged use of piperacillin-tazobactam. However, no other probable aetiology of eosinophilia could be identified, and the eosinophil abnormality associated with administration of piperacillin-tazobactam resolved soon after the termination of antibiotic therapy. We reasoned that the eosinophilia was probably related to piperacillin-tazobactam as a non-immediate DHR. The mechanism of piperacillin-tazobactam-induced eosinophilia is not entirely understood, but one theory is that activation of interleukin-5 (IL-5) on accumulation of toxic metabolites could cause activation of eosinophils and inflammatory cascades.13 Although there is no accurate diagnostic test or pathognomonic sign, the diagnosis of DRESS syndrome should be considered after exposure to piperacillin-tazobactam for longer than 2 weeks.
Bone marrow suppression is a rare and serious adverse effect of piperacillin-tazobactam, and it has been reported that abnormalities occurred after 2 weeks of prolonged antibiotic use.8 The most common abnormality is neutropenia that is often accompanied with thrombocytopenia. Thrombocytopenia rarely develops alone. Thus, we demonstrate an unusual isolated thrombocytopenia after a long course of piperacillin-tazobactam. To our knowledge, isolated thrombocytopenia is thought likely to be due to an immune-mediated reaction induced by drug administration that occurs suddenly and precipitously. Bose et al described a case of abrupt and severe thrombocytopenia within 2 days of piperacillin-tazobactam administration.14 The patient had a positive test for immunoglobulin G (IgG) antiplatelet antibodies to piperacillin-tazobactam therapy, supporting the speculation of immune-related thrombocytopenia. Alzahrani et al reported two cases of possible immune thrombocytopenia that developed rapidly and severely in association with re-exposure to piperacillin-tazobactam.15 Also the platelet count in peripheral blood improved after the discontinuation of piperacillin-tazobactam and the initiation of corticosteroid therapy, suggesting the possibility of immune-mediated thrombocytopenia.
In our case, the patient developed wild thrombocytopenia without any positive results of auto-immune antibodies or change in complement C3. Since we stopped piperacillin-tazobactam immediately after the side effect occurred, the thrombocytopenia quickly resolved without corticosteroid therapy. It has been suggested that this later-onset thrombocytopenia is dependent on a delayed-type hypersensitivity. Among antibiotics, the beta-lactam antibiotics are a common cause of immune thrombocytopenia, while a beta-lactam-beta-lactamase inhibitor combination, such as piperacillin-tazobactam, has rarely been reported to induce immune-mediated thrombocytopenia. The aetiology of drug-induced immune thrombocytopenia is complex and the mechanism of piperacillin-related thrombocytopenia is possibly associated with hapten-induced antibodies. Some studies have suggested that small molecules like drugs might induce an immune response when linked to macromolecules such as proteins. The combination acts as a hapten and triggers a humoral immune response. On re-exposure to the drug, this leads to platelet destruction and this mechanism may explain the haemolytic anaemia.16 Another report revealed that piperacillin can induce hapten-specific antibodies that are reactive with piperacillin-coated blood cells.17 This similar mechanism may account for the thrombocytopenia that is rarely seen in patients after treatment with piperacillin, but this still needs further confirmation experimentally. An explanation whereby the later-onset thrombocytopenia caused by piperacillin-tazobactam likely occurs as a result of direct toxicity of myeloid precursors should not be excluded.
Moreover, our patient also manifested liver dysfunction, having previously had normal liver function, while the haematological abnormality appeared after the onset of drug-induced fever, and the hepatic value returned to the normal level 1 week after drug cessation. Although hepatic dysfunction has been reported previously in patients on piperacillin-tazobactam therapy, there is no apparent relationship with mortality or progression. Saloojee et al showed that among 225 critically ill patients enrolled in a retrospective study, piperacillin-tazobactam was found to be associated with hepatic dysfunction18. McDonald et al showed there were no significant differences between the high-dose and licensed dose of piperacillin-tazobactam therapy in terms of hepatotoxicity.19 Another report indicates that the beta-lactamantibiotics may induce leucopenia in sever liver dysfunction.20 In the present case, there was no other explanation for this complication except for the exposure to piperacillin-tazobactam as there was no evidence of sepsis, or other responsible drugs. We speculated that the hepatic dysfunction was associated with antibiotic use.
In conclusion, this is the first description of an unusual case of fever, eosinophilia, thrombocytopenia and liver damage induced by piperacillin-tazobactam. The antibiotic-induced fever may precede bone marrow suppression. Eosinophilia is a rare adverse effect of piperacillin-tazobactam and caution is needed regarding the DRESS syndrome in patients with long duration of piperacillin-tazobactam treatment.
Learning points
This is an unusual case of adverse effects induced by long-term use of piperacillin-tazobactam that has not been observed previously for methicillin-sensitive Staphylococcus aureus.
Eosinophilia is rarely seen following piperacillin-tazobactam treatment, especially accompanying other adverse effects simultaneously.
Clinicians should be aware of possible adverse effects in patients receiving long-term antibiotic treatment.
Data availability statement
All data relevant to the study are included in the article.
Ethics statements
Patient consent for publication
Parental/guardian consent obtained.
Contributors: JL: overall manuscript writing and interpretation. GW and FZ: interpretation of results. XS: manuscript modification and submission.
Funding: This study was funded by National Natural Science Foundation of China (82070011, 81670073), Jiangsu Commission of Health (K2019004) and "333 project" of Jiangsu Province (BRA2019339).
Competing interests: None declared.
Provenance and peer review: Not commissioned; externally peer reviewed. | Recovered | ReactionOutcome | CC BY-NC | 33558219 | 18,987,367 | 2021-02-08 |
What was the outcome of reaction 'Eosinophilia'? | An unusual case of piperacillin-tazobactam-induced fever, eosinophilia, thrombocytopenia and liver damage.
Piperacillin-tazobactam is a broad-spectrum antimicrobial agent that is commonly used in clinical practice. The development of delayed drug hypersensitivity reaction (DHR) has been reported in several cases previously. Here we describe an unusual case of non-immediate DHR due to a prolonged course of piperacillin-tazobactam. We report a 22-year-old man who developed fever, eosinophilia, thrombocytopenia and elevated hepatic enzymes following 17 days of piperacillin-tazobactam for methicillin-sensitive Staphylococcus aureus (MSSA) pneumonia. These adverse reactions were reversed immediately after antibiotic cessation. Our case highlights that clinicians should be aware of delayed adverse effects in patients receiving long-term piperacillin-tazobactam treatment.
pmcBackground
Piperacillin-tazobactam is a combination formulation of an ureidopenicillin and a beta-lactamase inhibitor with a broad spectrum of antibacterial activity.1 2 It is effective for the treatment of patients with polymicrobial infection caused by many Gram-negative, Gram-positive and beta-lactamase-producing bacteria, such as complicated nosocomial and intra-abdominal infections, and also is regarded as empiric therapy for patients who present with fever and neutropenia.3
As a typical antibiotic, piperacillin-tazobactam is considered safe and well tolerated. However, some adverse reactions have been reported. The most frequent complications include diarrhoea and hepatic dysfunction.4 Eosinophilia with fever and haematological abnormality have been described as severe adverse effects of piperacillin-tazobactam, and are also characteristically regarded as part of the non-immediate drug hypersensitivity reactions (DHRs).5 6 Non-immediate DHRs tend to occur in patients receiving piperacillin-tazobactam therapy over 10 days.7 Here we report an unusual case of a non-immediate DHR reaction to piperacillin-tazobactam.
Case presentation
A previously healthy 22-year-old man presented at our emergency room in January 2020 with high fever (up to 40℃) for a week, accompanied with cough and expectoration. He had 3- year history of smoking without intravenous drug abuse. Physical examination revealed: body temperature 39.5℃; blood pressure 101/54 mmHg and tachypnea of 28 breaths/minute. There were no signs of wounds or skin abscesses. No obvious rhonchi was heard at bilateral lungs and no murmurs were audible in the cardiac valve areas. Initial laboratory tests in the emergency room included: white blood cell count 30.45×109/L, neutrophils 26.95×109/L, platelets 469×109/L, C-reactive protein (CRP) 78 mg/L (normal range 0–8 mg/L) and lactate dehydrogenase (LDH) 657 U/L. Computed tomography (CT) of the chest indicated multiple patchy opacities with cavities. The patient was admitted for further investigation and treatment.
Cardiac ultrasound indicated no signs of bacterial endocarditis. Methicillin-sensitive Staphylococcus aureus (MSSA) was isolated from sputum. Repeated blood cultures were negative. HIV and hepatitis B virus tests were negative. Tests for active and latent tuberculosis, including mycobacterium cultures of sputum samples and the interferon-γ release test for tuberculosis infection, were negative. Chest CT showed multiple dense consolidation with cavities at both side of the lungs and also indicated some cavities with gas-liquid level formation inside pulmonary abscesses (figure 1). A small quantity of pleural effusion presented on the scan. No obvious abnormality was found on abdominal CT. A diagnosis was made of S. aureus pneumonia, complicated by pulmonary abscess. Initially the patient empirically received intravenous vancomycin, 1 g twice daily, and imipenem 1 g every 6 hours. Three days later the patient’s body temperature had markedly decreased. Give the presence of MSSA and abnormality of liver function, antimicrobial therapy was switched to intravenous piperacillin-tazobactam 4.5 g every 8 hours per day.
Figure 1 Computed tomography (CT) images of a 22-year-old patient admitted with Staphylococcus aureus pneumonia in January 2020. CT showed multiple patchy opacities with cavities, some of which had gas-liquid level formation inside in the emergency room (A) and after admission (B). During the initiation of vancomycin and imipenem, slightly absorbed parts of inflammatory lesions were revealed on CT (C). Piperacillin-tazobactam treatment improved the CT findings on day 6 following administration (D). No indication of new infection was found after drug-induced fever. (E). No obvious focus was seen on CT scan 3 months after discharge (F).
Intravenous piperacillin-tazobactam apparently further improved the patient's symptoms and CT appearance. His body temperature remained normal for 10 days. However, 17 days after continuous treatment with piperacillin-tazobactam, the patient suddenly developed a high fever with a body temperature of 38.5℃ and did not complain of any other symptoms. Detailed physical examination did not reveal any abnormal findings. Blood samples were taken for culture. Repeated chest CT did not show any deterioration or was suggestive of a new infection for the recurrence of fever. Laboratory analysis indicated reduced platelets (66×109/L) compared with the initial level (figure 2). On the following days, the patient also had eosinophilia (1.36×109/L) and liver function abnormality (alanine aminotransferase (ALT) 78 U/L, aspartate aminotransferase (AST) 223 U/L). Potential viral infection of the upper respiratory tract was excluded.
Figure 2 The development of eosinophilia, thrombocytopenia and liver function test abnormality during the course of piperacillin-tazobactam treatment with normal values for white cell count. Blood counts of eosinophils and platelets returned to normal levels after cessation of piperacillin-tazobactam on day 14 following initiation. Liver parameters returned to normal after 1 week following cessation of piperacillin-tazobactam treatment. PCT, procalcitonin.
The piperacillin-tazobactam was suspected to be the most likely cause of the recurrent fever, eosinophilia, thrombocytopenia and hepatic abnormalities, and hence was stopped. The fever quickly resolved within 24 hours following the termination of piperacillin-tazobactam treatment and did not recur afterwards. Platelet and eosinophil counts normalised on day 3 and day 7 after cessation of piperacillin-tazobactam, respectively. The parameters of hepatic function declined nearly to normal levels after a week following piperacillin-tazobactam cessation. The patient did not receive any additional medication (including antibiotic therapy) for the recurrent fever until discharge, and underwent supportive treatment without any complications.
Investigations
This is an uncommon case of adverse drug response caused by piperacillin-tazobactam. Previous reports have revealed several cases of haematological abnormalities that were suspected as probably being piperacillin-tazobactam-induced side effects, including neutropenia, thrombocytopenia or anaemia.8 9 Other reports showed that eosinophilia with systemic symptoms are regarded as kinds of adverse effects caused by the antibiotics.5 10 In our work, we found a special case of delayed thrombocytopenia and eosinophilia that occurred simultaneously after the use of piperacillin-tazobactam for the treatment of S. aureus pneumonia. The patient’s laboratory and clinical factors did not show evidence of latent infection in other locations. The possibile involvement of the upper respiratory tract was excluded.
Treatment
The patient' diagnosis was S. aureus pneumonia, complicated by pulmonary abscesses. The use of intravenous piperacillin-tazobactam apparently improved the patient's symptoms and CT appearance. Although the patient developed fever, eosinophilia, thrombocytopenia and liver damage caused by the treatment, the unusual syndromes gradually disappeared after cessation of piperacillin-tazobactama.
Outcome and follow-up
The fever resolved within 24 hours after stopping piperacillin-tazobactam treatment. The platelet and eosinophil counts both returned to normal after the cessation of piperacillin-tazobactam. The parameters of hepatic function also declined nearly to normal levels following treatment termination.
Discussion
In the present case, the patient started to show the side effects of fever, thrombocytopenia and eosinophilia after 17 days of piperacillin-tazobactam treatment. This is similar to previous reports in which drug induced-fever and associated adverse effects occurred from 11 to 17 days after the initiation of piperacillin-tazobactam administration. We have experienced this several times and have described this as the ‘dangerous period’ for piperacillin-tazobactam-induced fever. Consequently we stopped piperacillin-tazobactam therapy immediately without starting any other antibiotics or medication. Fortunately, this patient's fever disappeared within 24 hours of the piperacillin-tazobactam therapy being discontinued. Although the patient's blood CRP and procalcitonin increased in tandem with the fever, they soon declined on day 3 after the termination of piperacillin-tazobactam therapy. Based on the evidence, we believe there is a correlation between the described side effects and piperacillin-tazobactam therapy.
It has been reported in some cases that piperacillin-tazobactam-induced fever is regarded as a hypersensitivity reaction. Fever, eosinophilia, thrombocytopenia and liver damage are all part of the drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome.5 DRESS syndrome is a life-threatening, rare adverse effect that frequently develops following exposure to antibiotics or antiepileptics, which is characterised by fever, rash, elevated liver enzyme levels, and leukocytosis with eosinophilia.11 The RegiSCAR (European Register of Severe Cutaneous Adverse Reactions) is a scoring system which is most commonly used to categorise cases of DRESS into four groups: no case, possible case, probable case and definite case. Our patient presented several of the described features including fever, eosinophilia and elevated liver enzymes. Typical rash and enlarged lymph nodes were not detected in our patient. Use of the RegiSCAR indicated a possible relationship (score of 3) between our patient’s manifestation of DRESS syndrome and treatment with piperacillin-tazobactam.12
Our patient’s presentation of a fever and an elevated CRP lasting for a transient period evoked a suspicion of latent viral and haematological infection probably after prolonged use of piperacillin-tazobactam. However, no other probable aetiology of eosinophilia could be identified, and the eosinophil abnormality associated with administration of piperacillin-tazobactam resolved soon after the termination of antibiotic therapy. We reasoned that the eosinophilia was probably related to piperacillin-tazobactam as a non-immediate DHR. The mechanism of piperacillin-tazobactam-induced eosinophilia is not entirely understood, but one theory is that activation of interleukin-5 (IL-5) on accumulation of toxic metabolites could cause activation of eosinophils and inflammatory cascades.13 Although there is no accurate diagnostic test or pathognomonic sign, the diagnosis of DRESS syndrome should be considered after exposure to piperacillin-tazobactam for longer than 2 weeks.
Bone marrow suppression is a rare and serious adverse effect of piperacillin-tazobactam, and it has been reported that abnormalities occurred after 2 weeks of prolonged antibiotic use.8 The most common abnormality is neutropenia that is often accompanied with thrombocytopenia. Thrombocytopenia rarely develops alone. Thus, we demonstrate an unusual isolated thrombocytopenia after a long course of piperacillin-tazobactam. To our knowledge, isolated thrombocytopenia is thought likely to be due to an immune-mediated reaction induced by drug administration that occurs suddenly and precipitously. Bose et al described a case of abrupt and severe thrombocytopenia within 2 days of piperacillin-tazobactam administration.14 The patient had a positive test for immunoglobulin G (IgG) antiplatelet antibodies to piperacillin-tazobactam therapy, supporting the speculation of immune-related thrombocytopenia. Alzahrani et al reported two cases of possible immune thrombocytopenia that developed rapidly and severely in association with re-exposure to piperacillin-tazobactam.15 Also the platelet count in peripheral blood improved after the discontinuation of piperacillin-tazobactam and the initiation of corticosteroid therapy, suggesting the possibility of immune-mediated thrombocytopenia.
In our case, the patient developed wild thrombocytopenia without any positive results of auto-immune antibodies or change in complement C3. Since we stopped piperacillin-tazobactam immediately after the side effect occurred, the thrombocytopenia quickly resolved without corticosteroid therapy. It has been suggested that this later-onset thrombocytopenia is dependent on a delayed-type hypersensitivity. Among antibiotics, the beta-lactam antibiotics are a common cause of immune thrombocytopenia, while a beta-lactam-beta-lactamase inhibitor combination, such as piperacillin-tazobactam, has rarely been reported to induce immune-mediated thrombocytopenia. The aetiology of drug-induced immune thrombocytopenia is complex and the mechanism of piperacillin-related thrombocytopenia is possibly associated with hapten-induced antibodies. Some studies have suggested that small molecules like drugs might induce an immune response when linked to macromolecules such as proteins. The combination acts as a hapten and triggers a humoral immune response. On re-exposure to the drug, this leads to platelet destruction and this mechanism may explain the haemolytic anaemia.16 Another report revealed that piperacillin can induce hapten-specific antibodies that are reactive with piperacillin-coated blood cells.17 This similar mechanism may account for the thrombocytopenia that is rarely seen in patients after treatment with piperacillin, but this still needs further confirmation experimentally. An explanation whereby the later-onset thrombocytopenia caused by piperacillin-tazobactam likely occurs as a result of direct toxicity of myeloid precursors should not be excluded.
Moreover, our patient also manifested liver dysfunction, having previously had normal liver function, while the haematological abnormality appeared after the onset of drug-induced fever, and the hepatic value returned to the normal level 1 week after drug cessation. Although hepatic dysfunction has been reported previously in patients on piperacillin-tazobactam therapy, there is no apparent relationship with mortality or progression. Saloojee et al showed that among 225 critically ill patients enrolled in a retrospective study, piperacillin-tazobactam was found to be associated with hepatic dysfunction18. McDonald et al showed there were no significant differences between the high-dose and licensed dose of piperacillin-tazobactam therapy in terms of hepatotoxicity.19 Another report indicates that the beta-lactamantibiotics may induce leucopenia in sever liver dysfunction.20 In the present case, there was no other explanation for this complication except for the exposure to piperacillin-tazobactam as there was no evidence of sepsis, or other responsible drugs. We speculated that the hepatic dysfunction was associated with antibiotic use.
In conclusion, this is the first description of an unusual case of fever, eosinophilia, thrombocytopenia and liver damage induced by piperacillin-tazobactam. The antibiotic-induced fever may precede bone marrow suppression. Eosinophilia is a rare adverse effect of piperacillin-tazobactam and caution is needed regarding the DRESS syndrome in patients with long duration of piperacillin-tazobactam treatment.
Learning points
This is an unusual case of adverse effects induced by long-term use of piperacillin-tazobactam that has not been observed previously for methicillin-sensitive Staphylococcus aureus.
Eosinophilia is rarely seen following piperacillin-tazobactam treatment, especially accompanying other adverse effects simultaneously.
Clinicians should be aware of possible adverse effects in patients receiving long-term antibiotic treatment.
Data availability statement
All data relevant to the study are included in the article.
Ethics statements
Patient consent for publication
Parental/guardian consent obtained.
Contributors: JL: overall manuscript writing and interpretation. GW and FZ: interpretation of results. XS: manuscript modification and submission.
Funding: This study was funded by National Natural Science Foundation of China (82070011, 81670073), Jiangsu Commission of Health (K2019004) and "333 project" of Jiangsu Province (BRA2019339).
Competing interests: None declared.
Provenance and peer review: Not commissioned; externally peer reviewed. | Recovered | ReactionOutcome | CC BY-NC | 33558219 | 18,987,367 | 2021-02-08 |
What was the outcome of reaction 'Hepatic enzyme increased'? | An unusual case of piperacillin-tazobactam-induced fever, eosinophilia, thrombocytopenia and liver damage.
Piperacillin-tazobactam is a broad-spectrum antimicrobial agent that is commonly used in clinical practice. The development of delayed drug hypersensitivity reaction (DHR) has been reported in several cases previously. Here we describe an unusual case of non-immediate DHR due to a prolonged course of piperacillin-tazobactam. We report a 22-year-old man who developed fever, eosinophilia, thrombocytopenia and elevated hepatic enzymes following 17 days of piperacillin-tazobactam for methicillin-sensitive Staphylococcus aureus (MSSA) pneumonia. These adverse reactions were reversed immediately after antibiotic cessation. Our case highlights that clinicians should be aware of delayed adverse effects in patients receiving long-term piperacillin-tazobactam treatment.
pmcBackground
Piperacillin-tazobactam is a combination formulation of an ureidopenicillin and a beta-lactamase inhibitor with a broad spectrum of antibacterial activity.1 2 It is effective for the treatment of patients with polymicrobial infection caused by many Gram-negative, Gram-positive and beta-lactamase-producing bacteria, such as complicated nosocomial and intra-abdominal infections, and also is regarded as empiric therapy for patients who present with fever and neutropenia.3
As a typical antibiotic, piperacillin-tazobactam is considered safe and well tolerated. However, some adverse reactions have been reported. The most frequent complications include diarrhoea and hepatic dysfunction.4 Eosinophilia with fever and haematological abnormality have been described as severe adverse effects of piperacillin-tazobactam, and are also characteristically regarded as part of the non-immediate drug hypersensitivity reactions (DHRs).5 6 Non-immediate DHRs tend to occur in patients receiving piperacillin-tazobactam therapy over 10 days.7 Here we report an unusual case of a non-immediate DHR reaction to piperacillin-tazobactam.
Case presentation
A previously healthy 22-year-old man presented at our emergency room in January 2020 with high fever (up to 40℃) for a week, accompanied with cough and expectoration. He had 3- year history of smoking without intravenous drug abuse. Physical examination revealed: body temperature 39.5℃; blood pressure 101/54 mmHg and tachypnea of 28 breaths/minute. There were no signs of wounds or skin abscesses. No obvious rhonchi was heard at bilateral lungs and no murmurs were audible in the cardiac valve areas. Initial laboratory tests in the emergency room included: white blood cell count 30.45×109/L, neutrophils 26.95×109/L, platelets 469×109/L, C-reactive protein (CRP) 78 mg/L (normal range 0–8 mg/L) and lactate dehydrogenase (LDH) 657 U/L. Computed tomography (CT) of the chest indicated multiple patchy opacities with cavities. The patient was admitted for further investigation and treatment.
Cardiac ultrasound indicated no signs of bacterial endocarditis. Methicillin-sensitive Staphylococcus aureus (MSSA) was isolated from sputum. Repeated blood cultures were negative. HIV and hepatitis B virus tests were negative. Tests for active and latent tuberculosis, including mycobacterium cultures of sputum samples and the interferon-γ release test for tuberculosis infection, were negative. Chest CT showed multiple dense consolidation with cavities at both side of the lungs and also indicated some cavities with gas-liquid level formation inside pulmonary abscesses (figure 1). A small quantity of pleural effusion presented on the scan. No obvious abnormality was found on abdominal CT. A diagnosis was made of S. aureus pneumonia, complicated by pulmonary abscess. Initially the patient empirically received intravenous vancomycin, 1 g twice daily, and imipenem 1 g every 6 hours. Three days later the patient’s body temperature had markedly decreased. Give the presence of MSSA and abnormality of liver function, antimicrobial therapy was switched to intravenous piperacillin-tazobactam 4.5 g every 8 hours per day.
Figure 1 Computed tomography (CT) images of a 22-year-old patient admitted with Staphylococcus aureus pneumonia in January 2020. CT showed multiple patchy opacities with cavities, some of which had gas-liquid level formation inside in the emergency room (A) and after admission (B). During the initiation of vancomycin and imipenem, slightly absorbed parts of inflammatory lesions were revealed on CT (C). Piperacillin-tazobactam treatment improved the CT findings on day 6 following administration (D). No indication of new infection was found after drug-induced fever. (E). No obvious focus was seen on CT scan 3 months after discharge (F).
Intravenous piperacillin-tazobactam apparently further improved the patient's symptoms and CT appearance. His body temperature remained normal for 10 days. However, 17 days after continuous treatment with piperacillin-tazobactam, the patient suddenly developed a high fever with a body temperature of 38.5℃ and did not complain of any other symptoms. Detailed physical examination did not reveal any abnormal findings. Blood samples were taken for culture. Repeated chest CT did not show any deterioration or was suggestive of a new infection for the recurrence of fever. Laboratory analysis indicated reduced platelets (66×109/L) compared with the initial level (figure 2). On the following days, the patient also had eosinophilia (1.36×109/L) and liver function abnormality (alanine aminotransferase (ALT) 78 U/L, aspartate aminotransferase (AST) 223 U/L). Potential viral infection of the upper respiratory tract was excluded.
Figure 2 The development of eosinophilia, thrombocytopenia and liver function test abnormality during the course of piperacillin-tazobactam treatment with normal values for white cell count. Blood counts of eosinophils and platelets returned to normal levels after cessation of piperacillin-tazobactam on day 14 following initiation. Liver parameters returned to normal after 1 week following cessation of piperacillin-tazobactam treatment. PCT, procalcitonin.
The piperacillin-tazobactam was suspected to be the most likely cause of the recurrent fever, eosinophilia, thrombocytopenia and hepatic abnormalities, and hence was stopped. The fever quickly resolved within 24 hours following the termination of piperacillin-tazobactam treatment and did not recur afterwards. Platelet and eosinophil counts normalised on day 3 and day 7 after cessation of piperacillin-tazobactam, respectively. The parameters of hepatic function declined nearly to normal levels after a week following piperacillin-tazobactam cessation. The patient did not receive any additional medication (including antibiotic therapy) for the recurrent fever until discharge, and underwent supportive treatment without any complications.
Investigations
This is an uncommon case of adverse drug response caused by piperacillin-tazobactam. Previous reports have revealed several cases of haematological abnormalities that were suspected as probably being piperacillin-tazobactam-induced side effects, including neutropenia, thrombocytopenia or anaemia.8 9 Other reports showed that eosinophilia with systemic symptoms are regarded as kinds of adverse effects caused by the antibiotics.5 10 In our work, we found a special case of delayed thrombocytopenia and eosinophilia that occurred simultaneously after the use of piperacillin-tazobactam for the treatment of S. aureus pneumonia. The patient’s laboratory and clinical factors did not show evidence of latent infection in other locations. The possibile involvement of the upper respiratory tract was excluded.
Treatment
The patient' diagnosis was S. aureus pneumonia, complicated by pulmonary abscesses. The use of intravenous piperacillin-tazobactam apparently improved the patient's symptoms and CT appearance. Although the patient developed fever, eosinophilia, thrombocytopenia and liver damage caused by the treatment, the unusual syndromes gradually disappeared after cessation of piperacillin-tazobactama.
Outcome and follow-up
The fever resolved within 24 hours after stopping piperacillin-tazobactam treatment. The platelet and eosinophil counts both returned to normal after the cessation of piperacillin-tazobactam. The parameters of hepatic function also declined nearly to normal levels following treatment termination.
Discussion
In the present case, the patient started to show the side effects of fever, thrombocytopenia and eosinophilia after 17 days of piperacillin-tazobactam treatment. This is similar to previous reports in which drug induced-fever and associated adverse effects occurred from 11 to 17 days after the initiation of piperacillin-tazobactam administration. We have experienced this several times and have described this as the ‘dangerous period’ for piperacillin-tazobactam-induced fever. Consequently we stopped piperacillin-tazobactam therapy immediately without starting any other antibiotics or medication. Fortunately, this patient's fever disappeared within 24 hours of the piperacillin-tazobactam therapy being discontinued. Although the patient's blood CRP and procalcitonin increased in tandem with the fever, they soon declined on day 3 after the termination of piperacillin-tazobactam therapy. Based on the evidence, we believe there is a correlation between the described side effects and piperacillin-tazobactam therapy.
It has been reported in some cases that piperacillin-tazobactam-induced fever is regarded as a hypersensitivity reaction. Fever, eosinophilia, thrombocytopenia and liver damage are all part of the drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome.5 DRESS syndrome is a life-threatening, rare adverse effect that frequently develops following exposure to antibiotics or antiepileptics, which is characterised by fever, rash, elevated liver enzyme levels, and leukocytosis with eosinophilia.11 The RegiSCAR (European Register of Severe Cutaneous Adverse Reactions) is a scoring system which is most commonly used to categorise cases of DRESS into four groups: no case, possible case, probable case and definite case. Our patient presented several of the described features including fever, eosinophilia and elevated liver enzymes. Typical rash and enlarged lymph nodes were not detected in our patient. Use of the RegiSCAR indicated a possible relationship (score of 3) between our patient’s manifestation of DRESS syndrome and treatment with piperacillin-tazobactam.12
Our patient’s presentation of a fever and an elevated CRP lasting for a transient period evoked a suspicion of latent viral and haematological infection probably after prolonged use of piperacillin-tazobactam. However, no other probable aetiology of eosinophilia could be identified, and the eosinophil abnormality associated with administration of piperacillin-tazobactam resolved soon after the termination of antibiotic therapy. We reasoned that the eosinophilia was probably related to piperacillin-tazobactam as a non-immediate DHR. The mechanism of piperacillin-tazobactam-induced eosinophilia is not entirely understood, but one theory is that activation of interleukin-5 (IL-5) on accumulation of toxic metabolites could cause activation of eosinophils and inflammatory cascades.13 Although there is no accurate diagnostic test or pathognomonic sign, the diagnosis of DRESS syndrome should be considered after exposure to piperacillin-tazobactam for longer than 2 weeks.
Bone marrow suppression is a rare and serious adverse effect of piperacillin-tazobactam, and it has been reported that abnormalities occurred after 2 weeks of prolonged antibiotic use.8 The most common abnormality is neutropenia that is often accompanied with thrombocytopenia. Thrombocytopenia rarely develops alone. Thus, we demonstrate an unusual isolated thrombocytopenia after a long course of piperacillin-tazobactam. To our knowledge, isolated thrombocytopenia is thought likely to be due to an immune-mediated reaction induced by drug administration that occurs suddenly and precipitously. Bose et al described a case of abrupt and severe thrombocytopenia within 2 days of piperacillin-tazobactam administration.14 The patient had a positive test for immunoglobulin G (IgG) antiplatelet antibodies to piperacillin-tazobactam therapy, supporting the speculation of immune-related thrombocytopenia. Alzahrani et al reported two cases of possible immune thrombocytopenia that developed rapidly and severely in association with re-exposure to piperacillin-tazobactam.15 Also the platelet count in peripheral blood improved after the discontinuation of piperacillin-tazobactam and the initiation of corticosteroid therapy, suggesting the possibility of immune-mediated thrombocytopenia.
In our case, the patient developed wild thrombocytopenia without any positive results of auto-immune antibodies or change in complement C3. Since we stopped piperacillin-tazobactam immediately after the side effect occurred, the thrombocytopenia quickly resolved without corticosteroid therapy. It has been suggested that this later-onset thrombocytopenia is dependent on a delayed-type hypersensitivity. Among antibiotics, the beta-lactam antibiotics are a common cause of immune thrombocytopenia, while a beta-lactam-beta-lactamase inhibitor combination, such as piperacillin-tazobactam, has rarely been reported to induce immune-mediated thrombocytopenia. The aetiology of drug-induced immune thrombocytopenia is complex and the mechanism of piperacillin-related thrombocytopenia is possibly associated with hapten-induced antibodies. Some studies have suggested that small molecules like drugs might induce an immune response when linked to macromolecules such as proteins. The combination acts as a hapten and triggers a humoral immune response. On re-exposure to the drug, this leads to platelet destruction and this mechanism may explain the haemolytic anaemia.16 Another report revealed that piperacillin can induce hapten-specific antibodies that are reactive with piperacillin-coated blood cells.17 This similar mechanism may account for the thrombocytopenia that is rarely seen in patients after treatment with piperacillin, but this still needs further confirmation experimentally. An explanation whereby the later-onset thrombocytopenia caused by piperacillin-tazobactam likely occurs as a result of direct toxicity of myeloid precursors should not be excluded.
Moreover, our patient also manifested liver dysfunction, having previously had normal liver function, while the haematological abnormality appeared after the onset of drug-induced fever, and the hepatic value returned to the normal level 1 week after drug cessation. Although hepatic dysfunction has been reported previously in patients on piperacillin-tazobactam therapy, there is no apparent relationship with mortality or progression. Saloojee et al showed that among 225 critically ill patients enrolled in a retrospective study, piperacillin-tazobactam was found to be associated with hepatic dysfunction18. McDonald et al showed there were no significant differences between the high-dose and licensed dose of piperacillin-tazobactam therapy in terms of hepatotoxicity.19 Another report indicates that the beta-lactamantibiotics may induce leucopenia in sever liver dysfunction.20 In the present case, there was no other explanation for this complication except for the exposure to piperacillin-tazobactam as there was no evidence of sepsis, or other responsible drugs. We speculated that the hepatic dysfunction was associated with antibiotic use.
In conclusion, this is the first description of an unusual case of fever, eosinophilia, thrombocytopenia and liver damage induced by piperacillin-tazobactam. The antibiotic-induced fever may precede bone marrow suppression. Eosinophilia is a rare adverse effect of piperacillin-tazobactam and caution is needed regarding the DRESS syndrome in patients with long duration of piperacillin-tazobactam treatment.
Learning points
This is an unusual case of adverse effects induced by long-term use of piperacillin-tazobactam that has not been observed previously for methicillin-sensitive Staphylococcus aureus.
Eosinophilia is rarely seen following piperacillin-tazobactam treatment, especially accompanying other adverse effects simultaneously.
Clinicians should be aware of possible adverse effects in patients receiving long-term antibiotic treatment.
Data availability statement
All data relevant to the study are included in the article.
Ethics statements
Patient consent for publication
Parental/guardian consent obtained.
Contributors: JL: overall manuscript writing and interpretation. GW and FZ: interpretation of results. XS: manuscript modification and submission.
Funding: This study was funded by National Natural Science Foundation of China (82070011, 81670073), Jiangsu Commission of Health (K2019004) and "333 project" of Jiangsu Province (BRA2019339).
Competing interests: None declared.
Provenance and peer review: Not commissioned; externally peer reviewed. | Recovered | ReactionOutcome | CC BY-NC | 33558219 | 18,987,367 | 2021-02-08 |
What was the outcome of reaction 'Liver injury'? | An unusual case of piperacillin-tazobactam-induced fever, eosinophilia, thrombocytopenia and liver damage.
Piperacillin-tazobactam is a broad-spectrum antimicrobial agent that is commonly used in clinical practice. The development of delayed drug hypersensitivity reaction (DHR) has been reported in several cases previously. Here we describe an unusual case of non-immediate DHR due to a prolonged course of piperacillin-tazobactam. We report a 22-year-old man who developed fever, eosinophilia, thrombocytopenia and elevated hepatic enzymes following 17 days of piperacillin-tazobactam for methicillin-sensitive Staphylococcus aureus (MSSA) pneumonia. These adverse reactions were reversed immediately after antibiotic cessation. Our case highlights that clinicians should be aware of delayed adverse effects in patients receiving long-term piperacillin-tazobactam treatment.
pmcBackground
Piperacillin-tazobactam is a combination formulation of an ureidopenicillin and a beta-lactamase inhibitor with a broad spectrum of antibacterial activity.1 2 It is effective for the treatment of patients with polymicrobial infection caused by many Gram-negative, Gram-positive and beta-lactamase-producing bacteria, such as complicated nosocomial and intra-abdominal infections, and also is regarded as empiric therapy for patients who present with fever and neutropenia.3
As a typical antibiotic, piperacillin-tazobactam is considered safe and well tolerated. However, some adverse reactions have been reported. The most frequent complications include diarrhoea and hepatic dysfunction.4 Eosinophilia with fever and haematological abnormality have been described as severe adverse effects of piperacillin-tazobactam, and are also characteristically regarded as part of the non-immediate drug hypersensitivity reactions (DHRs).5 6 Non-immediate DHRs tend to occur in patients receiving piperacillin-tazobactam therapy over 10 days.7 Here we report an unusual case of a non-immediate DHR reaction to piperacillin-tazobactam.
Case presentation
A previously healthy 22-year-old man presented at our emergency room in January 2020 with high fever (up to 40℃) for a week, accompanied with cough and expectoration. He had 3- year history of smoking without intravenous drug abuse. Physical examination revealed: body temperature 39.5℃; blood pressure 101/54 mmHg and tachypnea of 28 breaths/minute. There were no signs of wounds or skin abscesses. No obvious rhonchi was heard at bilateral lungs and no murmurs were audible in the cardiac valve areas. Initial laboratory tests in the emergency room included: white blood cell count 30.45×109/L, neutrophils 26.95×109/L, platelets 469×109/L, C-reactive protein (CRP) 78 mg/L (normal range 0–8 mg/L) and lactate dehydrogenase (LDH) 657 U/L. Computed tomography (CT) of the chest indicated multiple patchy opacities with cavities. The patient was admitted for further investigation and treatment.
Cardiac ultrasound indicated no signs of bacterial endocarditis. Methicillin-sensitive Staphylococcus aureus (MSSA) was isolated from sputum. Repeated blood cultures were negative. HIV and hepatitis B virus tests were negative. Tests for active and latent tuberculosis, including mycobacterium cultures of sputum samples and the interferon-γ release test for tuberculosis infection, were negative. Chest CT showed multiple dense consolidation with cavities at both side of the lungs and also indicated some cavities with gas-liquid level formation inside pulmonary abscesses (figure 1). A small quantity of pleural effusion presented on the scan. No obvious abnormality was found on abdominal CT. A diagnosis was made of S. aureus pneumonia, complicated by pulmonary abscess. Initially the patient empirically received intravenous vancomycin, 1 g twice daily, and imipenem 1 g every 6 hours. Three days later the patient’s body temperature had markedly decreased. Give the presence of MSSA and abnormality of liver function, antimicrobial therapy was switched to intravenous piperacillin-tazobactam 4.5 g every 8 hours per day.
Figure 1 Computed tomography (CT) images of a 22-year-old patient admitted with Staphylococcus aureus pneumonia in January 2020. CT showed multiple patchy opacities with cavities, some of which had gas-liquid level formation inside in the emergency room (A) and after admission (B). During the initiation of vancomycin and imipenem, slightly absorbed parts of inflammatory lesions were revealed on CT (C). Piperacillin-tazobactam treatment improved the CT findings on day 6 following administration (D). No indication of new infection was found after drug-induced fever. (E). No obvious focus was seen on CT scan 3 months after discharge (F).
Intravenous piperacillin-tazobactam apparently further improved the patient's symptoms and CT appearance. His body temperature remained normal for 10 days. However, 17 days after continuous treatment with piperacillin-tazobactam, the patient suddenly developed a high fever with a body temperature of 38.5℃ and did not complain of any other symptoms. Detailed physical examination did not reveal any abnormal findings. Blood samples were taken for culture. Repeated chest CT did not show any deterioration or was suggestive of a new infection for the recurrence of fever. Laboratory analysis indicated reduced platelets (66×109/L) compared with the initial level (figure 2). On the following days, the patient also had eosinophilia (1.36×109/L) and liver function abnormality (alanine aminotransferase (ALT) 78 U/L, aspartate aminotransferase (AST) 223 U/L). Potential viral infection of the upper respiratory tract was excluded.
Figure 2 The development of eosinophilia, thrombocytopenia and liver function test abnormality during the course of piperacillin-tazobactam treatment with normal values for white cell count. Blood counts of eosinophils and platelets returned to normal levels after cessation of piperacillin-tazobactam on day 14 following initiation. Liver parameters returned to normal after 1 week following cessation of piperacillin-tazobactam treatment. PCT, procalcitonin.
The piperacillin-tazobactam was suspected to be the most likely cause of the recurrent fever, eosinophilia, thrombocytopenia and hepatic abnormalities, and hence was stopped. The fever quickly resolved within 24 hours following the termination of piperacillin-tazobactam treatment and did not recur afterwards. Platelet and eosinophil counts normalised on day 3 and day 7 after cessation of piperacillin-tazobactam, respectively. The parameters of hepatic function declined nearly to normal levels after a week following piperacillin-tazobactam cessation. The patient did not receive any additional medication (including antibiotic therapy) for the recurrent fever until discharge, and underwent supportive treatment without any complications.
Investigations
This is an uncommon case of adverse drug response caused by piperacillin-tazobactam. Previous reports have revealed several cases of haematological abnormalities that were suspected as probably being piperacillin-tazobactam-induced side effects, including neutropenia, thrombocytopenia or anaemia.8 9 Other reports showed that eosinophilia with systemic symptoms are regarded as kinds of adverse effects caused by the antibiotics.5 10 In our work, we found a special case of delayed thrombocytopenia and eosinophilia that occurred simultaneously after the use of piperacillin-tazobactam for the treatment of S. aureus pneumonia. The patient’s laboratory and clinical factors did not show evidence of latent infection in other locations. The possibile involvement of the upper respiratory tract was excluded.
Treatment
The patient' diagnosis was S. aureus pneumonia, complicated by pulmonary abscesses. The use of intravenous piperacillin-tazobactam apparently improved the patient's symptoms and CT appearance. Although the patient developed fever, eosinophilia, thrombocytopenia and liver damage caused by the treatment, the unusual syndromes gradually disappeared after cessation of piperacillin-tazobactama.
Outcome and follow-up
The fever resolved within 24 hours after stopping piperacillin-tazobactam treatment. The platelet and eosinophil counts both returned to normal after the cessation of piperacillin-tazobactam. The parameters of hepatic function also declined nearly to normal levels following treatment termination.
Discussion
In the present case, the patient started to show the side effects of fever, thrombocytopenia and eosinophilia after 17 days of piperacillin-tazobactam treatment. This is similar to previous reports in which drug induced-fever and associated adverse effects occurred from 11 to 17 days after the initiation of piperacillin-tazobactam administration. We have experienced this several times and have described this as the ‘dangerous period’ for piperacillin-tazobactam-induced fever. Consequently we stopped piperacillin-tazobactam therapy immediately without starting any other antibiotics or medication. Fortunately, this patient's fever disappeared within 24 hours of the piperacillin-tazobactam therapy being discontinued. Although the patient's blood CRP and procalcitonin increased in tandem with the fever, they soon declined on day 3 after the termination of piperacillin-tazobactam therapy. Based on the evidence, we believe there is a correlation between the described side effects and piperacillin-tazobactam therapy.
It has been reported in some cases that piperacillin-tazobactam-induced fever is regarded as a hypersensitivity reaction. Fever, eosinophilia, thrombocytopenia and liver damage are all part of the drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome.5 DRESS syndrome is a life-threatening, rare adverse effect that frequently develops following exposure to antibiotics or antiepileptics, which is characterised by fever, rash, elevated liver enzyme levels, and leukocytosis with eosinophilia.11 The RegiSCAR (European Register of Severe Cutaneous Adverse Reactions) is a scoring system which is most commonly used to categorise cases of DRESS into four groups: no case, possible case, probable case and definite case. Our patient presented several of the described features including fever, eosinophilia and elevated liver enzymes. Typical rash and enlarged lymph nodes were not detected in our patient. Use of the RegiSCAR indicated a possible relationship (score of 3) between our patient’s manifestation of DRESS syndrome and treatment with piperacillin-tazobactam.12
Our patient’s presentation of a fever and an elevated CRP lasting for a transient period evoked a suspicion of latent viral and haematological infection probably after prolonged use of piperacillin-tazobactam. However, no other probable aetiology of eosinophilia could be identified, and the eosinophil abnormality associated with administration of piperacillin-tazobactam resolved soon after the termination of antibiotic therapy. We reasoned that the eosinophilia was probably related to piperacillin-tazobactam as a non-immediate DHR. The mechanism of piperacillin-tazobactam-induced eosinophilia is not entirely understood, but one theory is that activation of interleukin-5 (IL-5) on accumulation of toxic metabolites could cause activation of eosinophils and inflammatory cascades.13 Although there is no accurate diagnostic test or pathognomonic sign, the diagnosis of DRESS syndrome should be considered after exposure to piperacillin-tazobactam for longer than 2 weeks.
Bone marrow suppression is a rare and serious adverse effect of piperacillin-tazobactam, and it has been reported that abnormalities occurred after 2 weeks of prolonged antibiotic use.8 The most common abnormality is neutropenia that is often accompanied with thrombocytopenia. Thrombocytopenia rarely develops alone. Thus, we demonstrate an unusual isolated thrombocytopenia after a long course of piperacillin-tazobactam. To our knowledge, isolated thrombocytopenia is thought likely to be due to an immune-mediated reaction induced by drug administration that occurs suddenly and precipitously. Bose et al described a case of abrupt and severe thrombocytopenia within 2 days of piperacillin-tazobactam administration.14 The patient had a positive test for immunoglobulin G (IgG) antiplatelet antibodies to piperacillin-tazobactam therapy, supporting the speculation of immune-related thrombocytopenia. Alzahrani et al reported two cases of possible immune thrombocytopenia that developed rapidly and severely in association with re-exposure to piperacillin-tazobactam.15 Also the platelet count in peripheral blood improved after the discontinuation of piperacillin-tazobactam and the initiation of corticosteroid therapy, suggesting the possibility of immune-mediated thrombocytopenia.
In our case, the patient developed wild thrombocytopenia without any positive results of auto-immune antibodies or change in complement C3. Since we stopped piperacillin-tazobactam immediately after the side effect occurred, the thrombocytopenia quickly resolved without corticosteroid therapy. It has been suggested that this later-onset thrombocytopenia is dependent on a delayed-type hypersensitivity. Among antibiotics, the beta-lactam antibiotics are a common cause of immune thrombocytopenia, while a beta-lactam-beta-lactamase inhibitor combination, such as piperacillin-tazobactam, has rarely been reported to induce immune-mediated thrombocytopenia. The aetiology of drug-induced immune thrombocytopenia is complex and the mechanism of piperacillin-related thrombocytopenia is possibly associated with hapten-induced antibodies. Some studies have suggested that small molecules like drugs might induce an immune response when linked to macromolecules such as proteins. The combination acts as a hapten and triggers a humoral immune response. On re-exposure to the drug, this leads to platelet destruction and this mechanism may explain the haemolytic anaemia.16 Another report revealed that piperacillin can induce hapten-specific antibodies that are reactive with piperacillin-coated blood cells.17 This similar mechanism may account for the thrombocytopenia that is rarely seen in patients after treatment with piperacillin, but this still needs further confirmation experimentally. An explanation whereby the later-onset thrombocytopenia caused by piperacillin-tazobactam likely occurs as a result of direct toxicity of myeloid precursors should not be excluded.
Moreover, our patient also manifested liver dysfunction, having previously had normal liver function, while the haematological abnormality appeared after the onset of drug-induced fever, and the hepatic value returned to the normal level 1 week after drug cessation. Although hepatic dysfunction has been reported previously in patients on piperacillin-tazobactam therapy, there is no apparent relationship with mortality or progression. Saloojee et al showed that among 225 critically ill patients enrolled in a retrospective study, piperacillin-tazobactam was found to be associated with hepatic dysfunction18. McDonald et al showed there were no significant differences between the high-dose and licensed dose of piperacillin-tazobactam therapy in terms of hepatotoxicity.19 Another report indicates that the beta-lactamantibiotics may induce leucopenia in sever liver dysfunction.20 In the present case, there was no other explanation for this complication except for the exposure to piperacillin-tazobactam as there was no evidence of sepsis, or other responsible drugs. We speculated that the hepatic dysfunction was associated with antibiotic use.
In conclusion, this is the first description of an unusual case of fever, eosinophilia, thrombocytopenia and liver damage induced by piperacillin-tazobactam. The antibiotic-induced fever may precede bone marrow suppression. Eosinophilia is a rare adverse effect of piperacillin-tazobactam and caution is needed regarding the DRESS syndrome in patients with long duration of piperacillin-tazobactam treatment.
Learning points
This is an unusual case of adverse effects induced by long-term use of piperacillin-tazobactam that has not been observed previously for methicillin-sensitive Staphylococcus aureus.
Eosinophilia is rarely seen following piperacillin-tazobactam treatment, especially accompanying other adverse effects simultaneously.
Clinicians should be aware of possible adverse effects in patients receiving long-term antibiotic treatment.
Data availability statement
All data relevant to the study are included in the article.
Ethics statements
Patient consent for publication
Parental/guardian consent obtained.
Contributors: JL: overall manuscript writing and interpretation. GW and FZ: interpretation of results. XS: manuscript modification and submission.
Funding: This study was funded by National Natural Science Foundation of China (82070011, 81670073), Jiangsu Commission of Health (K2019004) and "333 project" of Jiangsu Province (BRA2019339).
Competing interests: None declared.
Provenance and peer review: Not commissioned; externally peer reviewed. | Recovered | ReactionOutcome | CC BY-NC | 33558219 | 18,952,530 | 2021-02-08 |
What was the outcome of reaction 'Pyrexia'? | An unusual case of piperacillin-tazobactam-induced fever, eosinophilia, thrombocytopenia and liver damage.
Piperacillin-tazobactam is a broad-spectrum antimicrobial agent that is commonly used in clinical practice. The development of delayed drug hypersensitivity reaction (DHR) has been reported in several cases previously. Here we describe an unusual case of non-immediate DHR due to a prolonged course of piperacillin-tazobactam. We report a 22-year-old man who developed fever, eosinophilia, thrombocytopenia and elevated hepatic enzymes following 17 days of piperacillin-tazobactam for methicillin-sensitive Staphylococcus aureus (MSSA) pneumonia. These adverse reactions were reversed immediately after antibiotic cessation. Our case highlights that clinicians should be aware of delayed adverse effects in patients receiving long-term piperacillin-tazobactam treatment.
pmcBackground
Piperacillin-tazobactam is a combination formulation of an ureidopenicillin and a beta-lactamase inhibitor with a broad spectrum of antibacterial activity.1 2 It is effective for the treatment of patients with polymicrobial infection caused by many Gram-negative, Gram-positive and beta-lactamase-producing bacteria, such as complicated nosocomial and intra-abdominal infections, and also is regarded as empiric therapy for patients who present with fever and neutropenia.3
As a typical antibiotic, piperacillin-tazobactam is considered safe and well tolerated. However, some adverse reactions have been reported. The most frequent complications include diarrhoea and hepatic dysfunction.4 Eosinophilia with fever and haematological abnormality have been described as severe adverse effects of piperacillin-tazobactam, and are also characteristically regarded as part of the non-immediate drug hypersensitivity reactions (DHRs).5 6 Non-immediate DHRs tend to occur in patients receiving piperacillin-tazobactam therapy over 10 days.7 Here we report an unusual case of a non-immediate DHR reaction to piperacillin-tazobactam.
Case presentation
A previously healthy 22-year-old man presented at our emergency room in January 2020 with high fever (up to 40℃) for a week, accompanied with cough and expectoration. He had 3- year history of smoking without intravenous drug abuse. Physical examination revealed: body temperature 39.5℃; blood pressure 101/54 mmHg and tachypnea of 28 breaths/minute. There were no signs of wounds or skin abscesses. No obvious rhonchi was heard at bilateral lungs and no murmurs were audible in the cardiac valve areas. Initial laboratory tests in the emergency room included: white blood cell count 30.45×109/L, neutrophils 26.95×109/L, platelets 469×109/L, C-reactive protein (CRP) 78 mg/L (normal range 0–8 mg/L) and lactate dehydrogenase (LDH) 657 U/L. Computed tomography (CT) of the chest indicated multiple patchy opacities with cavities. The patient was admitted for further investigation and treatment.
Cardiac ultrasound indicated no signs of bacterial endocarditis. Methicillin-sensitive Staphylococcus aureus (MSSA) was isolated from sputum. Repeated blood cultures were negative. HIV and hepatitis B virus tests were negative. Tests for active and latent tuberculosis, including mycobacterium cultures of sputum samples and the interferon-γ release test for tuberculosis infection, were negative. Chest CT showed multiple dense consolidation with cavities at both side of the lungs and also indicated some cavities with gas-liquid level formation inside pulmonary abscesses (figure 1). A small quantity of pleural effusion presented on the scan. No obvious abnormality was found on abdominal CT. A diagnosis was made of S. aureus pneumonia, complicated by pulmonary abscess. Initially the patient empirically received intravenous vancomycin, 1 g twice daily, and imipenem 1 g every 6 hours. Three days later the patient’s body temperature had markedly decreased. Give the presence of MSSA and abnormality of liver function, antimicrobial therapy was switched to intravenous piperacillin-tazobactam 4.5 g every 8 hours per day.
Figure 1 Computed tomography (CT) images of a 22-year-old patient admitted with Staphylococcus aureus pneumonia in January 2020. CT showed multiple patchy opacities with cavities, some of which had gas-liquid level formation inside in the emergency room (A) and after admission (B). During the initiation of vancomycin and imipenem, slightly absorbed parts of inflammatory lesions were revealed on CT (C). Piperacillin-tazobactam treatment improved the CT findings on day 6 following administration (D). No indication of new infection was found after drug-induced fever. (E). No obvious focus was seen on CT scan 3 months after discharge (F).
Intravenous piperacillin-tazobactam apparently further improved the patient's symptoms and CT appearance. His body temperature remained normal for 10 days. However, 17 days after continuous treatment with piperacillin-tazobactam, the patient suddenly developed a high fever with a body temperature of 38.5℃ and did not complain of any other symptoms. Detailed physical examination did not reveal any abnormal findings. Blood samples were taken for culture. Repeated chest CT did not show any deterioration or was suggestive of a new infection for the recurrence of fever. Laboratory analysis indicated reduced platelets (66×109/L) compared with the initial level (figure 2). On the following days, the patient also had eosinophilia (1.36×109/L) and liver function abnormality (alanine aminotransferase (ALT) 78 U/L, aspartate aminotransferase (AST) 223 U/L). Potential viral infection of the upper respiratory tract was excluded.
Figure 2 The development of eosinophilia, thrombocytopenia and liver function test abnormality during the course of piperacillin-tazobactam treatment with normal values for white cell count. Blood counts of eosinophils and platelets returned to normal levels after cessation of piperacillin-tazobactam on day 14 following initiation. Liver parameters returned to normal after 1 week following cessation of piperacillin-tazobactam treatment. PCT, procalcitonin.
The piperacillin-tazobactam was suspected to be the most likely cause of the recurrent fever, eosinophilia, thrombocytopenia and hepatic abnormalities, and hence was stopped. The fever quickly resolved within 24 hours following the termination of piperacillin-tazobactam treatment and did not recur afterwards. Platelet and eosinophil counts normalised on day 3 and day 7 after cessation of piperacillin-tazobactam, respectively. The parameters of hepatic function declined nearly to normal levels after a week following piperacillin-tazobactam cessation. The patient did not receive any additional medication (including antibiotic therapy) for the recurrent fever until discharge, and underwent supportive treatment without any complications.
Investigations
This is an uncommon case of adverse drug response caused by piperacillin-tazobactam. Previous reports have revealed several cases of haematological abnormalities that were suspected as probably being piperacillin-tazobactam-induced side effects, including neutropenia, thrombocytopenia or anaemia.8 9 Other reports showed that eosinophilia with systemic symptoms are regarded as kinds of adverse effects caused by the antibiotics.5 10 In our work, we found a special case of delayed thrombocytopenia and eosinophilia that occurred simultaneously after the use of piperacillin-tazobactam for the treatment of S. aureus pneumonia. The patient’s laboratory and clinical factors did not show evidence of latent infection in other locations. The possibile involvement of the upper respiratory tract was excluded.
Treatment
The patient' diagnosis was S. aureus pneumonia, complicated by pulmonary abscesses. The use of intravenous piperacillin-tazobactam apparently improved the patient's symptoms and CT appearance. Although the patient developed fever, eosinophilia, thrombocytopenia and liver damage caused by the treatment, the unusual syndromes gradually disappeared after cessation of piperacillin-tazobactama.
Outcome and follow-up
The fever resolved within 24 hours after stopping piperacillin-tazobactam treatment. The platelet and eosinophil counts both returned to normal after the cessation of piperacillin-tazobactam. The parameters of hepatic function also declined nearly to normal levels following treatment termination.
Discussion
In the present case, the patient started to show the side effects of fever, thrombocytopenia and eosinophilia after 17 days of piperacillin-tazobactam treatment. This is similar to previous reports in which drug induced-fever and associated adverse effects occurred from 11 to 17 days after the initiation of piperacillin-tazobactam administration. We have experienced this several times and have described this as the ‘dangerous period’ for piperacillin-tazobactam-induced fever. Consequently we stopped piperacillin-tazobactam therapy immediately without starting any other antibiotics or medication. Fortunately, this patient's fever disappeared within 24 hours of the piperacillin-tazobactam therapy being discontinued. Although the patient's blood CRP and procalcitonin increased in tandem with the fever, they soon declined on day 3 after the termination of piperacillin-tazobactam therapy. Based on the evidence, we believe there is a correlation between the described side effects and piperacillin-tazobactam therapy.
It has been reported in some cases that piperacillin-tazobactam-induced fever is regarded as a hypersensitivity reaction. Fever, eosinophilia, thrombocytopenia and liver damage are all part of the drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome.5 DRESS syndrome is a life-threatening, rare adverse effect that frequently develops following exposure to antibiotics or antiepileptics, which is characterised by fever, rash, elevated liver enzyme levels, and leukocytosis with eosinophilia.11 The RegiSCAR (European Register of Severe Cutaneous Adverse Reactions) is a scoring system which is most commonly used to categorise cases of DRESS into four groups: no case, possible case, probable case and definite case. Our patient presented several of the described features including fever, eosinophilia and elevated liver enzymes. Typical rash and enlarged lymph nodes were not detected in our patient. Use of the RegiSCAR indicated a possible relationship (score of 3) between our patient’s manifestation of DRESS syndrome and treatment with piperacillin-tazobactam.12
Our patient’s presentation of a fever and an elevated CRP lasting for a transient period evoked a suspicion of latent viral and haematological infection probably after prolonged use of piperacillin-tazobactam. However, no other probable aetiology of eosinophilia could be identified, and the eosinophil abnormality associated with administration of piperacillin-tazobactam resolved soon after the termination of antibiotic therapy. We reasoned that the eosinophilia was probably related to piperacillin-tazobactam as a non-immediate DHR. The mechanism of piperacillin-tazobactam-induced eosinophilia is not entirely understood, but one theory is that activation of interleukin-5 (IL-5) on accumulation of toxic metabolites could cause activation of eosinophils and inflammatory cascades.13 Although there is no accurate diagnostic test or pathognomonic sign, the diagnosis of DRESS syndrome should be considered after exposure to piperacillin-tazobactam for longer than 2 weeks.
Bone marrow suppression is a rare and serious adverse effect of piperacillin-tazobactam, and it has been reported that abnormalities occurred after 2 weeks of prolonged antibiotic use.8 The most common abnormality is neutropenia that is often accompanied with thrombocytopenia. Thrombocytopenia rarely develops alone. Thus, we demonstrate an unusual isolated thrombocytopenia after a long course of piperacillin-tazobactam. To our knowledge, isolated thrombocytopenia is thought likely to be due to an immune-mediated reaction induced by drug administration that occurs suddenly and precipitously. Bose et al described a case of abrupt and severe thrombocytopenia within 2 days of piperacillin-tazobactam administration.14 The patient had a positive test for immunoglobulin G (IgG) antiplatelet antibodies to piperacillin-tazobactam therapy, supporting the speculation of immune-related thrombocytopenia. Alzahrani et al reported two cases of possible immune thrombocytopenia that developed rapidly and severely in association with re-exposure to piperacillin-tazobactam.15 Also the platelet count in peripheral blood improved after the discontinuation of piperacillin-tazobactam and the initiation of corticosteroid therapy, suggesting the possibility of immune-mediated thrombocytopenia.
In our case, the patient developed wild thrombocytopenia without any positive results of auto-immune antibodies or change in complement C3. Since we stopped piperacillin-tazobactam immediately after the side effect occurred, the thrombocytopenia quickly resolved without corticosteroid therapy. It has been suggested that this later-onset thrombocytopenia is dependent on a delayed-type hypersensitivity. Among antibiotics, the beta-lactam antibiotics are a common cause of immune thrombocytopenia, while a beta-lactam-beta-lactamase inhibitor combination, such as piperacillin-tazobactam, has rarely been reported to induce immune-mediated thrombocytopenia. The aetiology of drug-induced immune thrombocytopenia is complex and the mechanism of piperacillin-related thrombocytopenia is possibly associated with hapten-induced antibodies. Some studies have suggested that small molecules like drugs might induce an immune response when linked to macromolecules such as proteins. The combination acts as a hapten and triggers a humoral immune response. On re-exposure to the drug, this leads to platelet destruction and this mechanism may explain the haemolytic anaemia.16 Another report revealed that piperacillin can induce hapten-specific antibodies that are reactive with piperacillin-coated blood cells.17 This similar mechanism may account for the thrombocytopenia that is rarely seen in patients after treatment with piperacillin, but this still needs further confirmation experimentally. An explanation whereby the later-onset thrombocytopenia caused by piperacillin-tazobactam likely occurs as a result of direct toxicity of myeloid precursors should not be excluded.
Moreover, our patient also manifested liver dysfunction, having previously had normal liver function, while the haematological abnormality appeared after the onset of drug-induced fever, and the hepatic value returned to the normal level 1 week after drug cessation. Although hepatic dysfunction has been reported previously in patients on piperacillin-tazobactam therapy, there is no apparent relationship with mortality or progression. Saloojee et al showed that among 225 critically ill patients enrolled in a retrospective study, piperacillin-tazobactam was found to be associated with hepatic dysfunction18. McDonald et al showed there were no significant differences between the high-dose and licensed dose of piperacillin-tazobactam therapy in terms of hepatotoxicity.19 Another report indicates that the beta-lactamantibiotics may induce leucopenia in sever liver dysfunction.20 In the present case, there was no other explanation for this complication except for the exposure to piperacillin-tazobactam as there was no evidence of sepsis, or other responsible drugs. We speculated that the hepatic dysfunction was associated with antibiotic use.
In conclusion, this is the first description of an unusual case of fever, eosinophilia, thrombocytopenia and liver damage induced by piperacillin-tazobactam. The antibiotic-induced fever may precede bone marrow suppression. Eosinophilia is a rare adverse effect of piperacillin-tazobactam and caution is needed regarding the DRESS syndrome in patients with long duration of piperacillin-tazobactam treatment.
Learning points
This is an unusual case of adverse effects induced by long-term use of piperacillin-tazobactam that has not been observed previously for methicillin-sensitive Staphylococcus aureus.
Eosinophilia is rarely seen following piperacillin-tazobactam treatment, especially accompanying other adverse effects simultaneously.
Clinicians should be aware of possible adverse effects in patients receiving long-term antibiotic treatment.
Data availability statement
All data relevant to the study are included in the article.
Ethics statements
Patient consent for publication
Parental/guardian consent obtained.
Contributors: JL: overall manuscript writing and interpretation. GW and FZ: interpretation of results. XS: manuscript modification and submission.
Funding: This study was funded by National Natural Science Foundation of China (82070011, 81670073), Jiangsu Commission of Health (K2019004) and "333 project" of Jiangsu Province (BRA2019339).
Competing interests: None declared.
Provenance and peer review: Not commissioned; externally peer reviewed. | Recovered | ReactionOutcome | CC BY-NC | 33558219 | 18,987,367 | 2021-02-08 |
What was the outcome of reaction 'Thrombocytopenia'? | An unusual case of piperacillin-tazobactam-induced fever, eosinophilia, thrombocytopenia and liver damage.
Piperacillin-tazobactam is a broad-spectrum antimicrobial agent that is commonly used in clinical practice. The development of delayed drug hypersensitivity reaction (DHR) has been reported in several cases previously. Here we describe an unusual case of non-immediate DHR due to a prolonged course of piperacillin-tazobactam. We report a 22-year-old man who developed fever, eosinophilia, thrombocytopenia and elevated hepatic enzymes following 17 days of piperacillin-tazobactam for methicillin-sensitive Staphylococcus aureus (MSSA) pneumonia. These adverse reactions were reversed immediately after antibiotic cessation. Our case highlights that clinicians should be aware of delayed adverse effects in patients receiving long-term piperacillin-tazobactam treatment.
pmcBackground
Piperacillin-tazobactam is a combination formulation of an ureidopenicillin and a beta-lactamase inhibitor with a broad spectrum of antibacterial activity.1 2 It is effective for the treatment of patients with polymicrobial infection caused by many Gram-negative, Gram-positive and beta-lactamase-producing bacteria, such as complicated nosocomial and intra-abdominal infections, and also is regarded as empiric therapy for patients who present with fever and neutropenia.3
As a typical antibiotic, piperacillin-tazobactam is considered safe and well tolerated. However, some adverse reactions have been reported. The most frequent complications include diarrhoea and hepatic dysfunction.4 Eosinophilia with fever and haematological abnormality have been described as severe adverse effects of piperacillin-tazobactam, and are also characteristically regarded as part of the non-immediate drug hypersensitivity reactions (DHRs).5 6 Non-immediate DHRs tend to occur in patients receiving piperacillin-tazobactam therapy over 10 days.7 Here we report an unusual case of a non-immediate DHR reaction to piperacillin-tazobactam.
Case presentation
A previously healthy 22-year-old man presented at our emergency room in January 2020 with high fever (up to 40℃) for a week, accompanied with cough and expectoration. He had 3- year history of smoking without intravenous drug abuse. Physical examination revealed: body temperature 39.5℃; blood pressure 101/54 mmHg and tachypnea of 28 breaths/minute. There were no signs of wounds or skin abscesses. No obvious rhonchi was heard at bilateral lungs and no murmurs were audible in the cardiac valve areas. Initial laboratory tests in the emergency room included: white blood cell count 30.45×109/L, neutrophils 26.95×109/L, platelets 469×109/L, C-reactive protein (CRP) 78 mg/L (normal range 0–8 mg/L) and lactate dehydrogenase (LDH) 657 U/L. Computed tomography (CT) of the chest indicated multiple patchy opacities with cavities. The patient was admitted for further investigation and treatment.
Cardiac ultrasound indicated no signs of bacterial endocarditis. Methicillin-sensitive Staphylococcus aureus (MSSA) was isolated from sputum. Repeated blood cultures were negative. HIV and hepatitis B virus tests were negative. Tests for active and latent tuberculosis, including mycobacterium cultures of sputum samples and the interferon-γ release test for tuberculosis infection, were negative. Chest CT showed multiple dense consolidation with cavities at both side of the lungs and also indicated some cavities with gas-liquid level formation inside pulmonary abscesses (figure 1). A small quantity of pleural effusion presented on the scan. No obvious abnormality was found on abdominal CT. A diagnosis was made of S. aureus pneumonia, complicated by pulmonary abscess. Initially the patient empirically received intravenous vancomycin, 1 g twice daily, and imipenem 1 g every 6 hours. Three days later the patient’s body temperature had markedly decreased. Give the presence of MSSA and abnormality of liver function, antimicrobial therapy was switched to intravenous piperacillin-tazobactam 4.5 g every 8 hours per day.
Figure 1 Computed tomography (CT) images of a 22-year-old patient admitted with Staphylococcus aureus pneumonia in January 2020. CT showed multiple patchy opacities with cavities, some of which had gas-liquid level formation inside in the emergency room (A) and after admission (B). During the initiation of vancomycin and imipenem, slightly absorbed parts of inflammatory lesions were revealed on CT (C). Piperacillin-tazobactam treatment improved the CT findings on day 6 following administration (D). No indication of new infection was found after drug-induced fever. (E). No obvious focus was seen on CT scan 3 months after discharge (F).
Intravenous piperacillin-tazobactam apparently further improved the patient's symptoms and CT appearance. His body temperature remained normal for 10 days. However, 17 days after continuous treatment with piperacillin-tazobactam, the patient suddenly developed a high fever with a body temperature of 38.5℃ and did not complain of any other symptoms. Detailed physical examination did not reveal any abnormal findings. Blood samples were taken for culture. Repeated chest CT did not show any deterioration or was suggestive of a new infection for the recurrence of fever. Laboratory analysis indicated reduced platelets (66×109/L) compared with the initial level (figure 2). On the following days, the patient also had eosinophilia (1.36×109/L) and liver function abnormality (alanine aminotransferase (ALT) 78 U/L, aspartate aminotransferase (AST) 223 U/L). Potential viral infection of the upper respiratory tract was excluded.
Figure 2 The development of eosinophilia, thrombocytopenia and liver function test abnormality during the course of piperacillin-tazobactam treatment with normal values for white cell count. Blood counts of eosinophils and platelets returned to normal levels after cessation of piperacillin-tazobactam on day 14 following initiation. Liver parameters returned to normal after 1 week following cessation of piperacillin-tazobactam treatment. PCT, procalcitonin.
The piperacillin-tazobactam was suspected to be the most likely cause of the recurrent fever, eosinophilia, thrombocytopenia and hepatic abnormalities, and hence was stopped. The fever quickly resolved within 24 hours following the termination of piperacillin-tazobactam treatment and did not recur afterwards. Platelet and eosinophil counts normalised on day 3 and day 7 after cessation of piperacillin-tazobactam, respectively. The parameters of hepatic function declined nearly to normal levels after a week following piperacillin-tazobactam cessation. The patient did not receive any additional medication (including antibiotic therapy) for the recurrent fever until discharge, and underwent supportive treatment without any complications.
Investigations
This is an uncommon case of adverse drug response caused by piperacillin-tazobactam. Previous reports have revealed several cases of haematological abnormalities that were suspected as probably being piperacillin-tazobactam-induced side effects, including neutropenia, thrombocytopenia or anaemia.8 9 Other reports showed that eosinophilia with systemic symptoms are regarded as kinds of adverse effects caused by the antibiotics.5 10 In our work, we found a special case of delayed thrombocytopenia and eosinophilia that occurred simultaneously after the use of piperacillin-tazobactam for the treatment of S. aureus pneumonia. The patient’s laboratory and clinical factors did not show evidence of latent infection in other locations. The possibile involvement of the upper respiratory tract was excluded.
Treatment
The patient' diagnosis was S. aureus pneumonia, complicated by pulmonary abscesses. The use of intravenous piperacillin-tazobactam apparently improved the patient's symptoms and CT appearance. Although the patient developed fever, eosinophilia, thrombocytopenia and liver damage caused by the treatment, the unusual syndromes gradually disappeared after cessation of piperacillin-tazobactama.
Outcome and follow-up
The fever resolved within 24 hours after stopping piperacillin-tazobactam treatment. The platelet and eosinophil counts both returned to normal after the cessation of piperacillin-tazobactam. The parameters of hepatic function also declined nearly to normal levels following treatment termination.
Discussion
In the present case, the patient started to show the side effects of fever, thrombocytopenia and eosinophilia after 17 days of piperacillin-tazobactam treatment. This is similar to previous reports in which drug induced-fever and associated adverse effects occurred from 11 to 17 days after the initiation of piperacillin-tazobactam administration. We have experienced this several times and have described this as the ‘dangerous period’ for piperacillin-tazobactam-induced fever. Consequently we stopped piperacillin-tazobactam therapy immediately without starting any other antibiotics or medication. Fortunately, this patient's fever disappeared within 24 hours of the piperacillin-tazobactam therapy being discontinued. Although the patient's blood CRP and procalcitonin increased in tandem with the fever, they soon declined on day 3 after the termination of piperacillin-tazobactam therapy. Based on the evidence, we believe there is a correlation between the described side effects and piperacillin-tazobactam therapy.
It has been reported in some cases that piperacillin-tazobactam-induced fever is regarded as a hypersensitivity reaction. Fever, eosinophilia, thrombocytopenia and liver damage are all part of the drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome.5 DRESS syndrome is a life-threatening, rare adverse effect that frequently develops following exposure to antibiotics or antiepileptics, which is characterised by fever, rash, elevated liver enzyme levels, and leukocytosis with eosinophilia.11 The RegiSCAR (European Register of Severe Cutaneous Adverse Reactions) is a scoring system which is most commonly used to categorise cases of DRESS into four groups: no case, possible case, probable case and definite case. Our patient presented several of the described features including fever, eosinophilia and elevated liver enzymes. Typical rash and enlarged lymph nodes were not detected in our patient. Use of the RegiSCAR indicated a possible relationship (score of 3) between our patient’s manifestation of DRESS syndrome and treatment with piperacillin-tazobactam.12
Our patient’s presentation of a fever and an elevated CRP lasting for a transient period evoked a suspicion of latent viral and haematological infection probably after prolonged use of piperacillin-tazobactam. However, no other probable aetiology of eosinophilia could be identified, and the eosinophil abnormality associated with administration of piperacillin-tazobactam resolved soon after the termination of antibiotic therapy. We reasoned that the eosinophilia was probably related to piperacillin-tazobactam as a non-immediate DHR. The mechanism of piperacillin-tazobactam-induced eosinophilia is not entirely understood, but one theory is that activation of interleukin-5 (IL-5) on accumulation of toxic metabolites could cause activation of eosinophils and inflammatory cascades.13 Although there is no accurate diagnostic test or pathognomonic sign, the diagnosis of DRESS syndrome should be considered after exposure to piperacillin-tazobactam for longer than 2 weeks.
Bone marrow suppression is a rare and serious adverse effect of piperacillin-tazobactam, and it has been reported that abnormalities occurred after 2 weeks of prolonged antibiotic use.8 The most common abnormality is neutropenia that is often accompanied with thrombocytopenia. Thrombocytopenia rarely develops alone. Thus, we demonstrate an unusual isolated thrombocytopenia after a long course of piperacillin-tazobactam. To our knowledge, isolated thrombocytopenia is thought likely to be due to an immune-mediated reaction induced by drug administration that occurs suddenly and precipitously. Bose et al described a case of abrupt and severe thrombocytopenia within 2 days of piperacillin-tazobactam administration.14 The patient had a positive test for immunoglobulin G (IgG) antiplatelet antibodies to piperacillin-tazobactam therapy, supporting the speculation of immune-related thrombocytopenia. Alzahrani et al reported two cases of possible immune thrombocytopenia that developed rapidly and severely in association with re-exposure to piperacillin-tazobactam.15 Also the platelet count in peripheral blood improved after the discontinuation of piperacillin-tazobactam and the initiation of corticosteroid therapy, suggesting the possibility of immune-mediated thrombocytopenia.
In our case, the patient developed wild thrombocytopenia without any positive results of auto-immune antibodies or change in complement C3. Since we stopped piperacillin-tazobactam immediately after the side effect occurred, the thrombocytopenia quickly resolved without corticosteroid therapy. It has been suggested that this later-onset thrombocytopenia is dependent on a delayed-type hypersensitivity. Among antibiotics, the beta-lactam antibiotics are a common cause of immune thrombocytopenia, while a beta-lactam-beta-lactamase inhibitor combination, such as piperacillin-tazobactam, has rarely been reported to induce immune-mediated thrombocytopenia. The aetiology of drug-induced immune thrombocytopenia is complex and the mechanism of piperacillin-related thrombocytopenia is possibly associated with hapten-induced antibodies. Some studies have suggested that small molecules like drugs might induce an immune response when linked to macromolecules such as proteins. The combination acts as a hapten and triggers a humoral immune response. On re-exposure to the drug, this leads to platelet destruction and this mechanism may explain the haemolytic anaemia.16 Another report revealed that piperacillin can induce hapten-specific antibodies that are reactive with piperacillin-coated blood cells.17 This similar mechanism may account for the thrombocytopenia that is rarely seen in patients after treatment with piperacillin, but this still needs further confirmation experimentally. An explanation whereby the later-onset thrombocytopenia caused by piperacillin-tazobactam likely occurs as a result of direct toxicity of myeloid precursors should not be excluded.
Moreover, our patient also manifested liver dysfunction, having previously had normal liver function, while the haematological abnormality appeared after the onset of drug-induced fever, and the hepatic value returned to the normal level 1 week after drug cessation. Although hepatic dysfunction has been reported previously in patients on piperacillin-tazobactam therapy, there is no apparent relationship with mortality or progression. Saloojee et al showed that among 225 critically ill patients enrolled in a retrospective study, piperacillin-tazobactam was found to be associated with hepatic dysfunction18. McDonald et al showed there were no significant differences between the high-dose and licensed dose of piperacillin-tazobactam therapy in terms of hepatotoxicity.19 Another report indicates that the beta-lactamantibiotics may induce leucopenia in sever liver dysfunction.20 In the present case, there was no other explanation for this complication except for the exposure to piperacillin-tazobactam as there was no evidence of sepsis, or other responsible drugs. We speculated that the hepatic dysfunction was associated with antibiotic use.
In conclusion, this is the first description of an unusual case of fever, eosinophilia, thrombocytopenia and liver damage induced by piperacillin-tazobactam. The antibiotic-induced fever may precede bone marrow suppression. Eosinophilia is a rare adverse effect of piperacillin-tazobactam and caution is needed regarding the DRESS syndrome in patients with long duration of piperacillin-tazobactam treatment.
Learning points
This is an unusual case of adverse effects induced by long-term use of piperacillin-tazobactam that has not been observed previously for methicillin-sensitive Staphylococcus aureus.
Eosinophilia is rarely seen following piperacillin-tazobactam treatment, especially accompanying other adverse effects simultaneously.
Clinicians should be aware of possible adverse effects in patients receiving long-term antibiotic treatment.
Data availability statement
All data relevant to the study are included in the article.
Ethics statements
Patient consent for publication
Parental/guardian consent obtained.
Contributors: JL: overall manuscript writing and interpretation. GW and FZ: interpretation of results. XS: manuscript modification and submission.
Funding: This study was funded by National Natural Science Foundation of China (82070011, 81670073), Jiangsu Commission of Health (K2019004) and "333 project" of Jiangsu Province (BRA2019339).
Competing interests: None declared.
Provenance and peer review: Not commissioned; externally peer reviewed. | Recovered | ReactionOutcome | CC BY-NC | 33558219 | 18,987,367 | 2021-02-08 |
What was the outcome of reaction 'Type IV hypersensitivity reaction'? | An unusual case of piperacillin-tazobactam-induced fever, eosinophilia, thrombocytopenia and liver damage.
Piperacillin-tazobactam is a broad-spectrum antimicrobial agent that is commonly used in clinical practice. The development of delayed drug hypersensitivity reaction (DHR) has been reported in several cases previously. Here we describe an unusual case of non-immediate DHR due to a prolonged course of piperacillin-tazobactam. We report a 22-year-old man who developed fever, eosinophilia, thrombocytopenia and elevated hepatic enzymes following 17 days of piperacillin-tazobactam for methicillin-sensitive Staphylococcus aureus (MSSA) pneumonia. These adverse reactions were reversed immediately after antibiotic cessation. Our case highlights that clinicians should be aware of delayed adverse effects in patients receiving long-term piperacillin-tazobactam treatment.
pmcBackground
Piperacillin-tazobactam is a combination formulation of an ureidopenicillin and a beta-lactamase inhibitor with a broad spectrum of antibacterial activity.1 2 It is effective for the treatment of patients with polymicrobial infection caused by many Gram-negative, Gram-positive and beta-lactamase-producing bacteria, such as complicated nosocomial and intra-abdominal infections, and also is regarded as empiric therapy for patients who present with fever and neutropenia.3
As a typical antibiotic, piperacillin-tazobactam is considered safe and well tolerated. However, some adverse reactions have been reported. The most frequent complications include diarrhoea and hepatic dysfunction.4 Eosinophilia with fever and haematological abnormality have been described as severe adverse effects of piperacillin-tazobactam, and are also characteristically regarded as part of the non-immediate drug hypersensitivity reactions (DHRs).5 6 Non-immediate DHRs tend to occur in patients receiving piperacillin-tazobactam therapy over 10 days.7 Here we report an unusual case of a non-immediate DHR reaction to piperacillin-tazobactam.
Case presentation
A previously healthy 22-year-old man presented at our emergency room in January 2020 with high fever (up to 40℃) for a week, accompanied with cough and expectoration. He had 3- year history of smoking without intravenous drug abuse. Physical examination revealed: body temperature 39.5℃; blood pressure 101/54 mmHg and tachypnea of 28 breaths/minute. There were no signs of wounds or skin abscesses. No obvious rhonchi was heard at bilateral lungs and no murmurs were audible in the cardiac valve areas. Initial laboratory tests in the emergency room included: white blood cell count 30.45×109/L, neutrophils 26.95×109/L, platelets 469×109/L, C-reactive protein (CRP) 78 mg/L (normal range 0–8 mg/L) and lactate dehydrogenase (LDH) 657 U/L. Computed tomography (CT) of the chest indicated multiple patchy opacities with cavities. The patient was admitted for further investigation and treatment.
Cardiac ultrasound indicated no signs of bacterial endocarditis. Methicillin-sensitive Staphylococcus aureus (MSSA) was isolated from sputum. Repeated blood cultures were negative. HIV and hepatitis B virus tests were negative. Tests for active and latent tuberculosis, including mycobacterium cultures of sputum samples and the interferon-γ release test for tuberculosis infection, were negative. Chest CT showed multiple dense consolidation with cavities at both side of the lungs and also indicated some cavities with gas-liquid level formation inside pulmonary abscesses (figure 1). A small quantity of pleural effusion presented on the scan. No obvious abnormality was found on abdominal CT. A diagnosis was made of S. aureus pneumonia, complicated by pulmonary abscess. Initially the patient empirically received intravenous vancomycin, 1 g twice daily, and imipenem 1 g every 6 hours. Three days later the patient’s body temperature had markedly decreased. Give the presence of MSSA and abnormality of liver function, antimicrobial therapy was switched to intravenous piperacillin-tazobactam 4.5 g every 8 hours per day.
Figure 1 Computed tomography (CT) images of a 22-year-old patient admitted with Staphylococcus aureus pneumonia in January 2020. CT showed multiple patchy opacities with cavities, some of which had gas-liquid level formation inside in the emergency room (A) and after admission (B). During the initiation of vancomycin and imipenem, slightly absorbed parts of inflammatory lesions were revealed on CT (C). Piperacillin-tazobactam treatment improved the CT findings on day 6 following administration (D). No indication of new infection was found after drug-induced fever. (E). No obvious focus was seen on CT scan 3 months after discharge (F).
Intravenous piperacillin-tazobactam apparently further improved the patient's symptoms and CT appearance. His body temperature remained normal for 10 days. However, 17 days after continuous treatment with piperacillin-tazobactam, the patient suddenly developed a high fever with a body temperature of 38.5℃ and did not complain of any other symptoms. Detailed physical examination did not reveal any abnormal findings. Blood samples were taken for culture. Repeated chest CT did not show any deterioration or was suggestive of a new infection for the recurrence of fever. Laboratory analysis indicated reduced platelets (66×109/L) compared with the initial level (figure 2). On the following days, the patient also had eosinophilia (1.36×109/L) and liver function abnormality (alanine aminotransferase (ALT) 78 U/L, aspartate aminotransferase (AST) 223 U/L). Potential viral infection of the upper respiratory tract was excluded.
Figure 2 The development of eosinophilia, thrombocytopenia and liver function test abnormality during the course of piperacillin-tazobactam treatment with normal values for white cell count. Blood counts of eosinophils and platelets returned to normal levels after cessation of piperacillin-tazobactam on day 14 following initiation. Liver parameters returned to normal after 1 week following cessation of piperacillin-tazobactam treatment. PCT, procalcitonin.
The piperacillin-tazobactam was suspected to be the most likely cause of the recurrent fever, eosinophilia, thrombocytopenia and hepatic abnormalities, and hence was stopped. The fever quickly resolved within 24 hours following the termination of piperacillin-tazobactam treatment and did not recur afterwards. Platelet and eosinophil counts normalised on day 3 and day 7 after cessation of piperacillin-tazobactam, respectively. The parameters of hepatic function declined nearly to normal levels after a week following piperacillin-tazobactam cessation. The patient did not receive any additional medication (including antibiotic therapy) for the recurrent fever until discharge, and underwent supportive treatment without any complications.
Investigations
This is an uncommon case of adverse drug response caused by piperacillin-tazobactam. Previous reports have revealed several cases of haematological abnormalities that were suspected as probably being piperacillin-tazobactam-induced side effects, including neutropenia, thrombocytopenia or anaemia.8 9 Other reports showed that eosinophilia with systemic symptoms are regarded as kinds of adverse effects caused by the antibiotics.5 10 In our work, we found a special case of delayed thrombocytopenia and eosinophilia that occurred simultaneously after the use of piperacillin-tazobactam for the treatment of S. aureus pneumonia. The patient’s laboratory and clinical factors did not show evidence of latent infection in other locations. The possibile involvement of the upper respiratory tract was excluded.
Treatment
The patient' diagnosis was S. aureus pneumonia, complicated by pulmonary abscesses. The use of intravenous piperacillin-tazobactam apparently improved the patient's symptoms and CT appearance. Although the patient developed fever, eosinophilia, thrombocytopenia and liver damage caused by the treatment, the unusual syndromes gradually disappeared after cessation of piperacillin-tazobactama.
Outcome and follow-up
The fever resolved within 24 hours after stopping piperacillin-tazobactam treatment. The platelet and eosinophil counts both returned to normal after the cessation of piperacillin-tazobactam. The parameters of hepatic function also declined nearly to normal levels following treatment termination.
Discussion
In the present case, the patient started to show the side effects of fever, thrombocytopenia and eosinophilia after 17 days of piperacillin-tazobactam treatment. This is similar to previous reports in which drug induced-fever and associated adverse effects occurred from 11 to 17 days after the initiation of piperacillin-tazobactam administration. We have experienced this several times and have described this as the ‘dangerous period’ for piperacillin-tazobactam-induced fever. Consequently we stopped piperacillin-tazobactam therapy immediately without starting any other antibiotics or medication. Fortunately, this patient's fever disappeared within 24 hours of the piperacillin-tazobactam therapy being discontinued. Although the patient's blood CRP and procalcitonin increased in tandem with the fever, they soon declined on day 3 after the termination of piperacillin-tazobactam therapy. Based on the evidence, we believe there is a correlation between the described side effects and piperacillin-tazobactam therapy.
It has been reported in some cases that piperacillin-tazobactam-induced fever is regarded as a hypersensitivity reaction. Fever, eosinophilia, thrombocytopenia and liver damage are all part of the drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome.5 DRESS syndrome is a life-threatening, rare adverse effect that frequently develops following exposure to antibiotics or antiepileptics, which is characterised by fever, rash, elevated liver enzyme levels, and leukocytosis with eosinophilia.11 The RegiSCAR (European Register of Severe Cutaneous Adverse Reactions) is a scoring system which is most commonly used to categorise cases of DRESS into four groups: no case, possible case, probable case and definite case. Our patient presented several of the described features including fever, eosinophilia and elevated liver enzymes. Typical rash and enlarged lymph nodes were not detected in our patient. Use of the RegiSCAR indicated a possible relationship (score of 3) between our patient’s manifestation of DRESS syndrome and treatment with piperacillin-tazobactam.12
Our patient’s presentation of a fever and an elevated CRP lasting for a transient period evoked a suspicion of latent viral and haematological infection probably after prolonged use of piperacillin-tazobactam. However, no other probable aetiology of eosinophilia could be identified, and the eosinophil abnormality associated with administration of piperacillin-tazobactam resolved soon after the termination of antibiotic therapy. We reasoned that the eosinophilia was probably related to piperacillin-tazobactam as a non-immediate DHR. The mechanism of piperacillin-tazobactam-induced eosinophilia is not entirely understood, but one theory is that activation of interleukin-5 (IL-5) on accumulation of toxic metabolites could cause activation of eosinophils and inflammatory cascades.13 Although there is no accurate diagnostic test or pathognomonic sign, the diagnosis of DRESS syndrome should be considered after exposure to piperacillin-tazobactam for longer than 2 weeks.
Bone marrow suppression is a rare and serious adverse effect of piperacillin-tazobactam, and it has been reported that abnormalities occurred after 2 weeks of prolonged antibiotic use.8 The most common abnormality is neutropenia that is often accompanied with thrombocytopenia. Thrombocytopenia rarely develops alone. Thus, we demonstrate an unusual isolated thrombocytopenia after a long course of piperacillin-tazobactam. To our knowledge, isolated thrombocytopenia is thought likely to be due to an immune-mediated reaction induced by drug administration that occurs suddenly and precipitously. Bose et al described a case of abrupt and severe thrombocytopenia within 2 days of piperacillin-tazobactam administration.14 The patient had a positive test for immunoglobulin G (IgG) antiplatelet antibodies to piperacillin-tazobactam therapy, supporting the speculation of immune-related thrombocytopenia. Alzahrani et al reported two cases of possible immune thrombocytopenia that developed rapidly and severely in association with re-exposure to piperacillin-tazobactam.15 Also the platelet count in peripheral blood improved after the discontinuation of piperacillin-tazobactam and the initiation of corticosteroid therapy, suggesting the possibility of immune-mediated thrombocytopenia.
In our case, the patient developed wild thrombocytopenia without any positive results of auto-immune antibodies or change in complement C3. Since we stopped piperacillin-tazobactam immediately after the side effect occurred, the thrombocytopenia quickly resolved without corticosteroid therapy. It has been suggested that this later-onset thrombocytopenia is dependent on a delayed-type hypersensitivity. Among antibiotics, the beta-lactam antibiotics are a common cause of immune thrombocytopenia, while a beta-lactam-beta-lactamase inhibitor combination, such as piperacillin-tazobactam, has rarely been reported to induce immune-mediated thrombocytopenia. The aetiology of drug-induced immune thrombocytopenia is complex and the mechanism of piperacillin-related thrombocytopenia is possibly associated with hapten-induced antibodies. Some studies have suggested that small molecules like drugs might induce an immune response when linked to macromolecules such as proteins. The combination acts as a hapten and triggers a humoral immune response. On re-exposure to the drug, this leads to platelet destruction and this mechanism may explain the haemolytic anaemia.16 Another report revealed that piperacillin can induce hapten-specific antibodies that are reactive with piperacillin-coated blood cells.17 This similar mechanism may account for the thrombocytopenia that is rarely seen in patients after treatment with piperacillin, but this still needs further confirmation experimentally. An explanation whereby the later-onset thrombocytopenia caused by piperacillin-tazobactam likely occurs as a result of direct toxicity of myeloid precursors should not be excluded.
Moreover, our patient also manifested liver dysfunction, having previously had normal liver function, while the haematological abnormality appeared after the onset of drug-induced fever, and the hepatic value returned to the normal level 1 week after drug cessation. Although hepatic dysfunction has been reported previously in patients on piperacillin-tazobactam therapy, there is no apparent relationship with mortality or progression. Saloojee et al showed that among 225 critically ill patients enrolled in a retrospective study, piperacillin-tazobactam was found to be associated with hepatic dysfunction18. McDonald et al showed there were no significant differences between the high-dose and licensed dose of piperacillin-tazobactam therapy in terms of hepatotoxicity.19 Another report indicates that the beta-lactamantibiotics may induce leucopenia in sever liver dysfunction.20 In the present case, there was no other explanation for this complication except for the exposure to piperacillin-tazobactam as there was no evidence of sepsis, or other responsible drugs. We speculated that the hepatic dysfunction was associated with antibiotic use.
In conclusion, this is the first description of an unusual case of fever, eosinophilia, thrombocytopenia and liver damage induced by piperacillin-tazobactam. The antibiotic-induced fever may precede bone marrow suppression. Eosinophilia is a rare adverse effect of piperacillin-tazobactam and caution is needed regarding the DRESS syndrome in patients with long duration of piperacillin-tazobactam treatment.
Learning points
This is an unusual case of adverse effects induced by long-term use of piperacillin-tazobactam that has not been observed previously for methicillin-sensitive Staphylococcus aureus.
Eosinophilia is rarely seen following piperacillin-tazobactam treatment, especially accompanying other adverse effects simultaneously.
Clinicians should be aware of possible adverse effects in patients receiving long-term antibiotic treatment.
Data availability statement
All data relevant to the study are included in the article.
Ethics statements
Patient consent for publication
Parental/guardian consent obtained.
Contributors: JL: overall manuscript writing and interpretation. GW and FZ: interpretation of results. XS: manuscript modification and submission.
Funding: This study was funded by National Natural Science Foundation of China (82070011, 81670073), Jiangsu Commission of Health (K2019004) and "333 project" of Jiangsu Province (BRA2019339).
Competing interests: None declared.
Provenance and peer review: Not commissioned; externally peer reviewed. | Recovered | ReactionOutcome | CC BY-NC | 33558219 | 18,987,367 | 2021-02-08 |
Give an alphabetized list of all active substances of drugs taken by the patient who experienced 'Cytokine release syndrome'. | Biallelic loss of BCMA as a resistance mechanism to CAR T cell therapy in a patient with multiple myeloma.
BCMA targeting chimeric antigen receptor (CAR) T cell therapy has shown deep and durable responses in multiple myeloma. However, relapse following therapy is frequently observed, and mechanisms of resistance remain ill-defined. Here, we perform single cell genomic characterization of longitudinal samples from a patient who relapsed after initial CAR T cell treatment with lack of response to retreatment. We report selection, following initial CAR T cell infusion, of a clone with biallelic loss of BCMA acquired by deletion of one allele and a mutation that creates an early stop codon on the second allele. This loss leads to lack of CAR T cell proliferation following the second infusion and is reflected by lack of soluble BCMA in patient serum. Our analysis suggests the need for careful detection of BCMA gene alterations in multiple myeloma cells from relapse following CAR T cell therapy.
Introduction
Chimeric antigen receptor (CAR) T-cell therapy targeting B-cell maturation antigen (BCMA) has provided frequent, deep, and durable responses in relapsed, refractory multiple myeloma (MM), with initial Phase I/II studies reporting 73–100% overall response and 31–69% complete response1–3. However, progression-free survival in some studies have been <12 months, indicating myeloma recurrence despite the persistence of CAR T cells in a number of cases1,2. Importantly, among the small number of patients retreated with the same CAR T cell product at the time of progression, responses have been infrequent4,5. This highlights development of acquired resistance mechanisms6,7, which may preclude effectiveness of the second CAR T infusion, and may also explain relapse following the initial CAR T-cell therapy.
In this work, by performing single-cell transcriptome profiling on serially collected bone marrow (BM) samples, we show biallelic loss of BCMA as one of the resistance mechanisms to anti-BCMA CAR T-cell therapy with Idecabtagene Vicleucel in a patient with initial response but relapse with resistance to retreatment with the same CAR T-cell product. Furthermore, our results also highlight that MM cells may develop alternative paths to survive without BCMA.
Results
We evaluated samples from an individual patient who was diagnosed with IgG lambda MM with hypodiploidy and a complex karyotype with t(8;12) (q24;q14), clonal t(11;14) (q13;q32), and clonal deletion 13. The patient was treated with four lines of therapy including proteasome inhibitor, immunomodulatory agent, and anti-CD38 antibody before CAR T-cell therapy, with limited response. The patient was enrolled in a Phase I trial (CRB-401 ClinicalTrials.gov number, NCT02658929) of anti-BCMA CAR T-cell therapy with Idecabtagene Vicleucel (ide-cel) and received 150 × 106 CAR+ T cells at day 0 following lymphodepletion with fludarabine (30 mg/m2 per day) and cyclophosphamide (300 mg/m2 per day) on days −5, −4, and −3, as reported in ref. 1. The patient developed grade 1 cytokine release syndrome and achieved partial response by 3 months. The patient relapsed 9 months after the first CAR T infusion and was treated a second time with identical lymphodepletion and using the same CAR T-cell product as the first infusion but at a higher dose of 450 × 106 CAR+ T cells with no response (Fig. 1A, B).Fig. 1 Response to CAR T cell treatment and microenvironment changes.
A M spike and lambda free light chain evaluations for the patient. The y axis on left shows the M spike values (blue) and on the right it shows the lambda free light chain values (green). Time points (x axis) marked with red labels also shows the longitudinal sample collection for single-cell RNA sequencing. B Expansion of CAR T cells (y axis) measured with qPCR after first (blue) and second (red) infusions from day 0 to day 60 (x axis). C Timeline of the eight samples collected for single-cell RNA sequencing. D Thirteen single-cell clusters from eight longitudinal bone marrow samples. Annotation of cell clusters are marked in the bottom part with color codes. Cell embedings are shown by using UMAP1 and UMAP2. E Ide-cel expression in single cells. Only limited number of cells are CAR+ at 2 weeks after the first infusion. None of the other time points show CAR+ cells. F Re-clustered T cells divided by time points from study screening to 1 month after second infusion and T-cell annotations for CD4+ and CD8+ cells are shown with color codes. G Percentage of particular T-cell types (y axis) at each time point (x axis) evaluated with single-cell RNA seqeuecning for T-cell clusters (top figure legend). Percentages are reflecting the % of particular cluster at given time point within all T cell populations. H Gene-set enrichment FDR values for differentially expressed genes for two samples collected two weeks after first (blue) and second (green) infusions. I Percentage of T cells (y axis) expressing immune checkpoint inhibitors at each time point (x axis).
Changes in BM microenvironment post-CAR T-cell therapy
To delineate changes in BM cellular components as a potential mechanism underlying lack of response to CAR T-cell reinfusion, we performed single-cell transcriptome profiling on serially collected BM samples (Fig. 1C). Clustering analysis from 37,658 cells from 8 time points, before the first CAR T cell infusion to 1 month after the second infusion, identified 13 clusters consisting of hematopoietic cells and MM cells (Fig. 1D and Supplementary Fig. 1). The BM sample before the first infusion was depleted of CD138+ cells by cell selection. A small number of MM cells were observed at 2 weeks after the first infusion of the CAR T-cell therapy. Thereafter, MM cells became undetectable and remained undetectable until eight months after the first infusion, when biochemical as well as cytological relapse occurred (Fig. 2A and Supplementary Fig. 1B). We observed a predicted suppression of B-cell count at study entry as an effect of the MM cell growth, with B-cell recovery at 1 month coinciding with anti-MM response (3% of all cells) and reaching 18% at 8 months after first infusion (Supplementary Fig. 1B), and again suppressed to 3% at relapse. We detected CAR+ T cells in the BM only at 2 weeks after first infusion, when maximal CAR+ T-cell expansion was observed in blood using reverse-transcription PCR (RT-PCR)-based detection (Fig. 1B, E). We did not detect infused CAR T cells in the BM with single-cell transcriptome profiling after the second CAR T infusion, but a limited expansion was confirmed in the blood using RT-PCR (Fig. 1E). The 6-log expansion of CAR+ T cells in the blood after the first infusion is consistent with observed expansion in the KarMMA study, where 5.5 log expansion was observed in the responding patients with a median peak CAR+ T-cell expansion at day 112. A lower expansion (2-log) with the second infusion may represent environmental influences or MM-intrinsic factors.Fig. 2 Tumor-intrinsic changes.
A Cell embedings for plasma/multiple myeloma (MM) cells (green colors) and B cells (cream colors) are shown from screening to 2 weeks after second infusion (x axis). B cells are first detected at 1 month after first infusion and increased frequency until relapse. MM cells are detected at the 8 months after first infusion sample and remain same for further time points. B Soluble BCMA (sBCMA) level (y axis) at the study screening, after first infusion, relapse, and after second infusion (x axis) are shown. Time points makerd with * indicates the time points scRNAseq data also available. Screening refers to screening before first infusion (S1). Day 14 and Months 3 are refering to two weeks after first infusion (S2) and 3 months after first infusion (S4). Retreatment Screening is the relapse after first infusion (S6) and Retreatment Day 14 (S7) is 2 weeks after second infusion. C Expression levels of CD138, CCND1, XBP1, and RB1 in multiple myeloma (MM) cells and B cells. Normalized expression level scales are shown with legends. D Copy number predictions for each single cell (columns) from single-cell RNA sequencing data for chromosomal arms (rows). Deletions are shown with blue and gains are shown with red color for MM cells (left) and B cells (right). E Copy number estimates for CD138+ cells after second CAR T-cell infusion using whole exome sequencing. The top panel displays total copy number log-ratio where diploid state is shown with purple line and the second panel displays allele-specific log odds ratio data for allele-specific copy number calls with chromosomes alternating in blue and gray. Third panel shows the corresponding integer (black line for total copy number, red line for minor copy number) copy number calls. The bottom panel shows the predicted clonality of each events. Dark blue colors show regions with colonal copy number alterations and light blue color shows subclonal copy number events. F Percentage (x axis) of single multiple myeloma/plasma cells with various copy number deletions (del) or gains (y axis). Copy number events for each cell predicted using single-cell RNA sequencing. G Somatic mutaitons detected at relapse after second infusion with whole exome sequencing. Nonsense mutation which creates early stop codon in BCMA (top panel) and missense TP53 mutation (bottom panel) are shown in their amino acid locations. Protein domains are shown with color codes in each genes. H Clonal evolution of MM cells from diagnosis to relapse after second CAR T-cell infusion. I Co-occurrences of deletion 17p (del17p) and deletion 16p (del16p) on large-scale MM cohort. Clonal (red color), subclonal (yellow) deletions are shown for newly diagnosed MM patients (columns) and only patients with del16p and/or del17p are shown.
Re-clustering of the T-cell cluster showed an increased proportion of CD4+ helper and T-regulatory cells (Treg) 2 weeks after first infusion (Fig. 1F, G and Supplementary Fig. 2), and these two clusters had high expression of proliferation-related genes (Fig. 1H and Supplementary Data 1 and 2). However, Treg proportion remained similar at the second infusion, ruling out its impact on lack of expansion of CAR+ T cells. To detect any unusual endogenous T-cell activity that may potentially affect CAR T-cell function, we investigated inhibitory markers CD274 (PD-L1), PDCD1 (PD-1), LAG3, TIGIT at early and late time points including after second infusion. As can be seen (Fig. 1I and Supplementary Table 1), at no time point the proportion of the cells expressing these checkpoint inhibitors is higher then the base line. Moreover, the absence of change in these markers on endogenous T cells does not mean that the CAR+ T cells do not express these markers. However, in absence of detectable CAR T cells there is no direct way to look at expressed inhibitory markers on CAR T cells. Therefore, future studies will require investigation of resistance associated with presence of checkpoint inhibitors.
Role of tumor intrinsic factors in resistance
As we did not delineate a role of the BM milieu mediating suppression of CAR T-cell expansion and function following second infusion, we next explored tumor intrinsic factors. We evaluated soluble BCMA (sBCMA) level (produced predominantly by MM cells) in serum at different time points, and observed high levels before the first CAR T cell infusion, which dropped significantly to a very low level coincident with the clinical response; however, sBCMA remained low even at the time of relapse with increased burden of MM, indicating a lack of BCMA production by MM cells (Fig. 2B). We therefore investigated genomic changes in MM cells at the time of relapse. This patient had clonal t(11;14) translocation (96% of all cells) and clonal deletion 13 (94% of all cells) at the time of diagnosis. A similar clonal composition was observed by fluorescence in situ hybridization (FISH) analysis at study enrollment, when 4% of the cells also showed deletion 17p. Our single-cell transcriptomic analysis of BM samples identified three samples (at the time of relapse and post second CAR T-cell infusion) with significant numbers of MM cells, evidenced by expression of CD138 and XBP1 (markers of plasma cells), CCND1 (upregulated in this patient with t(11;14)), and lack of RB1 (downregulated in this patient with del13) (Fig. 2C). Imputation of copy number alterations from single-cell transcriptomic data showed that the majority of MM cells had a deletion of 16p, including the BCMA locus located on 16p13.13. (Fig. 2D). We further validated these findings using deep whole exome sequencing (WES) of purified CD138+ cells collected 2 weeks after the second CAR T infusion. Of note, copy number alterations detected by WES almost completely overlapped with CNAs predicted by single-cell RNA sequencing (scRNAseq), including deletion 16p (Fig. 2E). Before the first CAR T-cell infusion, 4% of BM MM cells showed deletion 17p, whereas after the second infusion both WES and scRNAseq prediction showed that del17p and del16p were clonal, and longitudinal scRNAseq analysis indicated that del17p and del16p co-occurred in the same clone (Fig. 2D, F). Interestingly, WES also identified a high subclonal (~70%) nonsense mutation (p.Q38*) in BCMA that creates an early stop codon in the BCMA gene (Fig. 2G and Supplementary Fig. 3). This biallelic BCMA loss, acquired with one copy deletion and a second copy loss-of-function mutation, provides the molecular basis for lack of BCMA expression in MM cells at the time of relapse.
Discussion
This case represents initial response followed by development of an acquired resistant phenotype as represented by both relapse and then lack of response to second CAR T infusion (Fig. 2H). BCMA represents an important component of plasma cell function, and thus its loss is not frequently observed. However, this case highlights a possibility that myeloma cells may be able to acuire alternative growth mechanisms to survive without BCMA expression and related signaling intermediates. Studies have shown that MM usually shows substantial inter and intra-tumor heterogeneity, which is closely related to progression, resistance to therapy, and recurrences8–12. Loss of several other targets for different treatments, such as CRBN with immunomodulatory agents or BCL-2 with venetoclax, has been associated with resistance to these treatments13,14. A single antigen targeting CAR T-cell treatment may also be affected by the loss of target as a result of tumor evolution and selection. Targeted antigen-negative relapse is one of the main reasons for resistance to CD19-directed CAR T-cell therapy and accounts for ~9–25% of cases of relapse in other hematological cancers3,4,6,7. In addition to antigen loss, immune-mediated rejection of the murine construct may play a role in resistance15. We did observe low level anti-drug antibodies (ADAs) at 6 months post first infusion, which persisted during the retreatment. ADA could have potential impact on CAR T cell expansion following second infusion. However, lack of BCMA expression was likely the predominant factor responsible for lack of response to second infusion. The extent of the role of ADA in this setting will need to be ascertained in a larger cohort of patients in the future. Previously, a large study evaluating CD19-targeted CAR T-cell therapy in B-cell malignincies showed that addition of fludarabine to cyclophosphamide-based lymphodepletion before the first infusion and an increased dose in the second infusion compared to the first infusion would increase the response rate16, both of which were followed in the currect study.
Here we describe emergence of a clone with loss of BCMA target leading to acquired resistance to retreatment. However, as it is equally important and previously shown in other hematological cancers, there are other possible factors such as microenvironmental changes and immune-mediated rejection of the murine construct that may contribute to resistance to CAR T-cell therapies. Here we only report one mechanism with limited power; however, future studies with larger sample size will be able to determine the dominant resistance factors and expected frequency of each mechanism in MM. We also observed a clonal TP53 missense mutation (p.P278T) (Fig. 2G) using WES, suggesting that both TP53 and BCMA had deletion in one allele and mutation in the second allele. We analyzed our data from 300 newly diagnosed MM patients and using a conservative estimate observed del16p in 6% patients (44% were subclonal deletions) and, interestingly, it co-occured with del17p in 77% of the del16p patients (sixfold encrichmnet, hypergeometric test p-value = 3.38e − 11, Fig. 2I). Importantly, we also observed that 36% of patients with del17p also carried del16p. These results support our previous observation regarding similar relative timing for both deletion events8,17, and may highlight the need to carefully examine for BCMA gene alterations in patients being retreated with subsequent BCMA targeting therapy at relapse from initial BCMA CAR T-cell treatment. The co-occurrence of 16p deletion in patients with del 17p also underscores the need to further evaluate the role of BCMA targted therapies in high-risk del17p MM. It would also be important to further investigate, with more sensitive methods, the presence and frequency of very low subclonality del16p. In general, WES data from 1300 newly diagnosed MM patients failed to detect any missense or nonsense mutations in BCMA18. This suggests that pressure of specific BCMA-targeted treatment can select for a very low level of biallelic deletion (BCMA and TP53) in these patients (Fig. 2H). As BCMA has a functional role in MM, such BCMA-independent growth on one hand may indicate a more aggressive phenotype, but it may also suggest a new vulnerability that can be targeted by alternative therapies. Anecdotal instances of post-CAR T-cell sensitivity to various therapies have been reported and the index patient in this report has remained alive 3 years from CAR T-cell therapy.
This case represents molecular characteristics of MM. It identifies significant genomic evolution that may represent clonal selection and/or induction of new changes under the pressure of therapy. Our results suggest that BCMA-negative cell populations may get selected under strong treatments like CAR T-cell therapies. Although the platform we have used was not sensitive enough to detect the presence of low-level resistant cells at an early stage, our results still support a possible role for sensitive and deep sequencing of BCMA locus before CAR T-cell reinfusion or consideration of sequential BCMA-targeted therapies, to identify the outgrowth of a rare MM cell with BCMA loss. Recently, CAR T-cell therapy approach simultaneously targeting dual antigens BCMA and GPRC5D was shown as one approach to prevent BCMA escape-driven relapse19. The presence of subclonal changes may also provide clinically important information supporting dual antigen-targeted CAR T cell or other combination or maintenance therapies.
Methods
Patient samples
All eight samples for scRNAseq (CD138− sample before the first infusion (S1) and BM mononuclear cells from S2 to S8) and CD138+ sample for WES have been collected from an individual patients’ posterior superior iliac spine area, who was enrolled in a phase I clinical study (CRB-401 ClinicalTrials.gov number, NCT02658929) of bb2121 involving patients with relapsed or refractory MM was initiated. The primary outcome results of this clinical trial have been published1. The study was conducted in accordance with the Declaration of Helsinki and International Conference on Harmonisation guidelines for Good Clinical Practice. The protocol was approved by Dana Farber/Harvard Cancer Center Institutional Review Board, and samples and data were obtained after a written informed consent was signed by the patient.
Single-cell RNA sequencing
For all eight samples, single-cell library constructions were performed using Chromium Single Cell 3′ Reagent kits v2. Each sample was processed individually according to 10× genomics protocols. Poly-A selected transcripts were reverse transcribed and full-length cDNA along with cell barcode identifiers were PCR amplified. The constructed libraries then sequenced with Illumina platform using paired-end sequencing. On average each sample sequenced with 118 M reads (range 87 M–141 M) (Suplementary Table 1). The Cell Ranger Suite (v3.1.0) from 10× genomics with GRCh38 reference genome was used to perform sample de-multiplexing, barcode processing and unique molecular identifier counting. Cellranger mkfastq and count funtions were used to quantify the expression values for captured single cells. The filtered gene-barcode matrix from Cellranger output then used for downstream analysis with Seurat (v3.1.5)20,21 to filter out Gel Bead-In Emulsions do not actually contain cells. Estimated number of cells per sample before additional filtering with Seurat20,21 was 5864 (range 4868–7801) and mean reads per cell was 20,682 (range 14,730–28,924). Additional quality control measurements can be found in Supplementary Tables 2 and 3.
Filtered counts then transferred to R and Seurat for downstream analysis. Only cells with at least 200 detected features and only feateres that are detected in 3 or more cells were kept for downstream analysis. After these additional filtering steps with Seurat, 4707 cells (range 3075–6818) per sample with 3695 reads per cell were used (Supplemantary Table 1 and Supplementary Fig. 4). Integration of multiple single-cell datasets was performed using anchored Analysis with SCTransform20,21 workflow and using 5000 integration features. First 20 dimensions for the Principle Componenet Analysis were used for clustering and Uniform Manifold Approximation and Projection analysis. Single-cell visualizations and downstream marker detections then performed as explained in Seurat website. Resolution was set to 0.3 for the clustering analysis. Known cell-type annotations were perfomed using SingleR(v1.4.0)22, as well as known gene surface markers for T, NK, B, plasma cells, monocytes, and erythyrocytes (CD3D, CD3E, CD3G, CD4, CD8A, CD5, NCAM1, CCL5, KLRC1, KLRD1, KLRC2, CD79A, CD79B, CCND1, SLAMF7, XBP1, POU2AF1, CD38, IRF4, CD14, FCGR3A, CD68, PECAM1, HBB) (Supplementary Fig. 1). T-cell subgroups also identified using T-cell subgroup-specific markers (CD4, CD8A, CCR4, CCR6, FOXP3, IL2RA, CCR7, IL7R, CD8A, CD8B, FASLG, IFNG, NKG7, GZMB, GZMH) (Supplemantary Fig. 2). Cytotoxic CD8+ T-cell makers were collected from Zavidij et al.23. Copy number analysis for the scRNAseq was done using CONICSmat(v0.1)24 and plasma cells were compared with B cells as reference set. Only the chromosomal arms that passed Bayesian information criteria > 0 and adjusted p-value < 1e−5 were considered significantly altered. Differentially expressed genes were detected using FindAllMarkers and FindMarkers function in the Seurat21 package. Gene-set enrichment analysis was done using molecular signature database (MSigDb) provided by Broad Institute25,26.
Whole exome sequencing
WES data for tumor sample generated from CD138+ cells collected after the second infusion. Peripheral blood mononuclear cells were used as germline control. WES libraries generated using Twist Bioscience Human Core Exome Kit and sequenced as 75 bp paired-end reads with Illumina Novoseq platform. The average sequence coverage for targeted regions was 110× for tumor sample and 602× for germline DNA. We aligned paired-end reads using BWA-mem (v0.7.17-r1188)27 to GRCh38. We followed GATK (v4.0.11) best practice to mark duplicated reads with MarkDuplicates function and base quality score recalibration with ApplyBQSR28. Mutect229 was used to call mutations. Only mutation calls with at least 10× coverage for tumor and germline samples and passed FilterMutectCalls function were annoted using Variant Effect Predictor from Ensembl (v100). Allele-specific copy number calls as well as ploidy and purity of the sample were analyzed using FACETS (v0.6.1) (Fraction and Allele-Specific Copy Number Estimates from Tumor Sequencing)30.
FISH analysis
CD138+ sorted BM plasma cells were analyzed by FISH using commercially available probes specific for 8q24.1, del13, 17p13.1, gain11, gain1q22, t(4;14), t(11;14), t(14;16), t(14;20) by Mayo Clinic Laboratories. All probes were set up separately and for each probe, plasma cells (if possible) are scored and the result for each probe is reported.
Other statistical analysis
All other analyses were completed in the R programming language. Data preparation and processing were done using ggplot2, cowplot, and dplyr packages. R maftools was used for downstream analysis for the Single Nucleotide Variant (SNV) and small insertion deletion data. Protein domains were combined with SNV calls using ProteinPaint to generate lollipop plots.
Detecting CAR+ cells with qPCR
Copies of vector transgene per microgram genomic DNA was determined by quantitative PCR (qPCR) as previously described1. Briefly, CD3+ cells were isolated to high purity from whole blood. Genomic DNA from the purified CD3+ cell pellet was extracted and DNA concentration was determined. Purified CD3+ DNA (100 ng) was included in the qPCR reaction for specific quantification of the bb2121 transgene (Psi-gag) and a reference housekeeping gene (RNaseP). Detection and quantification of the Psi-Gag sequence and RNaseP were achieved using target-specific oligonucleotide primers and dual-labeled oligonucleotide hydrolysis probes1. The amplified targets were detected in real time by Stratagene Mx3005P instrument using TaqMan® Universal PCR Master Mix, no UNG (Thermo Fisher Scientific), and quantified using a standard curve. Quantified copies of vector transgene per reaction is reported as copies per standardized input DNA (100 ng). Primer probe sequences are shown in Supplementary Table 4.
Reporting summary
Further information on research design is available in the Nature Research Reporting Summary linked to this article.
Supplementary information
Supplementary Information
Descriptions of Additional Supplementary Files
Supplementary Data 1
Supplementary Data 2
Reporting Summary
Peer review information
Nature Communications thanks the anonymous reviewers for their contribution to the peer review of this work.
Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Supplementary information
The online version contains supplementary material available at 10.1038/s41467-021-21177-5.
Acknowledgements
This study has been supported by NIH grants P01 CA155258 and P50 CA100707, Celgene Corporation and VA Healthcare System Grant 5I01BX001584, and Paula and Roger Riney Foundation grant.
Author contributions
M.K.S. and N.M. designed and conduct the study. M.K.S., M.F., A.A.S., A.H.B., Y.T., R.P., A.A., A.S., T.C., F.P., K.H., S.K., H.A.L., K.C.M., and N.M. collected the data. M.K.S., A.A.S., A.H.B., R.P., and N.M. analyzed the data. All authors discussed the data and wrote the manuscript.
Data availability
The single-cell RNA sequencing data generated in this study have been deposited in the GEO database under accession code GSE164551. In addition, the single-cell RNA sequencing dataset, BAM file for BCMA locus, SNP counts for allelic copy number, and meta data for single cells after clustering with Seurat are also available in the Harvard Dataverse database under accession code doi:10.7910/DVN/1RKYQ8 [10.7910/DVN/1RKYQ8]. The remaining data are available within the Article, Supplementary Information, or available from the authors upon request.
Competing interests
K.C.A. has received consulting fees from Bristol-Myers Squibb, Celgene, Gilead, Janssen, Precision Biosciences, Sanofi-Aventis, Takeda, and Tolero, and on the board of directors and stock options Oncopep. N.C.M. is a consultant for BMS, Janssen, Oncopep, Amgen, Karyopharm, Legened, Abbvie, Takeda, and GSK, and on the board of directors and stock options Oncopep. T.C., K.H., and S.K. are employed by Bristol-Myers Squibb. F.P. is employed by Bluebird Bio. Other authors declare no competing interests. | CYCLOPHOSPHAMIDE, FLUDARABINE PHOSPHATE, IDECABTAGENE VICLEUCEL | DrugsGivenReaction | CC BY | 33558511 | 19,879,775 | 2021-02-08 |
What was the dosage of drug 'CYCLOPHOSPHAMIDE'? | Biallelic loss of BCMA as a resistance mechanism to CAR T cell therapy in a patient with multiple myeloma.
BCMA targeting chimeric antigen receptor (CAR) T cell therapy has shown deep and durable responses in multiple myeloma. However, relapse following therapy is frequently observed, and mechanisms of resistance remain ill-defined. Here, we perform single cell genomic characterization of longitudinal samples from a patient who relapsed after initial CAR T cell treatment with lack of response to retreatment. We report selection, following initial CAR T cell infusion, of a clone with biallelic loss of BCMA acquired by deletion of one allele and a mutation that creates an early stop codon on the second allele. This loss leads to lack of CAR T cell proliferation following the second infusion and is reflected by lack of soluble BCMA in patient serum. Our analysis suggests the need for careful detection of BCMA gene alterations in multiple myeloma cells from relapse following CAR T cell therapy.
Introduction
Chimeric antigen receptor (CAR) T-cell therapy targeting B-cell maturation antigen (BCMA) has provided frequent, deep, and durable responses in relapsed, refractory multiple myeloma (MM), with initial Phase I/II studies reporting 73–100% overall response and 31–69% complete response1–3. However, progression-free survival in some studies have been <12 months, indicating myeloma recurrence despite the persistence of CAR T cells in a number of cases1,2. Importantly, among the small number of patients retreated with the same CAR T cell product at the time of progression, responses have been infrequent4,5. This highlights development of acquired resistance mechanisms6,7, which may preclude effectiveness of the second CAR T infusion, and may also explain relapse following the initial CAR T-cell therapy.
In this work, by performing single-cell transcriptome profiling on serially collected bone marrow (BM) samples, we show biallelic loss of BCMA as one of the resistance mechanisms to anti-BCMA CAR T-cell therapy with Idecabtagene Vicleucel in a patient with initial response but relapse with resistance to retreatment with the same CAR T-cell product. Furthermore, our results also highlight that MM cells may develop alternative paths to survive without BCMA.
Results
We evaluated samples from an individual patient who was diagnosed with IgG lambda MM with hypodiploidy and a complex karyotype with t(8;12) (q24;q14), clonal t(11;14) (q13;q32), and clonal deletion 13. The patient was treated with four lines of therapy including proteasome inhibitor, immunomodulatory agent, and anti-CD38 antibody before CAR T-cell therapy, with limited response. The patient was enrolled in a Phase I trial (CRB-401 ClinicalTrials.gov number, NCT02658929) of anti-BCMA CAR T-cell therapy with Idecabtagene Vicleucel (ide-cel) and received 150 × 106 CAR+ T cells at day 0 following lymphodepletion with fludarabine (30 mg/m2 per day) and cyclophosphamide (300 mg/m2 per day) on days −5, −4, and −3, as reported in ref. 1. The patient developed grade 1 cytokine release syndrome and achieved partial response by 3 months. The patient relapsed 9 months after the first CAR T infusion and was treated a second time with identical lymphodepletion and using the same CAR T-cell product as the first infusion but at a higher dose of 450 × 106 CAR+ T cells with no response (Fig. 1A, B).Fig. 1 Response to CAR T cell treatment and microenvironment changes.
A M spike and lambda free light chain evaluations for the patient. The y axis on left shows the M spike values (blue) and on the right it shows the lambda free light chain values (green). Time points (x axis) marked with red labels also shows the longitudinal sample collection for single-cell RNA sequencing. B Expansion of CAR T cells (y axis) measured with qPCR after first (blue) and second (red) infusions from day 0 to day 60 (x axis). C Timeline of the eight samples collected for single-cell RNA sequencing. D Thirteen single-cell clusters from eight longitudinal bone marrow samples. Annotation of cell clusters are marked in the bottom part with color codes. Cell embedings are shown by using UMAP1 and UMAP2. E Ide-cel expression in single cells. Only limited number of cells are CAR+ at 2 weeks after the first infusion. None of the other time points show CAR+ cells. F Re-clustered T cells divided by time points from study screening to 1 month after second infusion and T-cell annotations for CD4+ and CD8+ cells are shown with color codes. G Percentage of particular T-cell types (y axis) at each time point (x axis) evaluated with single-cell RNA seqeuecning for T-cell clusters (top figure legend). Percentages are reflecting the % of particular cluster at given time point within all T cell populations. H Gene-set enrichment FDR values for differentially expressed genes for two samples collected two weeks after first (blue) and second (green) infusions. I Percentage of T cells (y axis) expressing immune checkpoint inhibitors at each time point (x axis).
Changes in BM microenvironment post-CAR T-cell therapy
To delineate changes in BM cellular components as a potential mechanism underlying lack of response to CAR T-cell reinfusion, we performed single-cell transcriptome profiling on serially collected BM samples (Fig. 1C). Clustering analysis from 37,658 cells from 8 time points, before the first CAR T cell infusion to 1 month after the second infusion, identified 13 clusters consisting of hematopoietic cells and MM cells (Fig. 1D and Supplementary Fig. 1). The BM sample before the first infusion was depleted of CD138+ cells by cell selection. A small number of MM cells were observed at 2 weeks after the first infusion of the CAR T-cell therapy. Thereafter, MM cells became undetectable and remained undetectable until eight months after the first infusion, when biochemical as well as cytological relapse occurred (Fig. 2A and Supplementary Fig. 1B). We observed a predicted suppression of B-cell count at study entry as an effect of the MM cell growth, with B-cell recovery at 1 month coinciding with anti-MM response (3% of all cells) and reaching 18% at 8 months after first infusion (Supplementary Fig. 1B), and again suppressed to 3% at relapse. We detected CAR+ T cells in the BM only at 2 weeks after first infusion, when maximal CAR+ T-cell expansion was observed in blood using reverse-transcription PCR (RT-PCR)-based detection (Fig. 1B, E). We did not detect infused CAR T cells in the BM with single-cell transcriptome profiling after the second CAR T infusion, but a limited expansion was confirmed in the blood using RT-PCR (Fig. 1E). The 6-log expansion of CAR+ T cells in the blood after the first infusion is consistent with observed expansion in the KarMMA study, where 5.5 log expansion was observed in the responding patients with a median peak CAR+ T-cell expansion at day 112. A lower expansion (2-log) with the second infusion may represent environmental influences or MM-intrinsic factors.Fig. 2 Tumor-intrinsic changes.
A Cell embedings for plasma/multiple myeloma (MM) cells (green colors) and B cells (cream colors) are shown from screening to 2 weeks after second infusion (x axis). B cells are first detected at 1 month after first infusion and increased frequency until relapse. MM cells are detected at the 8 months after first infusion sample and remain same for further time points. B Soluble BCMA (sBCMA) level (y axis) at the study screening, after first infusion, relapse, and after second infusion (x axis) are shown. Time points makerd with * indicates the time points scRNAseq data also available. Screening refers to screening before first infusion (S1). Day 14 and Months 3 are refering to two weeks after first infusion (S2) and 3 months after first infusion (S4). Retreatment Screening is the relapse after first infusion (S6) and Retreatment Day 14 (S7) is 2 weeks after second infusion. C Expression levels of CD138, CCND1, XBP1, and RB1 in multiple myeloma (MM) cells and B cells. Normalized expression level scales are shown with legends. D Copy number predictions for each single cell (columns) from single-cell RNA sequencing data for chromosomal arms (rows). Deletions are shown with blue and gains are shown with red color for MM cells (left) and B cells (right). E Copy number estimates for CD138+ cells after second CAR T-cell infusion using whole exome sequencing. The top panel displays total copy number log-ratio where diploid state is shown with purple line and the second panel displays allele-specific log odds ratio data for allele-specific copy number calls with chromosomes alternating in blue and gray. Third panel shows the corresponding integer (black line for total copy number, red line for minor copy number) copy number calls. The bottom panel shows the predicted clonality of each events. Dark blue colors show regions with colonal copy number alterations and light blue color shows subclonal copy number events. F Percentage (x axis) of single multiple myeloma/plasma cells with various copy number deletions (del) or gains (y axis). Copy number events for each cell predicted using single-cell RNA sequencing. G Somatic mutaitons detected at relapse after second infusion with whole exome sequencing. Nonsense mutation which creates early stop codon in BCMA (top panel) and missense TP53 mutation (bottom panel) are shown in their amino acid locations. Protein domains are shown with color codes in each genes. H Clonal evolution of MM cells from diagnosis to relapse after second CAR T-cell infusion. I Co-occurrences of deletion 17p (del17p) and deletion 16p (del16p) on large-scale MM cohort. Clonal (red color), subclonal (yellow) deletions are shown for newly diagnosed MM patients (columns) and only patients with del16p and/or del17p are shown.
Re-clustering of the T-cell cluster showed an increased proportion of CD4+ helper and T-regulatory cells (Treg) 2 weeks after first infusion (Fig. 1F, G and Supplementary Fig. 2), and these two clusters had high expression of proliferation-related genes (Fig. 1H and Supplementary Data 1 and 2). However, Treg proportion remained similar at the second infusion, ruling out its impact on lack of expansion of CAR+ T cells. To detect any unusual endogenous T-cell activity that may potentially affect CAR T-cell function, we investigated inhibitory markers CD274 (PD-L1), PDCD1 (PD-1), LAG3, TIGIT at early and late time points including after second infusion. As can be seen (Fig. 1I and Supplementary Table 1), at no time point the proportion of the cells expressing these checkpoint inhibitors is higher then the base line. Moreover, the absence of change in these markers on endogenous T cells does not mean that the CAR+ T cells do not express these markers. However, in absence of detectable CAR T cells there is no direct way to look at expressed inhibitory markers on CAR T cells. Therefore, future studies will require investigation of resistance associated with presence of checkpoint inhibitors.
Role of tumor intrinsic factors in resistance
As we did not delineate a role of the BM milieu mediating suppression of CAR T-cell expansion and function following second infusion, we next explored tumor intrinsic factors. We evaluated soluble BCMA (sBCMA) level (produced predominantly by MM cells) in serum at different time points, and observed high levels before the first CAR T cell infusion, which dropped significantly to a very low level coincident with the clinical response; however, sBCMA remained low even at the time of relapse with increased burden of MM, indicating a lack of BCMA production by MM cells (Fig. 2B). We therefore investigated genomic changes in MM cells at the time of relapse. This patient had clonal t(11;14) translocation (96% of all cells) and clonal deletion 13 (94% of all cells) at the time of diagnosis. A similar clonal composition was observed by fluorescence in situ hybridization (FISH) analysis at study enrollment, when 4% of the cells also showed deletion 17p. Our single-cell transcriptomic analysis of BM samples identified three samples (at the time of relapse and post second CAR T-cell infusion) with significant numbers of MM cells, evidenced by expression of CD138 and XBP1 (markers of plasma cells), CCND1 (upregulated in this patient with t(11;14)), and lack of RB1 (downregulated in this patient with del13) (Fig. 2C). Imputation of copy number alterations from single-cell transcriptomic data showed that the majority of MM cells had a deletion of 16p, including the BCMA locus located on 16p13.13. (Fig. 2D). We further validated these findings using deep whole exome sequencing (WES) of purified CD138+ cells collected 2 weeks after the second CAR T infusion. Of note, copy number alterations detected by WES almost completely overlapped with CNAs predicted by single-cell RNA sequencing (scRNAseq), including deletion 16p (Fig. 2E). Before the first CAR T-cell infusion, 4% of BM MM cells showed deletion 17p, whereas after the second infusion both WES and scRNAseq prediction showed that del17p and del16p were clonal, and longitudinal scRNAseq analysis indicated that del17p and del16p co-occurred in the same clone (Fig. 2D, F). Interestingly, WES also identified a high subclonal (~70%) nonsense mutation (p.Q38*) in BCMA that creates an early stop codon in the BCMA gene (Fig. 2G and Supplementary Fig. 3). This biallelic BCMA loss, acquired with one copy deletion and a second copy loss-of-function mutation, provides the molecular basis for lack of BCMA expression in MM cells at the time of relapse.
Discussion
This case represents initial response followed by development of an acquired resistant phenotype as represented by both relapse and then lack of response to second CAR T infusion (Fig. 2H). BCMA represents an important component of plasma cell function, and thus its loss is not frequently observed. However, this case highlights a possibility that myeloma cells may be able to acuire alternative growth mechanisms to survive without BCMA expression and related signaling intermediates. Studies have shown that MM usually shows substantial inter and intra-tumor heterogeneity, which is closely related to progression, resistance to therapy, and recurrences8–12. Loss of several other targets for different treatments, such as CRBN with immunomodulatory agents or BCL-2 with venetoclax, has been associated with resistance to these treatments13,14. A single antigen targeting CAR T-cell treatment may also be affected by the loss of target as a result of tumor evolution and selection. Targeted antigen-negative relapse is one of the main reasons for resistance to CD19-directed CAR T-cell therapy and accounts for ~9–25% of cases of relapse in other hematological cancers3,4,6,7. In addition to antigen loss, immune-mediated rejection of the murine construct may play a role in resistance15. We did observe low level anti-drug antibodies (ADAs) at 6 months post first infusion, which persisted during the retreatment. ADA could have potential impact on CAR T cell expansion following second infusion. However, lack of BCMA expression was likely the predominant factor responsible for lack of response to second infusion. The extent of the role of ADA in this setting will need to be ascertained in a larger cohort of patients in the future. Previously, a large study evaluating CD19-targeted CAR T-cell therapy in B-cell malignincies showed that addition of fludarabine to cyclophosphamide-based lymphodepletion before the first infusion and an increased dose in the second infusion compared to the first infusion would increase the response rate16, both of which were followed in the currect study.
Here we describe emergence of a clone with loss of BCMA target leading to acquired resistance to retreatment. However, as it is equally important and previously shown in other hematological cancers, there are other possible factors such as microenvironmental changes and immune-mediated rejection of the murine construct that may contribute to resistance to CAR T-cell therapies. Here we only report one mechanism with limited power; however, future studies with larger sample size will be able to determine the dominant resistance factors and expected frequency of each mechanism in MM. We also observed a clonal TP53 missense mutation (p.P278T) (Fig. 2G) using WES, suggesting that both TP53 and BCMA had deletion in one allele and mutation in the second allele. We analyzed our data from 300 newly diagnosed MM patients and using a conservative estimate observed del16p in 6% patients (44% were subclonal deletions) and, interestingly, it co-occured with del17p in 77% of the del16p patients (sixfold encrichmnet, hypergeometric test p-value = 3.38e − 11, Fig. 2I). Importantly, we also observed that 36% of patients with del17p also carried del16p. These results support our previous observation regarding similar relative timing for both deletion events8,17, and may highlight the need to carefully examine for BCMA gene alterations in patients being retreated with subsequent BCMA targeting therapy at relapse from initial BCMA CAR T-cell treatment. The co-occurrence of 16p deletion in patients with del 17p also underscores the need to further evaluate the role of BCMA targted therapies in high-risk del17p MM. It would also be important to further investigate, with more sensitive methods, the presence and frequency of very low subclonality del16p. In general, WES data from 1300 newly diagnosed MM patients failed to detect any missense or nonsense mutations in BCMA18. This suggests that pressure of specific BCMA-targeted treatment can select for a very low level of biallelic deletion (BCMA and TP53) in these patients (Fig. 2H). As BCMA has a functional role in MM, such BCMA-independent growth on one hand may indicate a more aggressive phenotype, but it may also suggest a new vulnerability that can be targeted by alternative therapies. Anecdotal instances of post-CAR T-cell sensitivity to various therapies have been reported and the index patient in this report has remained alive 3 years from CAR T-cell therapy.
This case represents molecular characteristics of MM. It identifies significant genomic evolution that may represent clonal selection and/or induction of new changes under the pressure of therapy. Our results suggest that BCMA-negative cell populations may get selected under strong treatments like CAR T-cell therapies. Although the platform we have used was not sensitive enough to detect the presence of low-level resistant cells at an early stage, our results still support a possible role for sensitive and deep sequencing of BCMA locus before CAR T-cell reinfusion or consideration of sequential BCMA-targeted therapies, to identify the outgrowth of a rare MM cell with BCMA loss. Recently, CAR T-cell therapy approach simultaneously targeting dual antigens BCMA and GPRC5D was shown as one approach to prevent BCMA escape-driven relapse19. The presence of subclonal changes may also provide clinically important information supporting dual antigen-targeted CAR T cell or other combination or maintenance therapies.
Methods
Patient samples
All eight samples for scRNAseq (CD138− sample before the first infusion (S1) and BM mononuclear cells from S2 to S8) and CD138+ sample for WES have been collected from an individual patients’ posterior superior iliac spine area, who was enrolled in a phase I clinical study (CRB-401 ClinicalTrials.gov number, NCT02658929) of bb2121 involving patients with relapsed or refractory MM was initiated. The primary outcome results of this clinical trial have been published1. The study was conducted in accordance with the Declaration of Helsinki and International Conference on Harmonisation guidelines for Good Clinical Practice. The protocol was approved by Dana Farber/Harvard Cancer Center Institutional Review Board, and samples and data were obtained after a written informed consent was signed by the patient.
Single-cell RNA sequencing
For all eight samples, single-cell library constructions were performed using Chromium Single Cell 3′ Reagent kits v2. Each sample was processed individually according to 10× genomics protocols. Poly-A selected transcripts were reverse transcribed and full-length cDNA along with cell barcode identifiers were PCR amplified. The constructed libraries then sequenced with Illumina platform using paired-end sequencing. On average each sample sequenced with 118 M reads (range 87 M–141 M) (Suplementary Table 1). The Cell Ranger Suite (v3.1.0) from 10× genomics with GRCh38 reference genome was used to perform sample de-multiplexing, barcode processing and unique molecular identifier counting. Cellranger mkfastq and count funtions were used to quantify the expression values for captured single cells. The filtered gene-barcode matrix from Cellranger output then used for downstream analysis with Seurat (v3.1.5)20,21 to filter out Gel Bead-In Emulsions do not actually contain cells. Estimated number of cells per sample before additional filtering with Seurat20,21 was 5864 (range 4868–7801) and mean reads per cell was 20,682 (range 14,730–28,924). Additional quality control measurements can be found in Supplementary Tables 2 and 3.
Filtered counts then transferred to R and Seurat for downstream analysis. Only cells with at least 200 detected features and only feateres that are detected in 3 or more cells were kept for downstream analysis. After these additional filtering steps with Seurat, 4707 cells (range 3075–6818) per sample with 3695 reads per cell were used (Supplemantary Table 1 and Supplementary Fig. 4). Integration of multiple single-cell datasets was performed using anchored Analysis with SCTransform20,21 workflow and using 5000 integration features. First 20 dimensions for the Principle Componenet Analysis were used for clustering and Uniform Manifold Approximation and Projection analysis. Single-cell visualizations and downstream marker detections then performed as explained in Seurat website. Resolution was set to 0.3 for the clustering analysis. Known cell-type annotations were perfomed using SingleR(v1.4.0)22, as well as known gene surface markers for T, NK, B, plasma cells, monocytes, and erythyrocytes (CD3D, CD3E, CD3G, CD4, CD8A, CD5, NCAM1, CCL5, KLRC1, KLRD1, KLRC2, CD79A, CD79B, CCND1, SLAMF7, XBP1, POU2AF1, CD38, IRF4, CD14, FCGR3A, CD68, PECAM1, HBB) (Supplementary Fig. 1). T-cell subgroups also identified using T-cell subgroup-specific markers (CD4, CD8A, CCR4, CCR6, FOXP3, IL2RA, CCR7, IL7R, CD8A, CD8B, FASLG, IFNG, NKG7, GZMB, GZMH) (Supplemantary Fig. 2). Cytotoxic CD8+ T-cell makers were collected from Zavidij et al.23. Copy number analysis for the scRNAseq was done using CONICSmat(v0.1)24 and plasma cells were compared with B cells as reference set. Only the chromosomal arms that passed Bayesian information criteria > 0 and adjusted p-value < 1e−5 were considered significantly altered. Differentially expressed genes were detected using FindAllMarkers and FindMarkers function in the Seurat21 package. Gene-set enrichment analysis was done using molecular signature database (MSigDb) provided by Broad Institute25,26.
Whole exome sequencing
WES data for tumor sample generated from CD138+ cells collected after the second infusion. Peripheral blood mononuclear cells were used as germline control. WES libraries generated using Twist Bioscience Human Core Exome Kit and sequenced as 75 bp paired-end reads with Illumina Novoseq platform. The average sequence coverage for targeted regions was 110× for tumor sample and 602× for germline DNA. We aligned paired-end reads using BWA-mem (v0.7.17-r1188)27 to GRCh38. We followed GATK (v4.0.11) best practice to mark duplicated reads with MarkDuplicates function and base quality score recalibration with ApplyBQSR28. Mutect229 was used to call mutations. Only mutation calls with at least 10× coverage for tumor and germline samples and passed FilterMutectCalls function were annoted using Variant Effect Predictor from Ensembl (v100). Allele-specific copy number calls as well as ploidy and purity of the sample were analyzed using FACETS (v0.6.1) (Fraction and Allele-Specific Copy Number Estimates from Tumor Sequencing)30.
FISH analysis
CD138+ sorted BM plasma cells were analyzed by FISH using commercially available probes specific for 8q24.1, del13, 17p13.1, gain11, gain1q22, t(4;14), t(11;14), t(14;16), t(14;20) by Mayo Clinic Laboratories. All probes were set up separately and for each probe, plasma cells (if possible) are scored and the result for each probe is reported.
Other statistical analysis
All other analyses were completed in the R programming language. Data preparation and processing were done using ggplot2, cowplot, and dplyr packages. R maftools was used for downstream analysis for the Single Nucleotide Variant (SNV) and small insertion deletion data. Protein domains were combined with SNV calls using ProteinPaint to generate lollipop plots.
Detecting CAR+ cells with qPCR
Copies of vector transgene per microgram genomic DNA was determined by quantitative PCR (qPCR) as previously described1. Briefly, CD3+ cells were isolated to high purity from whole blood. Genomic DNA from the purified CD3+ cell pellet was extracted and DNA concentration was determined. Purified CD3+ DNA (100 ng) was included in the qPCR reaction for specific quantification of the bb2121 transgene (Psi-gag) and a reference housekeeping gene (RNaseP). Detection and quantification of the Psi-Gag sequence and RNaseP were achieved using target-specific oligonucleotide primers and dual-labeled oligonucleotide hydrolysis probes1. The amplified targets were detected in real time by Stratagene Mx3005P instrument using TaqMan® Universal PCR Master Mix, no UNG (Thermo Fisher Scientific), and quantified using a standard curve. Quantified copies of vector transgene per reaction is reported as copies per standardized input DNA (100 ng). Primer probe sequences are shown in Supplementary Table 4.
Reporting summary
Further information on research design is available in the Nature Research Reporting Summary linked to this article.
Supplementary information
Supplementary Information
Descriptions of Additional Supplementary Files
Supplementary Data 1
Supplementary Data 2
Reporting Summary
Peer review information
Nature Communications thanks the anonymous reviewers for their contribution to the peer review of this work.
Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Supplementary information
The online version contains supplementary material available at 10.1038/s41467-021-21177-5.
Acknowledgements
This study has been supported by NIH grants P01 CA155258 and P50 CA100707, Celgene Corporation and VA Healthcare System Grant 5I01BX001584, and Paula and Roger Riney Foundation grant.
Author contributions
M.K.S. and N.M. designed and conduct the study. M.K.S., M.F., A.A.S., A.H.B., Y.T., R.P., A.A., A.S., T.C., F.P., K.H., S.K., H.A.L., K.C.M., and N.M. collected the data. M.K.S., A.A.S., A.H.B., R.P., and N.M. analyzed the data. All authors discussed the data and wrote the manuscript.
Data availability
The single-cell RNA sequencing data generated in this study have been deposited in the GEO database under accession code GSE164551. In addition, the single-cell RNA sequencing dataset, BAM file for BCMA locus, SNP counts for allelic copy number, and meta data for single cells after clustering with Seurat are also available in the Harvard Dataverse database under accession code doi:10.7910/DVN/1RKYQ8 [10.7910/DVN/1RKYQ8]. The remaining data are available within the Article, Supplementary Information, or available from the authors upon request.
Competing interests
K.C.A. has received consulting fees from Bristol-Myers Squibb, Celgene, Gilead, Janssen, Precision Biosciences, Sanofi-Aventis, Takeda, and Tolero, and on the board of directors and stock options Oncopep. N.C.M. is a consultant for BMS, Janssen, Oncopep, Amgen, Karyopharm, Legened, Abbvie, Takeda, and GSK, and on the board of directors and stock options Oncopep. T.C., K.H., and S.K. are employed by Bristol-Myers Squibb. F.P. is employed by Bluebird Bio. Other authors declare no competing interests. | 300 MG/M2 PER DAY ON DAYS ?5, ?4, AND ?3 | DrugDosageText | CC BY | 33558511 | 19,879,775 | 2021-02-08 |
What was the dosage of drug 'FLUDARABINE PHOSPHATE'? | Biallelic loss of BCMA as a resistance mechanism to CAR T cell therapy in a patient with multiple myeloma.
BCMA targeting chimeric antigen receptor (CAR) T cell therapy has shown deep and durable responses in multiple myeloma. However, relapse following therapy is frequently observed, and mechanisms of resistance remain ill-defined. Here, we perform single cell genomic characterization of longitudinal samples from a patient who relapsed after initial CAR T cell treatment with lack of response to retreatment. We report selection, following initial CAR T cell infusion, of a clone with biallelic loss of BCMA acquired by deletion of one allele and a mutation that creates an early stop codon on the second allele. This loss leads to lack of CAR T cell proliferation following the second infusion and is reflected by lack of soluble BCMA in patient serum. Our analysis suggests the need for careful detection of BCMA gene alterations in multiple myeloma cells from relapse following CAR T cell therapy.
Introduction
Chimeric antigen receptor (CAR) T-cell therapy targeting B-cell maturation antigen (BCMA) has provided frequent, deep, and durable responses in relapsed, refractory multiple myeloma (MM), with initial Phase I/II studies reporting 73–100% overall response and 31–69% complete response1–3. However, progression-free survival in some studies have been <12 months, indicating myeloma recurrence despite the persistence of CAR T cells in a number of cases1,2. Importantly, among the small number of patients retreated with the same CAR T cell product at the time of progression, responses have been infrequent4,5. This highlights development of acquired resistance mechanisms6,7, which may preclude effectiveness of the second CAR T infusion, and may also explain relapse following the initial CAR T-cell therapy.
In this work, by performing single-cell transcriptome profiling on serially collected bone marrow (BM) samples, we show biallelic loss of BCMA as one of the resistance mechanisms to anti-BCMA CAR T-cell therapy with Idecabtagene Vicleucel in a patient with initial response but relapse with resistance to retreatment with the same CAR T-cell product. Furthermore, our results also highlight that MM cells may develop alternative paths to survive without BCMA.
Results
We evaluated samples from an individual patient who was diagnosed with IgG lambda MM with hypodiploidy and a complex karyotype with t(8;12) (q24;q14), clonal t(11;14) (q13;q32), and clonal deletion 13. The patient was treated with four lines of therapy including proteasome inhibitor, immunomodulatory agent, and anti-CD38 antibody before CAR T-cell therapy, with limited response. The patient was enrolled in a Phase I trial (CRB-401 ClinicalTrials.gov number, NCT02658929) of anti-BCMA CAR T-cell therapy with Idecabtagene Vicleucel (ide-cel) and received 150 × 106 CAR+ T cells at day 0 following lymphodepletion with fludarabine (30 mg/m2 per day) and cyclophosphamide (300 mg/m2 per day) on days −5, −4, and −3, as reported in ref. 1. The patient developed grade 1 cytokine release syndrome and achieved partial response by 3 months. The patient relapsed 9 months after the first CAR T infusion and was treated a second time with identical lymphodepletion and using the same CAR T-cell product as the first infusion but at a higher dose of 450 × 106 CAR+ T cells with no response (Fig. 1A, B).Fig. 1 Response to CAR T cell treatment and microenvironment changes.
A M spike and lambda free light chain evaluations for the patient. The y axis on left shows the M spike values (blue) and on the right it shows the lambda free light chain values (green). Time points (x axis) marked with red labels also shows the longitudinal sample collection for single-cell RNA sequencing. B Expansion of CAR T cells (y axis) measured with qPCR after first (blue) and second (red) infusions from day 0 to day 60 (x axis). C Timeline of the eight samples collected for single-cell RNA sequencing. D Thirteen single-cell clusters from eight longitudinal bone marrow samples. Annotation of cell clusters are marked in the bottom part with color codes. Cell embedings are shown by using UMAP1 and UMAP2. E Ide-cel expression in single cells. Only limited number of cells are CAR+ at 2 weeks after the first infusion. None of the other time points show CAR+ cells. F Re-clustered T cells divided by time points from study screening to 1 month after second infusion and T-cell annotations for CD4+ and CD8+ cells are shown with color codes. G Percentage of particular T-cell types (y axis) at each time point (x axis) evaluated with single-cell RNA seqeuecning for T-cell clusters (top figure legend). Percentages are reflecting the % of particular cluster at given time point within all T cell populations. H Gene-set enrichment FDR values for differentially expressed genes for two samples collected two weeks after first (blue) and second (green) infusions. I Percentage of T cells (y axis) expressing immune checkpoint inhibitors at each time point (x axis).
Changes in BM microenvironment post-CAR T-cell therapy
To delineate changes in BM cellular components as a potential mechanism underlying lack of response to CAR T-cell reinfusion, we performed single-cell transcriptome profiling on serially collected BM samples (Fig. 1C). Clustering analysis from 37,658 cells from 8 time points, before the first CAR T cell infusion to 1 month after the second infusion, identified 13 clusters consisting of hematopoietic cells and MM cells (Fig. 1D and Supplementary Fig. 1). The BM sample before the first infusion was depleted of CD138+ cells by cell selection. A small number of MM cells were observed at 2 weeks after the first infusion of the CAR T-cell therapy. Thereafter, MM cells became undetectable and remained undetectable until eight months after the first infusion, when biochemical as well as cytological relapse occurred (Fig. 2A and Supplementary Fig. 1B). We observed a predicted suppression of B-cell count at study entry as an effect of the MM cell growth, with B-cell recovery at 1 month coinciding with anti-MM response (3% of all cells) and reaching 18% at 8 months after first infusion (Supplementary Fig. 1B), and again suppressed to 3% at relapse. We detected CAR+ T cells in the BM only at 2 weeks after first infusion, when maximal CAR+ T-cell expansion was observed in blood using reverse-transcription PCR (RT-PCR)-based detection (Fig. 1B, E). We did not detect infused CAR T cells in the BM with single-cell transcriptome profiling after the second CAR T infusion, but a limited expansion was confirmed in the blood using RT-PCR (Fig. 1E). The 6-log expansion of CAR+ T cells in the blood after the first infusion is consistent with observed expansion in the KarMMA study, where 5.5 log expansion was observed in the responding patients with a median peak CAR+ T-cell expansion at day 112. A lower expansion (2-log) with the second infusion may represent environmental influences or MM-intrinsic factors.Fig. 2 Tumor-intrinsic changes.
A Cell embedings for plasma/multiple myeloma (MM) cells (green colors) and B cells (cream colors) are shown from screening to 2 weeks after second infusion (x axis). B cells are first detected at 1 month after first infusion and increased frequency until relapse. MM cells are detected at the 8 months after first infusion sample and remain same for further time points. B Soluble BCMA (sBCMA) level (y axis) at the study screening, after first infusion, relapse, and after second infusion (x axis) are shown. Time points makerd with * indicates the time points scRNAseq data also available. Screening refers to screening before first infusion (S1). Day 14 and Months 3 are refering to two weeks after first infusion (S2) and 3 months after first infusion (S4). Retreatment Screening is the relapse after first infusion (S6) and Retreatment Day 14 (S7) is 2 weeks after second infusion. C Expression levels of CD138, CCND1, XBP1, and RB1 in multiple myeloma (MM) cells and B cells. Normalized expression level scales are shown with legends. D Copy number predictions for each single cell (columns) from single-cell RNA sequencing data for chromosomal arms (rows). Deletions are shown with blue and gains are shown with red color for MM cells (left) and B cells (right). E Copy number estimates for CD138+ cells after second CAR T-cell infusion using whole exome sequencing. The top panel displays total copy number log-ratio where diploid state is shown with purple line and the second panel displays allele-specific log odds ratio data for allele-specific copy number calls with chromosomes alternating in blue and gray. Third panel shows the corresponding integer (black line for total copy number, red line for minor copy number) copy number calls. The bottom panel shows the predicted clonality of each events. Dark blue colors show regions with colonal copy number alterations and light blue color shows subclonal copy number events. F Percentage (x axis) of single multiple myeloma/plasma cells with various copy number deletions (del) or gains (y axis). Copy number events for each cell predicted using single-cell RNA sequencing. G Somatic mutaitons detected at relapse after second infusion with whole exome sequencing. Nonsense mutation which creates early stop codon in BCMA (top panel) and missense TP53 mutation (bottom panel) are shown in their amino acid locations. Protein domains are shown with color codes in each genes. H Clonal evolution of MM cells from diagnosis to relapse after second CAR T-cell infusion. I Co-occurrences of deletion 17p (del17p) and deletion 16p (del16p) on large-scale MM cohort. Clonal (red color), subclonal (yellow) deletions are shown for newly diagnosed MM patients (columns) and only patients with del16p and/or del17p are shown.
Re-clustering of the T-cell cluster showed an increased proportion of CD4+ helper and T-regulatory cells (Treg) 2 weeks after first infusion (Fig. 1F, G and Supplementary Fig. 2), and these two clusters had high expression of proliferation-related genes (Fig. 1H and Supplementary Data 1 and 2). However, Treg proportion remained similar at the second infusion, ruling out its impact on lack of expansion of CAR+ T cells. To detect any unusual endogenous T-cell activity that may potentially affect CAR T-cell function, we investigated inhibitory markers CD274 (PD-L1), PDCD1 (PD-1), LAG3, TIGIT at early and late time points including after second infusion. As can be seen (Fig. 1I and Supplementary Table 1), at no time point the proportion of the cells expressing these checkpoint inhibitors is higher then the base line. Moreover, the absence of change in these markers on endogenous T cells does not mean that the CAR+ T cells do not express these markers. However, in absence of detectable CAR T cells there is no direct way to look at expressed inhibitory markers on CAR T cells. Therefore, future studies will require investigation of resistance associated with presence of checkpoint inhibitors.
Role of tumor intrinsic factors in resistance
As we did not delineate a role of the BM milieu mediating suppression of CAR T-cell expansion and function following second infusion, we next explored tumor intrinsic factors. We evaluated soluble BCMA (sBCMA) level (produced predominantly by MM cells) in serum at different time points, and observed high levels before the first CAR T cell infusion, which dropped significantly to a very low level coincident with the clinical response; however, sBCMA remained low even at the time of relapse with increased burden of MM, indicating a lack of BCMA production by MM cells (Fig. 2B). We therefore investigated genomic changes in MM cells at the time of relapse. This patient had clonal t(11;14) translocation (96% of all cells) and clonal deletion 13 (94% of all cells) at the time of diagnosis. A similar clonal composition was observed by fluorescence in situ hybridization (FISH) analysis at study enrollment, when 4% of the cells also showed deletion 17p. Our single-cell transcriptomic analysis of BM samples identified three samples (at the time of relapse and post second CAR T-cell infusion) with significant numbers of MM cells, evidenced by expression of CD138 and XBP1 (markers of plasma cells), CCND1 (upregulated in this patient with t(11;14)), and lack of RB1 (downregulated in this patient with del13) (Fig. 2C). Imputation of copy number alterations from single-cell transcriptomic data showed that the majority of MM cells had a deletion of 16p, including the BCMA locus located on 16p13.13. (Fig. 2D). We further validated these findings using deep whole exome sequencing (WES) of purified CD138+ cells collected 2 weeks after the second CAR T infusion. Of note, copy number alterations detected by WES almost completely overlapped with CNAs predicted by single-cell RNA sequencing (scRNAseq), including deletion 16p (Fig. 2E). Before the first CAR T-cell infusion, 4% of BM MM cells showed deletion 17p, whereas after the second infusion both WES and scRNAseq prediction showed that del17p and del16p were clonal, and longitudinal scRNAseq analysis indicated that del17p and del16p co-occurred in the same clone (Fig. 2D, F). Interestingly, WES also identified a high subclonal (~70%) nonsense mutation (p.Q38*) in BCMA that creates an early stop codon in the BCMA gene (Fig. 2G and Supplementary Fig. 3). This biallelic BCMA loss, acquired with one copy deletion and a second copy loss-of-function mutation, provides the molecular basis for lack of BCMA expression in MM cells at the time of relapse.
Discussion
This case represents initial response followed by development of an acquired resistant phenotype as represented by both relapse and then lack of response to second CAR T infusion (Fig. 2H). BCMA represents an important component of plasma cell function, and thus its loss is not frequently observed. However, this case highlights a possibility that myeloma cells may be able to acuire alternative growth mechanisms to survive without BCMA expression and related signaling intermediates. Studies have shown that MM usually shows substantial inter and intra-tumor heterogeneity, which is closely related to progression, resistance to therapy, and recurrences8–12. Loss of several other targets for different treatments, such as CRBN with immunomodulatory agents or BCL-2 with venetoclax, has been associated with resistance to these treatments13,14. A single antigen targeting CAR T-cell treatment may also be affected by the loss of target as a result of tumor evolution and selection. Targeted antigen-negative relapse is one of the main reasons for resistance to CD19-directed CAR T-cell therapy and accounts for ~9–25% of cases of relapse in other hematological cancers3,4,6,7. In addition to antigen loss, immune-mediated rejection of the murine construct may play a role in resistance15. We did observe low level anti-drug antibodies (ADAs) at 6 months post first infusion, which persisted during the retreatment. ADA could have potential impact on CAR T cell expansion following second infusion. However, lack of BCMA expression was likely the predominant factor responsible for lack of response to second infusion. The extent of the role of ADA in this setting will need to be ascertained in a larger cohort of patients in the future. Previously, a large study evaluating CD19-targeted CAR T-cell therapy in B-cell malignincies showed that addition of fludarabine to cyclophosphamide-based lymphodepletion before the first infusion and an increased dose in the second infusion compared to the first infusion would increase the response rate16, both of which were followed in the currect study.
Here we describe emergence of a clone with loss of BCMA target leading to acquired resistance to retreatment. However, as it is equally important and previously shown in other hematological cancers, there are other possible factors such as microenvironmental changes and immune-mediated rejection of the murine construct that may contribute to resistance to CAR T-cell therapies. Here we only report one mechanism with limited power; however, future studies with larger sample size will be able to determine the dominant resistance factors and expected frequency of each mechanism in MM. We also observed a clonal TP53 missense mutation (p.P278T) (Fig. 2G) using WES, suggesting that both TP53 and BCMA had deletion in one allele and mutation in the second allele. We analyzed our data from 300 newly diagnosed MM patients and using a conservative estimate observed del16p in 6% patients (44% were subclonal deletions) and, interestingly, it co-occured with del17p in 77% of the del16p patients (sixfold encrichmnet, hypergeometric test p-value = 3.38e − 11, Fig. 2I). Importantly, we also observed that 36% of patients with del17p also carried del16p. These results support our previous observation regarding similar relative timing for both deletion events8,17, and may highlight the need to carefully examine for BCMA gene alterations in patients being retreated with subsequent BCMA targeting therapy at relapse from initial BCMA CAR T-cell treatment. The co-occurrence of 16p deletion in patients with del 17p also underscores the need to further evaluate the role of BCMA targted therapies in high-risk del17p MM. It would also be important to further investigate, with more sensitive methods, the presence and frequency of very low subclonality del16p. In general, WES data from 1300 newly diagnosed MM patients failed to detect any missense or nonsense mutations in BCMA18. This suggests that pressure of specific BCMA-targeted treatment can select for a very low level of biallelic deletion (BCMA and TP53) in these patients (Fig. 2H). As BCMA has a functional role in MM, such BCMA-independent growth on one hand may indicate a more aggressive phenotype, but it may also suggest a new vulnerability that can be targeted by alternative therapies. Anecdotal instances of post-CAR T-cell sensitivity to various therapies have been reported and the index patient in this report has remained alive 3 years from CAR T-cell therapy.
This case represents molecular characteristics of MM. It identifies significant genomic evolution that may represent clonal selection and/or induction of new changes under the pressure of therapy. Our results suggest that BCMA-negative cell populations may get selected under strong treatments like CAR T-cell therapies. Although the platform we have used was not sensitive enough to detect the presence of low-level resistant cells at an early stage, our results still support a possible role for sensitive and deep sequencing of BCMA locus before CAR T-cell reinfusion or consideration of sequential BCMA-targeted therapies, to identify the outgrowth of a rare MM cell with BCMA loss. Recently, CAR T-cell therapy approach simultaneously targeting dual antigens BCMA and GPRC5D was shown as one approach to prevent BCMA escape-driven relapse19. The presence of subclonal changes may also provide clinically important information supporting dual antigen-targeted CAR T cell or other combination or maintenance therapies.
Methods
Patient samples
All eight samples for scRNAseq (CD138− sample before the first infusion (S1) and BM mononuclear cells from S2 to S8) and CD138+ sample for WES have been collected from an individual patients’ posterior superior iliac spine area, who was enrolled in a phase I clinical study (CRB-401 ClinicalTrials.gov number, NCT02658929) of bb2121 involving patients with relapsed or refractory MM was initiated. The primary outcome results of this clinical trial have been published1. The study was conducted in accordance with the Declaration of Helsinki and International Conference on Harmonisation guidelines for Good Clinical Practice. The protocol was approved by Dana Farber/Harvard Cancer Center Institutional Review Board, and samples and data were obtained after a written informed consent was signed by the patient.
Single-cell RNA sequencing
For all eight samples, single-cell library constructions were performed using Chromium Single Cell 3′ Reagent kits v2. Each sample was processed individually according to 10× genomics protocols. Poly-A selected transcripts were reverse transcribed and full-length cDNA along with cell barcode identifiers were PCR amplified. The constructed libraries then sequenced with Illumina platform using paired-end sequencing. On average each sample sequenced with 118 M reads (range 87 M–141 M) (Suplementary Table 1). The Cell Ranger Suite (v3.1.0) from 10× genomics with GRCh38 reference genome was used to perform sample de-multiplexing, barcode processing and unique molecular identifier counting. Cellranger mkfastq and count funtions were used to quantify the expression values for captured single cells. The filtered gene-barcode matrix from Cellranger output then used for downstream analysis with Seurat (v3.1.5)20,21 to filter out Gel Bead-In Emulsions do not actually contain cells. Estimated number of cells per sample before additional filtering with Seurat20,21 was 5864 (range 4868–7801) and mean reads per cell was 20,682 (range 14,730–28,924). Additional quality control measurements can be found in Supplementary Tables 2 and 3.
Filtered counts then transferred to R and Seurat for downstream analysis. Only cells with at least 200 detected features and only feateres that are detected in 3 or more cells were kept for downstream analysis. After these additional filtering steps with Seurat, 4707 cells (range 3075–6818) per sample with 3695 reads per cell were used (Supplemantary Table 1 and Supplementary Fig. 4). Integration of multiple single-cell datasets was performed using anchored Analysis with SCTransform20,21 workflow and using 5000 integration features. First 20 dimensions for the Principle Componenet Analysis were used for clustering and Uniform Manifold Approximation and Projection analysis. Single-cell visualizations and downstream marker detections then performed as explained in Seurat website. Resolution was set to 0.3 for the clustering analysis. Known cell-type annotations were perfomed using SingleR(v1.4.0)22, as well as known gene surface markers for T, NK, B, plasma cells, monocytes, and erythyrocytes (CD3D, CD3E, CD3G, CD4, CD8A, CD5, NCAM1, CCL5, KLRC1, KLRD1, KLRC2, CD79A, CD79B, CCND1, SLAMF7, XBP1, POU2AF1, CD38, IRF4, CD14, FCGR3A, CD68, PECAM1, HBB) (Supplementary Fig. 1). T-cell subgroups also identified using T-cell subgroup-specific markers (CD4, CD8A, CCR4, CCR6, FOXP3, IL2RA, CCR7, IL7R, CD8A, CD8B, FASLG, IFNG, NKG7, GZMB, GZMH) (Supplemantary Fig. 2). Cytotoxic CD8+ T-cell makers were collected from Zavidij et al.23. Copy number analysis for the scRNAseq was done using CONICSmat(v0.1)24 and plasma cells were compared with B cells as reference set. Only the chromosomal arms that passed Bayesian information criteria > 0 and adjusted p-value < 1e−5 were considered significantly altered. Differentially expressed genes were detected using FindAllMarkers and FindMarkers function in the Seurat21 package. Gene-set enrichment analysis was done using molecular signature database (MSigDb) provided by Broad Institute25,26.
Whole exome sequencing
WES data for tumor sample generated from CD138+ cells collected after the second infusion. Peripheral blood mononuclear cells were used as germline control. WES libraries generated using Twist Bioscience Human Core Exome Kit and sequenced as 75 bp paired-end reads with Illumina Novoseq platform. The average sequence coverage for targeted regions was 110× for tumor sample and 602× for germline DNA. We aligned paired-end reads using BWA-mem (v0.7.17-r1188)27 to GRCh38. We followed GATK (v4.0.11) best practice to mark duplicated reads with MarkDuplicates function and base quality score recalibration with ApplyBQSR28. Mutect229 was used to call mutations. Only mutation calls with at least 10× coverage for tumor and germline samples and passed FilterMutectCalls function were annoted using Variant Effect Predictor from Ensembl (v100). Allele-specific copy number calls as well as ploidy and purity of the sample were analyzed using FACETS (v0.6.1) (Fraction and Allele-Specific Copy Number Estimates from Tumor Sequencing)30.
FISH analysis
CD138+ sorted BM plasma cells were analyzed by FISH using commercially available probes specific for 8q24.1, del13, 17p13.1, gain11, gain1q22, t(4;14), t(11;14), t(14;16), t(14;20) by Mayo Clinic Laboratories. All probes were set up separately and for each probe, plasma cells (if possible) are scored and the result for each probe is reported.
Other statistical analysis
All other analyses were completed in the R programming language. Data preparation and processing were done using ggplot2, cowplot, and dplyr packages. R maftools was used for downstream analysis for the Single Nucleotide Variant (SNV) and small insertion deletion data. Protein domains were combined with SNV calls using ProteinPaint to generate lollipop plots.
Detecting CAR+ cells with qPCR
Copies of vector transgene per microgram genomic DNA was determined by quantitative PCR (qPCR) as previously described1. Briefly, CD3+ cells were isolated to high purity from whole blood. Genomic DNA from the purified CD3+ cell pellet was extracted and DNA concentration was determined. Purified CD3+ DNA (100 ng) was included in the qPCR reaction for specific quantification of the bb2121 transgene (Psi-gag) and a reference housekeeping gene (RNaseP). Detection and quantification of the Psi-Gag sequence and RNaseP were achieved using target-specific oligonucleotide primers and dual-labeled oligonucleotide hydrolysis probes1. The amplified targets were detected in real time by Stratagene Mx3005P instrument using TaqMan® Universal PCR Master Mix, no UNG (Thermo Fisher Scientific), and quantified using a standard curve. Quantified copies of vector transgene per reaction is reported as copies per standardized input DNA (100 ng). Primer probe sequences are shown in Supplementary Table 4.
Reporting summary
Further information on research design is available in the Nature Research Reporting Summary linked to this article.
Supplementary information
Supplementary Information
Descriptions of Additional Supplementary Files
Supplementary Data 1
Supplementary Data 2
Reporting Summary
Peer review information
Nature Communications thanks the anonymous reviewers for their contribution to the peer review of this work.
Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Supplementary information
The online version contains supplementary material available at 10.1038/s41467-021-21177-5.
Acknowledgements
This study has been supported by NIH grants P01 CA155258 and P50 CA100707, Celgene Corporation and VA Healthcare System Grant 5I01BX001584, and Paula and Roger Riney Foundation grant.
Author contributions
M.K.S. and N.M. designed and conduct the study. M.K.S., M.F., A.A.S., A.H.B., Y.T., R.P., A.A., A.S., T.C., F.P., K.H., S.K., H.A.L., K.C.M., and N.M. collected the data. M.K.S., A.A.S., A.H.B., R.P., and N.M. analyzed the data. All authors discussed the data and wrote the manuscript.
Data availability
The single-cell RNA sequencing data generated in this study have been deposited in the GEO database under accession code GSE164551. In addition, the single-cell RNA sequencing dataset, BAM file for BCMA locus, SNP counts for allelic copy number, and meta data for single cells after clustering with Seurat are also available in the Harvard Dataverse database under accession code doi:10.7910/DVN/1RKYQ8 [10.7910/DVN/1RKYQ8]. The remaining data are available within the Article, Supplementary Information, or available from the authors upon request.
Competing interests
K.C.A. has received consulting fees from Bristol-Myers Squibb, Celgene, Gilead, Janssen, Precision Biosciences, Sanofi-Aventis, Takeda, and Tolero, and on the board of directors and stock options Oncopep. N.C.M. is a consultant for BMS, Janssen, Oncopep, Amgen, Karyopharm, Legened, Abbvie, Takeda, and GSK, and on the board of directors and stock options Oncopep. T.C., K.H., and S.K. are employed by Bristol-Myers Squibb. F.P. is employed by Bluebird Bio. Other authors declare no competing interests. | 30 MG/M2 PER DAY ON DAYS ?5, ?4, AND ?3 | DrugDosageText | CC BY | 33558511 | 19,879,775 | 2021-02-08 |
Give an alphabetized list of all active substances of drugs taken by the patient who experienced 'Neuropathy peripheral'. | Neoadjuvant durvalumab plus weekly nab-paclitaxel and dose-dense doxorubicin/cyclophosphamide in triple-negative breast cancer.
The goal of this Phase I/II trial is to assess the safety and efficacy of administering durvalumab concurrent with weekly nab-paclitaxel and dose-dense doxorubicin/cyclophosphamide (ddAC) neoadjuvant therapy for stages I-III triple-negative breast cancer. The primary endpoint is pathologic complete response (pCR:ypT0/is, ypN0). The response was correlated with PDL1 expression and stromal tumor-infiltrating lymphocytes (sTILs). Two dose levels of durvalumab (3 and 10 mg/kg) were assessed. PD-L1 was assessed using the SP263 antibody; ≥1% immune and tumor cell staining was considered positive; sTILs were calculated as the area occupied by mononuclear inflammatory cells over the total intratumoral stromal area. 59 patients were evaluable for toxicity and 55 for efficacy in the Phase II study (10 mg/kg dose). No dose-limiting toxicities were observed in Phase I. In Phase II, pCR rate was 44% (95% CI: 30-57%); 18 patients (31%) experienced grade 3/4 treatment-related adverse events (AE), most frequently neutropenia (n = 4) and anemia (n = 4). Immune-related grade 3/4 AEs included Guillain-Barre syndrome (n = 1), colitis (n = 2), and hyperglycemia (n = 2). Of the 50 evaluable patients for PD-L1, 31 (62%) were PD-L1 positive. pCR rates were 55% (95% CI: 0.38-0.71) and 32% (95% CI: 0.12-0.56) in the PD-L1 positive and negative groups (p = 0.15), respectively. sTIL counts were available on 52 patients and were significantly higher in the pCR group (p = 0.0167). Concomitant administration of durvalumab with sequential weekly nab-paclitaxel and ddAC neoadjuvant chemotherapy resulted in a pCR rate of 44%; pCR rates were higher in sTIL-high cancers.
pmcIntroduction
The presence of immune cells in the tumor microenvironment of triple-negative breast cancer (TNBC) is associated with a good prognosis with1 or without adjuvant chemotherapy2, and is also predictive of pathologic complete response (pCR, ypT0/is, ypN0) after neoadjuvant chemotherapy3. Animal models of cancer also demonstrated that immune cells in the tumor microenvironment, particularly activated cytotoxic T cells, partially mediate chemotherapy response4,5. The availability of immune checkpoint inhibitors in the clinic that target the programmed cell death protein-1 (PD-1) and its ligands allow us to directly test if removing an important inhibitory signal from the immune microenvironment can lead to a more effective antitumor immune response and increase chemotherapy sensitivity. PD-1 is expressed on the surface of T cells and causes T-cell inhibition when it binds to either of its two ligands, programmed death-ligand-1 (PD-L1) and -2 (PD-L2). PD-L1 is expressed on the cell surface of cancer cells, macrophages, dendritic cells, and T cells6,7. There is a strong positive correlation between PD-L1 expression, immune infiltration, and tumor-infiltrating lymphocyte count, which explains the paradoxical observations that high PD-L1 expression is associated with better prognosis and higher pCR rate in breast cancer8,9.
Durvalumab is a monoclonal human immunoglobulin G1κ antibody that binds to PD-L1 and inhibits its interaction with PD-1 and CD80 (B7.1)10. The antibody also contains mutations in the constant domain of the heavy chain that reduces binding to complement protein C1q and to Fcγ receptors to avoid complement- and antibody-mediated cytotoxicity. In this trial (NCT02489448), we tested the hypothesis that durvalumab administered concurrently with sequential weekly nab-paclitaxel and dose-dense AC (ddAC) neoadjuvant chemotherapy will increase pCR rate above the historical pCR rate of 30% observed with the same chemotherapy regimen in TNBC in an earlier trial (SWOG S0800, NCT00856492)11. Among the different neoadjuvant chemotherapy options that can be combined with checkpoint inhibitors, we selected Nab-paclitaxel because it did not require steroid premedications12. In addition, there is preclinical evidence suggesting that nab-paclitaxel can release tumor antigens from rapidly dying cells13, which in turn might be able to prime antitumor T cells, a response that might be further amplified by the addition of checkpoint inhibitors.
Results
Patient population
Sixty-nine patients were screened for enrollment at Yale Cancer Center and its regional care centers; 60 patients consented to the trial between December 18, 2015, and November 21, 2018. One patient subsequently withdrew consent. The baseline characteristics of the remaining 59 patients are shown in Table 1. Seven patients were included in Phase I part of the study, four at 3 mg/kg and three at 10 mg/kg dose. Fifty-two patients were enrolled in the Phase II part at a 10 mg/kg dose. Two patients did not proceed to surgery—one developed irreversible altered mental status attributed to Guillen Barre syndrome and family opted for comfort care, the other completed treatment but died of sudden death in her home before undergoing surgery.Table 1 Patients characteristics.
Characteristics N (%)
All patients 59 (100)
Age (median 50 years)
≤40 11 (19)
41–50 19 (32)
51–69 29 (49)
≥70 0 (0)
Race/ethnicity
White (non-Hispanic) 35 (59)
Hispanic/Latino 5 (8)
Black 11 (19)
Asian/American Indian 4 (6)
Unknown 4 (6)
Clinical tumor size
T1 21 (35)
T2 30 (51)
T3 8 (14)
Clinical nodal status
cN0 31 (52)
cN1 25 (42)
cN2 1 (2)
cN3 3 (4)
Clinical stage at diagnosis
I 12 (20)
II 33 (56)
III 14 (24)
Histologic tumor grade
G1 1 (2)
G2 12 (20)
G3 45 (76)
Unknown 1 (2)
Durvalumab dose level
3 mg/kg 4 (7)
10 mg/kg 55 (93)
Pathologic response
pCR 26 (44)
RD 31 (53)
No surgery 2 (3)
Residual cancer burden (RCB)
RCB-I 7 (12)
RCB-II 18 (31)
RCB-III 6 (10)
No surgery 2 (3)
PD-L1 IHC
Negative 19 (32)
Positive (≥1%) 33 (56)
Not available 7 (12)
Stromal TIL count
0–10% 28 (48)
11–29% 10 (17)
≥30% 16 (27)
Not available 5 (8)
TIL tumor-infiltrating lymphocytes, IHC immunohistochemistry.
Efficacy
In the total intention-to-treat population in the Phase II trial who received the recommended Phase II dose of 10 mg/kg durvalumab (N = 55), the pCR rate was 44% (N = 24, 95% CI: 30–57%). Of the 55 patients, 19 (34.5%) received less than the planned 10 treatments with durvalumab, including 7 patients who received less than six doses. Among the 36 patients who received all 10 treatments, 17 (47%) had a pCR. Four patients had clinical progression and underwent surgery or switched to other chemotherapy. One of these patients who subsequently received carboplatin had a pCR at the surgery.
Among the 57 patients who received durvalumab at any dose level and completed surgery, pCR rate was 46%, including 2 pCRs among the 4 patients who received 3 mg/kg durvalumab in the phase I part of the study. The RCB class distribution was RCB-0 (pCR): 46%, RCB-I: 12%, RCB-II: 31%, and RCB-III: 10%. At a median follow-up of 20 months, there have been no recurrences in cases that achieved a pCR. Among those with residual disease, there were nine metastatic and two local recurrences. Three patients died from metastatic disease.
Biomarker results
The consort diagram shows data availability for biomarker analysis (Supplementary Fig. 1). Fifty-two patients had PD-L1 IHC results available; 63% (N = 33) were PD-L1 positive. Two patients with PD-L1 staining had no surgery. Among the 50 patients who completed surgery, patients who achieved pCR had nominally higher PD-L1 positivity rate, compared to those with RD, although this did not reach not statistical significance (74% (95% CI: 54–88%) vs. 52% (95% CI: 34–88%); p = 0.15), (Fig. 1a). The pCR rate was 55% (95% CI: 38–71%) in the PD-L1 positive group compared to 32% (95% CI: 12–56%) in the PD-L1 negative group, also not significantly different (p = 0.15; Fig. 2a). In the same tissues, a parallel study with quantitative measurement of PD-L1 using immunofluorescence showed a statistically significant association between PD-L1 expression as a continuous variable and pCR, which is reported separately14.Fig. 1 PD-L1 positivity and stromal TILs (sTILs) by pathologic response category.
a PD-L1-positivity rate by SP263 antibody in the pathologic complete response (pCR, 74%, n = 14), and residual disease (RD, 52%, n = 13) groups, respectively, p = 0.148 (two-sided Fisher’s exact test). b The percentage of manual stromal tumor-infiltrating lymphocytes (sTILs) and the median (horizontal line) in the pCR (median: 20%) and RD groups (median: 5%), error bars represent 95% confidence intervals, p = 0.0167 (Mann–Whitney U test).
Fig. 2 Distribution of pCR rate by PD-L1 status and manual stromal TILs (sTILs).
a pCR rates in the PD-L1-positive (55%; 95% CI: 0.38–0.71) and -negative (32%; 95% CI: 0.15–0.54) groups, p = 0.148 (two-sided Fisher’s exact test). b pCR rates in cancers with ≥30% sTIL (pCR 57%), 29–10% sTIL (pCR 60%), and <10% sTIL (pCR 29%) groups, p = 0.099 (two-sided Fisher’s exact test). c PD-L1 positivity rates in cancers with sTIL >30%, sTIL 29%–10%, and sTIL <10%, were 100%, 71% and 42%, respectively, p = 0.00015 (two-sided Fisher’s exact test). On all panels error bars represent standard deviations (s.d.).
Manual sTIL counts were available on 54 patients including the 2 patients who did not complete surgery. All patients with evaluable sTIL counts had at least 1% sTILs and 14 of the 52 patients (27%) had sTIL-high cancers defined as ≥30% sTILs. Figure 1b shows TIL counts in the pCR and RD groups. The pCR rates were 57%, 60%, and 29% among TIL-high (sTIL ≥ 30%), intermediate (sTIL 29–10%), and low (sTIL < 10%) groups, p = 0.099. (Fig. 2b). Forty-nine patients had both baseline sTIL and PD-L1 results available, Stromal TIL count was significantly higher in the PD-L1 positive group (median 27.5% vs. 5%; p < 0.001). In cancers with sTIL ≥30%, the PD-L1 positivity rate was 100%, in cancers with sTIL 11–29%, PD-L1 positivity was 71%, and in cancers with sTIL <10%, PD-L1 positivity was only 42% (p = 0.00015 (two-sided Fisher’s exact test); Fig. 2c). Patients whose tumors were PD-L1 positive and sTIL-high (≥30%) had a numerically higher pCR rate of 57% than those with PD-L1 positive but sTIL intermediate or low cancers (pCR rate 50%) or PD-L1 negative cancers (pCR rate 32%), but these differences did not reach statistical significance (p = 0.302, two-sided Fisher’s exact test).
In a multivariate analysis including PD-L1 expression (positive vs. negative), sTIL count (as a continuous variable), age, tumor size (T1 vs. T2/T3) NS nodal status (N− vs. N+), neither PD-L1 status (SP263 IHC) nor sTIL count was independently associated with pCR (Table 2).Table 2 Univariate and multivariate logistic regression analyses to identify possible independent predictors of pCR following neoadjuvant therapy.
Univariate analysis Multivariate analysisa
Variables OR (95% CI) p-value OR (95% CI) p-value
sTILs (continuous variable) 0.99 (0.98–1.01) 0.56 1.00 (0.98–1.01) 0.63
PD-L1 (POS vs. NEG) 2.63 (0.82–9.21) 0.11 2.62 (0.78–9.62) 0.13
Age (continuous variable) 1.00 (0.96–1.04) 0.94
T status (T1 vs. T2/3) 0.47 (0.15–1.44) 0.19
N status (N− vs. N+) 1.38 (0.49–4.00) 0.54
aCovariates included are age (as a continuous variable), T status (T1 vs. T2/3), and N status (N− vs. N+).
Safety and toxicity
All patients who received at least one dose of study-assigned therapy were evaluated for safety and toxicity. Overall, durvalumab was discontinued in 19 (32%) patients, including 2 patients in Phase I portion of the study. During nab-paclitaxel treatment durvalumab was discontinued in 9 patients, 5 due to local progression and 4 due to AEs, 3 of which were immune-related (irAE): one case each of autoimmune diabetes, Guillain–Barre syndrome (GBS), and optic neuritis. In addition, durvalumab was held in 3 patients for at least 1 cycle during nab-paclitaxel due to AEs—transaminitis, dermatitis, and fatigue—and was then continued with the AC portion of chemotherapy. During the AC portion of chemotherapy, durvalumab was discontinued in 9 patients, 7 due to AEs, 2 of which were irAEs: one pneumonitis and one dermatitis. In addition, 5 patients discontinued AC chemotherapy (one each for renal failure, fatigue, and rash, and two due to neutropenic fever) and proceeded to surgery before completing all the planned doses of durvalumab. Two patients were found to be ineligible for the AC portion of treatment due to underlying cardiac disease discovered during the study. Selected treatment-related and clinically relevant toxicities and immune-related adverse events reported within 180 days of the last investigational agent dose are summarized in Table 3. The irAEs observed have all previously been observed in the context of other clinical studies; no new safety concerns were identified. The most frequent irAEs reported were dermatitis and endocrinopathies, with thyroid dysfunction being the most common (hypo- and hyperthyroidism), occurring in 13% of patients including 4 patients who had hyperthyroidism that progressed to hypothyroidism. Adrenal insufficiency was observed in 1 patient. Two patients developed autoimmune diabetes characterized by low or undetectable C-peptide levels and in 1 of the 2 patients, autoantibodies against islet antigen 2 (IA-2).Table 3 Treatment-related adverse events occurring in ≥10% of patients, or grades 3–4 occurring in ≥2% of patients.
All grades Grades 3–4
Adverse event N (%)
Fatigue 50 (85) 1 (2)
Nausea 43 (73) 0 (0)
Alopecia 39 (66) 0 (0)
Anemia 35 (59) 4 (7)
Rash 35 (59) 1 (2)
Diarrhea 27 (46) 0 (0)
Peripheral sensory neuropathy 20 (37) 0 (0)
Leukopenia 16 (27) 3 (5)
Neutropenia 13 (22) 4 (7)
Vomiting 12 (20) 0 (0)
Anorexia 11 (19) 0 (0)
Dyspnea 9 (15) 1 (2)
Myalgia 9 (15) 0 (0)
Mucositis 7 (12) 1 (2)
ALT increased 7 (12) 0 (0)
Weight loss 7 (12) 0 (0)
Hypertension 6 (10) 0 (0)
Cough 6 (10) 0 (0)
Febrile neutropenia 3 (5) 3 (5)
Dehydration 3 (5) 2 (3)
Immune-related adverse events
Hypothyroidisma 8 (13) 0 (0)
Hyperthyroidismb 4 (7) 0 (0)
Adrenal insufficiency 1 (2) 0 (0)
Diabetes mellitus 2 (3) 2 (3)
Dermatitis 12 (20) 0 (0)
Colitis 4 (7) 2 (3)
Guillan–Barre syndrome 1 (2) 1 (2)
Optic neuritis 1 (2) 0 (0)
Pneumonitis 1 (2) 0 (0)
Arthritis 1 (2) 0 (0)
Parotitisc 1 (2)
SAE 14 n/a
SAE serious adverse event.
aTreatment-related adverse events were events that were attributed to a trial treatment by investigators.
bFour patients had both hyperthyroidism and hypothyroidism over the course of their treatment.
cImmune-related adverse event without a grade.
Two patients died. One discontinued therapy after one dose of durvalumab and two weekly treatments of nab-paclitaxel due to altered mental status attributed to Miller–Fisher variant of Guillain–Barre syndrome. Her mental status did not improve and the family opted for comfort care measures only. Her other co-morbid illnesses included hypertension, type 2 diabetes, and chronic obstructive pulmonary disease (COPD). The patient passed away several months later in a hospice. The other patient had completed 9 weekly treatments of nab-paclitaxel (further treatments were held because of peripheral neuropathy), 4 cycles of AC concurrent with durvalumab, and died of sudden death in her home before undergoing surgery. No autopsy was performed. Her other co-morbid illnesses included hypertension, hyperlipidemia, type 2 diabetes, history of coronary artery disease with a left ventricular ejection fraction (LVEF) of 50–55%.
Discussion
The addition of ten cycles of durvalumab (10 mg/kg every 2 weeks) to weekly nab-paclitaxel (100 mg/m2) and ddAC resulted in a pCR rate of 44% (95% CI: 30–57%) in patients with early-stage TNBC in our trial. An identical chemotherapy regimen demonstrated a pCR rate of 29% in TNBC in the SWOG S0800 trial11, while other sequential taxane anthracycline regimens reported pCR rates between 30 and 48% in TNBC15. Two randomized Phase II trials also compared durvalumab plus chemotherapy with chemotherapy alone as neoadjuvant therapy. The GeparNuevo trial in TNBC demonstrated a numerical but not statistically significant increase in pCR rate (53% vs. 44%, p = 0.287) when durvalumab (1500 mg every 4 weeks) was included with weekly nab-paclitaxel (125 mg/m2) and epirubicin/cyclophosphamide16. The Bayesian randomized I-SPY2 trial evaluated the combination of 1500 mg durvalumab every 4 weeks and olaparib 100 mg twice a day concurrent with weekly paclitaxel (80 mg/kg) followed by AC without durvalumab or olaparib vs. the same chemotherapy regimen alone and reported an increase in pCR rate from 27 to 47% in the TNBC population of the trial with a 98% probability that the experimental arm is superior to the control17. The 95% confidence interval of the pCR point estimate in our trial includes the pCR rates seen in the immunotherapy arms of both these randomized trials and therefore the results are consistent with an improvement in pCR rate with the inclusion of durvalumab.
The addition of pembrolizumab to neoadjuvant chemotherapy was also examined in two large randomized trials in TNBC. The KEYNOTE-522 trial showed a significant improvement in pCR rate with the inclusion of pembrolizumab with paclitaxel plus carboplatin followed by anthracycline/cyclophosphamide compared to the same chemotherapy plus placebo (65% vs. 51%, p < 0.001)18. Another, previously reported arm of the I-SPY2 trial, randomized patients to 4 cycles of pembrolizumab vs. placebo in combination with weekly paclitaxel followed by AC without pembrolizumab and reported a significant improvement in predicted pCR rates from 22% in the control arm to 60% in the pembrolizumab arm in TNBC19. Atezolizumab has also been evaluated in two neoadjuvant randomized trials in TNBC. The IMpassion-031 trial randomized patients to atezolizumab or placebo concurrent with nab-paclitaxel followed by doxorubicin/cyclophosphamide, the same chemotherapy regimen as in our current study, and showed a significant increase in pCR rate (58% vs. 41%, p = 0.0044)20. However, one randomized trial, the NeoTRIPaPDL1, that compared nab-paclitaxel/carboplatin with or without atezolizumab failed to show a significant improvement in pCR rate with the inclusion of atezolizumab (pCR rate 43% vs. 41%)21. One important difference is that NeoTRIPaPDL1, unlike all the other positive trials had no anthracycline component. However, it is difficult to attribute the lack of efficacy in this trial to the lack anthracyclines; (i) it is clear from multiple metastatic trials in breast cancer that immune checkpoint inhibitors are synergistic with single-agent nab-paclitaxel at similar doses as used in NeoTRIPaPDL1, (ii) the two immune checkpoint inhibitor arms of the ISPY trial demonstrated improvement in pCR even though immunotherapy was only administered during the paclitaxel phase of chemotherapy, (iii) in lung cancer and other cancers immune checkpoint inhibitors are clearly synergistic with taxane/carboplatin regimens, and finally (iv) a small, multi-arm, window of opportunity trial, TONIC22, randomized patients to nivolumab alone or with a brief concurrent induction therapy including either irradiation (3 × 8 Gy), or cyclophosphamide (50 mg orally daily for 2 weeks), or cisplatin (40 mg/m2 intravenously weekly × 2), or doxorubicin (15 mg intravenously weekly × 2) for 2 weeks, and reported the highest responses rates and upregulation of immune-related genes with cisplatin and with doxorubicin. While it remains unclear why the NeoTRIPaPDL1 trial was negative, overall, the majority of trials provide consistent evidence for an improvement in pCR rate when an immune checkpoint inhibitor is added to standard of care neoadjuvant chemotherapy in TNBC.
Next, we examined the relationship between TIL count and pCR rate and found that patients with pCR had significantly higher TIL counts than those with residual disease. TIL-high (i.e., TIL ≥ 30%) cancers (n = 14) had a pCR rate close to 60%. However, TIL count alone may not identify patients who selectively benefit from the inclusion of an immune checkpoint inhibitor in the neoadjuvant chemotherapy regimen, as it has been shown that immune-rich TNBC also has higher pCR rates with chemotherapy alone compared to immune-low cancers1–5. The pCR rate was also higher in PD-L1 positive tumors (55% vs. 32%) in our study; however, this difference was not statistically significant (p = 0.15). The lack of statistical significance is likely due to the small sample size (i.e., the same proportions of 17/31 pCR in PD-L1 positive and 6/19 pCR in PD-L1 negative cancers would have resulted in a p < 0.0001 in a 500-patient trial [corresponding numbers would be 170/310 and 60/190]). All other substantially larger randomized neoadjuvant immune checkpoint inhibitor trials have reported significantly higher pCR rates in PD-L1 positive TNBC, which was consistent across three different immune checkpoint inhibitors—pembrolizumab19, durvalumab16, and atezolizumab20,21 and three different IHC assays: 22C319, SP26316, and SP14221. However, these trials also showed that immune checkpoint therapy increases pCR rates even in PD-L1 negative cancers, and similar to TIL counts, PD-L1 status may not be useful in selecting patients for neoadjuvant immunotherapy.
The inability of PD-L1 protein expression, as determined by current assays, to identify patients who selectively benefit from immune checkpoint therapy in early-stage TNBC is very different from results obtained in metastatic TNBC where PD-L1 expression unequivocally identifies a subset of patients who have the potential to benefit from immune therapy. In the randomized IMpassion130 trial, only PD-L1 immune cell-positive patients (either with SP142, 22C3, or SP263 assays) showed improved progression-free survival (PFS) when atezolizumab was added to nab-paclitaxel as first-line therapy for metastatic TNBC23. In the KEYNOTE-119 trial, objective response rates and progression-free survival with single-agent pembrolizumab increased almost linearly as PD-L1 positivity increased (with 22C3 assay)24. The recently presented KEYNOTE 355 trial that compared pembrolizumab vs. placebo in addition to chemotherapy for metastatic TNBC in the first-line setting also demonstrated a statistically significant improvement in PFS in the pembrolizumab arm but only in PD-L1 positive cancers (CPS ≥ 10 using the 22C3 assay)25. The SAFIR-02 trial randomized patients with metastatic breast cancer who had a response or stable disease after 6 to 8 cycles of chemotherapy and had no actionable mutations, to maintenance single-agent durvalumab or continuation of chemotherapy. Maintenance durvalumab had inferior PFS in the entire population but demonstrated improved OS in the PD-L1 positive cancers (with SP142 assay)26. These results clearly demonstrate that unlike in stages I–III TNBC, PD-L1 positivity is required for the benefit of atezolizumab, pembrolizumab, and durvalumab in metastatic TNBC.
The biological reasons behind the distinct predictive functions of PD-L1 in metastatic vs. early-stage breast cancers are unclear. However, PD-L1 protein expression on immune cells, the primary cellular sources of PD-L1 expression in breast cancer, correlates closely with overall immune infiltration6–8 and metastatic lesions have been shown to have an overall more immune attenuated tissue microenvironment, even when immune cells are present, compared to primary tumors27–29. We hypothesize that in metastatic breast cancer, greater immune checkpoint inhibitor target expression (reflected by higher PD-L1 expression) may be required to obtain benefit from immune checkpoint inhibition, whereas low levels of the target (that may be missed by current PD-L1 IHC or TIL counting methods) may be sufficient to augment antitumor immune responses by immune checkpoint inhibitors in stages I–III TNBC. Indeed, in our study, all TNBCs had at least 1% sTILs but the PD-L1 positivity rate was only 42% in cancers with sTIL between 1 and 10%, compared to 100% positivity rate in cancers with sTIL ≥30%.
Immune-related adverse events were consistent with known adverse events of immune checkpoint inhibitors and no new safety concerns were identified. There were no perioperative complications. However, we did observe several severe irAEs including 2 patients (3%) with autoimmune type I diabetes. One patient presented with grade 3 hyperglycemia, diabetic ketoacidosis, low C-peptide, and increased islet antibody-2 (IA-2) after 4 cycles of durvalumab, requiring inpatient admission. She remains on long-term insulin treatment. The second patient presented with grade 4 hyperglycemia without diabetic ketoacidosis after completing 7 cycles of durvalumab. She had a history of metabolic syndrome (obesity, glucose intolerance) and was initially thought to have type II diabetes; however, her C-peptide level was low on presentation with a further decrease on follow-up testing 5 months later, indicating autoimmune type I-like diabetes. There were two deaths possibly related to treatment, one patient suffered a presumed cardiac arrest following completion of all study-related treatments but prior to undergoing surgery and one patient died after developing the Miller–Fisher variant of Guillain–Barre syndrome (GBS), a rare but previously reported neurologic complication of checkpoint inhibition characterized by ophthalmoplegia, ataxia, and hypersomnolence30. Notably, she developed GBS after only one dose of durvalumab. We recognize that our study had slightly higher than expected toxicity and mortality, we attribute this to more comorbidities in our study population than seen in the pivotal randomized trials. A growing number of randomized neoadjuvant trials with pembrolizumab, durvalumab, and atezolizumab including over 2000 patients with TNBC show good tolerability but also added immune-related toxicities. In the KEYNOTE-522 trial, 32% of patients experienced immune-related adverse events of any grade, and 12% had grade 3 or greater immune-related toxicities18. The most common were hypo-, and hyperthyroidism, and skin rash. Similar results were seen in Impassion-03120.
In summary, these results add to the growing literature that indicates the efficacy of immune checkpoint inhibitors in early-stage TNBC. Durvalumab concurrent with neoadjuvant nab-paclitaxel and ddAC chemotherapy resulted in a 44% pCR rate. Among the 62% of patients who had PD-L1 positive disease, the pCR rate was 55%, among PD-L1 negative cancers the pCR rate was 32%.
Methods
Study design
The primary objective of the Phase I part was to assess the safety of durvalumab concurrent with weekly nab-paclitaxel (100 mg/m2) × 12 treatments followed by doxorubicin (60 mg/m2) and cyclophosphamide (600 mg/m2) every 2 weeks (AC) × 4 treatments. Two dose levels, 3 mg/kg and 10 mg/kg, of durvalumab, administered every 2 weeks were explored following a 3 + 3 design. No steroid premedications were used during nab-paclitaxel treatment and durvalumab was administered immediately after completion of nab-paclitaxel. During AC, the first course of treatment was administered without dexamethasone pre-medication, but if clinically significant nausea or vomiting occurred subsequent courses were given with 20 mg dexamethasone. Approximately 24 h after administration of AC, 6 mg pegfilgrastim was administered followed by durvalumab. Dose-limiting toxicities (DLT) were monitored during the entire 20 weeks of therapy and for 4 weeks after completion of surgery before advancing to the next dose level. DLT was defined as any grade 4 immune-related adverse event (irAE), any grade 3 irAE that did not resolve to grade 2 within 3 days despite optimal management or did not resolve to ≤grade 1 within 14 days, and any ≥grade 3 non-irAE causally attributed to durvalumab. The primary efficacy objective was to assess pCR rate in patients who received the recommended Phase II dose including both the Phase I and phase II component. The efficacy study followed Simon’s two-stage design (p0 = 30%, p1 = 50%) with an interim efficacy analysis after the first 22 patients completed surgery and accrual was to be terminated if <7 patients experienced pCR, otherwise, accrual continued until 50 patients were evaluable for pCR. The maximum sample size was set to N = 61 allowing for replacement of non-evaluable patients. If >20 of 50 evaluable patients had pCR (40% observed pCR rate) the combination therapy would be recommended for further study. This was an investigator-initiated trial, and ethical approval was obtained from the Yale Human Investigations Committee (Yale University, HIC# 1409014537). Astra Zeneca provided study drug and funding for the trial but played no role in the study design, collection/analysis of data, or manuscript preparation.
Patients and assessments
The study was approved and was annually reviewed by the internal institutional review board and all patients provided a written consent form to join the study. All patients signed written informed consent prior to participation. Patients with clinical stages I–III, triple-negative breast cancer, defined as ER and PR < 1% positive and HER2 negative (IHC 0, 1+, or 2+, or FISH negative), for whom systemic chemotherapy was indicated according to NCCN treatment guidelines were eligible31. Exclusion criteria included contraindications for anthracycline, paclitaxel, or anti-PD-L1 therapies (e.g., active autoimmune disease, live vaccines within 30 days, prior transplants, immune deficiency, active immunosuppressive medications).
Adverse events (AE) were assessed every 2 weeks and graded according to NCI CTCAE v4.03. All patients who received at least one dose of durvalumab were included in toxicity analysis. Surgery was performed within 4 weeks of completion of neoadjuvant chemotherapy and the extent of residual cancer assessed by the local pathologist as part of routine care. Residual Cancer Burden was assessed centrally by a breast pathologist (E.R.)32.
Biomarker analysis
PD-L1 expression on formalin-fixed paraffin-embedded pretreatment biopsies was assessed with chromogenic immunohistochemistry (IHC) using the VENTANA PD-L1 (SP263) Assay performed according to the Federal Drug Administration (FDA) label. PD-L1 positivity was determined by consensus review of 2 pathologists (E.R., D.L.R.), and ≥1% staining on immune or tumor cells was considered positive. The percentage of stromal tumor-infiltrating lymphocytes (sTILs) was assessed on hematoxylin–eosin-stained slides and calculated as the area occupied by mononuclear inflammatory cells over the total intratumoral stromal area (E.R, K.S.). The association between pCR, PD-L1 expression, and sTILs along with clinicopathologic parameters (age, tumor size [T1 vs. T2/T3], nodal status [N0 vs. N1–N3]) was assessed using logistic regression. The pCR rates between PD-L1 positive and negative cohorts were compared using Fisher’s exact test. PD-L1 positivity rate in low, intermediate, and high sTIL cancers was assessed with a two-sided Fisher’s exact test. Median sTILs percent between cases with pCR and RD were compared using the Mann–Whitney U test.
Reporting summary
Further information on research design is available in the Nature Research Reporting Summary linked to this article.
Supplementary information
Supplementary Figure 1
Reporting Summary Checklist
Supplementary information
The online version contains supplementary material available at 10.1038/s41523-021-00219-7.
Acknowledgements
We thank the participating patients and their families, as well as the research nurses, trial coordinators, and operations staff, for their contributions, and we thank the investigators who enrolled patients in this trial. The research reported in this publication was supported by Astra Zeneca and grants from the National Cancer Institute (R01CA219647), the Breast Cancer Research Foundation, and the Susan Komen Foundation (SAC160076) to L.P.
Author contributions
Study design: L.P. Patient accrual: A.S., N.F., J.P., K.A., A.K., N.H., D.L., A.C., T.P., and L.P. Data analysis: J.F., M.M., E.R., K.S., C.F., T.B., E.I., T.Q., Y.B., K.B., D.R., and L.P. Manuscript writing: J.F., K.B., and L.P. Final review of manuscript: all authors.
Data availability
The data generated and analyzed during this study are described and shared openly in the following data record: 10.6084/m9.figshare.1336296833. The three data files containing all data are as follows. (1) Neoadjuvant Durvalumab Study_AEs_irAEs no dates.xlsx: Adverse events of all grades including detailed immune-related adverse events observed during our study. The file also includes data on the discontinuation of study drugs and the reason for those discontinuations. (2) Neoadjuvant Durvalumab Study_Demographics_Outcomes no dates.xlsx: Study participant demographics with no identifiable information and all dates removed from the data. Data includes baseline disease characteristics as well as outcomes in terms of survival and recurrence events up to the data cutoff of 8/15/2020. (3) Neoadjuvant Durvalumab Study_TIL counts_PDL1.xlsx - Tumor-infiltrating lymphocyte (TIL) counts (%) and PD-L1 status (positive vs. negative or unscorable) of patient’s tumors.
Competing interests
A.S. has received honoraria and consulting fees from Astra Zeneca. D.L.R. has served as an advisor and consultant for Amgen, Astra Zeneca, Biocept, BMS, Cell Signaling Technology, Cepheid, Daiichi Sankyo, GSK, Konica/Minolta, Merck, NanoString, NextCure, Odonate, Perkin Elmer, PAIGE.AI, Roche, Sanofi, Ventana, and Ultivue; received research funding from Amgen, Cepheid, NavigateBP, NextCure, Konica/Minolta, Lilly, and Ultivue; received instrument support from Akoya/Perkin Elmer, NanoString and Ventana; is a founder and equity holder of PixelGear, and received royalties from Rarecyte. L.P. has received consulting fees and honoraria from Astra Zeneca, Merck, Novartis, Bristol-Myers Squibb Genentech, Eisai, Pieris, Immunomedics, Seattle Genetics, Clovis, Syndax, H3Bio, and Daiichi. The remaining authors declare no competing interests.
Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. | CYCLOPHOSPHAMIDE, DOXORUBICIN, DURVALUMAB, PACLITAXEL | DrugsGivenReaction | CC BY | 33558513 | 18,936,228 | 2021-02-08 |
What was the dosage of drug 'CYCLOPHOSPHAMIDE'? | Neoadjuvant durvalumab plus weekly nab-paclitaxel and dose-dense doxorubicin/cyclophosphamide in triple-negative breast cancer.
The goal of this Phase I/II trial is to assess the safety and efficacy of administering durvalumab concurrent with weekly nab-paclitaxel and dose-dense doxorubicin/cyclophosphamide (ddAC) neoadjuvant therapy for stages I-III triple-negative breast cancer. The primary endpoint is pathologic complete response (pCR:ypT0/is, ypN0). The response was correlated with PDL1 expression and stromal tumor-infiltrating lymphocytes (sTILs). Two dose levels of durvalumab (3 and 10 mg/kg) were assessed. PD-L1 was assessed using the SP263 antibody; ≥1% immune and tumor cell staining was considered positive; sTILs were calculated as the area occupied by mononuclear inflammatory cells over the total intratumoral stromal area. 59 patients were evaluable for toxicity and 55 for efficacy in the Phase II study (10 mg/kg dose). No dose-limiting toxicities were observed in Phase I. In Phase II, pCR rate was 44% (95% CI: 30-57%); 18 patients (31%) experienced grade 3/4 treatment-related adverse events (AE), most frequently neutropenia (n = 4) and anemia (n = 4). Immune-related grade 3/4 AEs included Guillain-Barre syndrome (n = 1), colitis (n = 2), and hyperglycemia (n = 2). Of the 50 evaluable patients for PD-L1, 31 (62%) were PD-L1 positive. pCR rates were 55% (95% CI: 0.38-0.71) and 32% (95% CI: 0.12-0.56) in the PD-L1 positive and negative groups (p = 0.15), respectively. sTIL counts were available on 52 patients and were significantly higher in the pCR group (p = 0.0167). Concomitant administration of durvalumab with sequential weekly nab-paclitaxel and ddAC neoadjuvant chemotherapy resulted in a pCR rate of 44%; pCR rates were higher in sTIL-high cancers.
pmcIntroduction
The presence of immune cells in the tumor microenvironment of triple-negative breast cancer (TNBC) is associated with a good prognosis with1 or without adjuvant chemotherapy2, and is also predictive of pathologic complete response (pCR, ypT0/is, ypN0) after neoadjuvant chemotherapy3. Animal models of cancer also demonstrated that immune cells in the tumor microenvironment, particularly activated cytotoxic T cells, partially mediate chemotherapy response4,5. The availability of immune checkpoint inhibitors in the clinic that target the programmed cell death protein-1 (PD-1) and its ligands allow us to directly test if removing an important inhibitory signal from the immune microenvironment can lead to a more effective antitumor immune response and increase chemotherapy sensitivity. PD-1 is expressed on the surface of T cells and causes T-cell inhibition when it binds to either of its two ligands, programmed death-ligand-1 (PD-L1) and -2 (PD-L2). PD-L1 is expressed on the cell surface of cancer cells, macrophages, dendritic cells, and T cells6,7. There is a strong positive correlation between PD-L1 expression, immune infiltration, and tumor-infiltrating lymphocyte count, which explains the paradoxical observations that high PD-L1 expression is associated with better prognosis and higher pCR rate in breast cancer8,9.
Durvalumab is a monoclonal human immunoglobulin G1κ antibody that binds to PD-L1 and inhibits its interaction with PD-1 and CD80 (B7.1)10. The antibody also contains mutations in the constant domain of the heavy chain that reduces binding to complement protein C1q and to Fcγ receptors to avoid complement- and antibody-mediated cytotoxicity. In this trial (NCT02489448), we tested the hypothesis that durvalumab administered concurrently with sequential weekly nab-paclitaxel and dose-dense AC (ddAC) neoadjuvant chemotherapy will increase pCR rate above the historical pCR rate of 30% observed with the same chemotherapy regimen in TNBC in an earlier trial (SWOG S0800, NCT00856492)11. Among the different neoadjuvant chemotherapy options that can be combined with checkpoint inhibitors, we selected Nab-paclitaxel because it did not require steroid premedications12. In addition, there is preclinical evidence suggesting that nab-paclitaxel can release tumor antigens from rapidly dying cells13, which in turn might be able to prime antitumor T cells, a response that might be further amplified by the addition of checkpoint inhibitors.
Results
Patient population
Sixty-nine patients were screened for enrollment at Yale Cancer Center and its regional care centers; 60 patients consented to the trial between December 18, 2015, and November 21, 2018. One patient subsequently withdrew consent. The baseline characteristics of the remaining 59 patients are shown in Table 1. Seven patients were included in Phase I part of the study, four at 3 mg/kg and three at 10 mg/kg dose. Fifty-two patients were enrolled in the Phase II part at a 10 mg/kg dose. Two patients did not proceed to surgery—one developed irreversible altered mental status attributed to Guillen Barre syndrome and family opted for comfort care, the other completed treatment but died of sudden death in her home before undergoing surgery.Table 1 Patients characteristics.
Characteristics N (%)
All patients 59 (100)
Age (median 50 years)
≤40 11 (19)
41–50 19 (32)
51–69 29 (49)
≥70 0 (0)
Race/ethnicity
White (non-Hispanic) 35 (59)
Hispanic/Latino 5 (8)
Black 11 (19)
Asian/American Indian 4 (6)
Unknown 4 (6)
Clinical tumor size
T1 21 (35)
T2 30 (51)
T3 8 (14)
Clinical nodal status
cN0 31 (52)
cN1 25 (42)
cN2 1 (2)
cN3 3 (4)
Clinical stage at diagnosis
I 12 (20)
II 33 (56)
III 14 (24)
Histologic tumor grade
G1 1 (2)
G2 12 (20)
G3 45 (76)
Unknown 1 (2)
Durvalumab dose level
3 mg/kg 4 (7)
10 mg/kg 55 (93)
Pathologic response
pCR 26 (44)
RD 31 (53)
No surgery 2 (3)
Residual cancer burden (RCB)
RCB-I 7 (12)
RCB-II 18 (31)
RCB-III 6 (10)
No surgery 2 (3)
PD-L1 IHC
Negative 19 (32)
Positive (≥1%) 33 (56)
Not available 7 (12)
Stromal TIL count
0–10% 28 (48)
11–29% 10 (17)
≥30% 16 (27)
Not available 5 (8)
TIL tumor-infiltrating lymphocytes, IHC immunohistochemistry.
Efficacy
In the total intention-to-treat population in the Phase II trial who received the recommended Phase II dose of 10 mg/kg durvalumab (N = 55), the pCR rate was 44% (N = 24, 95% CI: 30–57%). Of the 55 patients, 19 (34.5%) received less than the planned 10 treatments with durvalumab, including 7 patients who received less than six doses. Among the 36 patients who received all 10 treatments, 17 (47%) had a pCR. Four patients had clinical progression and underwent surgery or switched to other chemotherapy. One of these patients who subsequently received carboplatin had a pCR at the surgery.
Among the 57 patients who received durvalumab at any dose level and completed surgery, pCR rate was 46%, including 2 pCRs among the 4 patients who received 3 mg/kg durvalumab in the phase I part of the study. The RCB class distribution was RCB-0 (pCR): 46%, RCB-I: 12%, RCB-II: 31%, and RCB-III: 10%. At a median follow-up of 20 months, there have been no recurrences in cases that achieved a pCR. Among those with residual disease, there were nine metastatic and two local recurrences. Three patients died from metastatic disease.
Biomarker results
The consort diagram shows data availability for biomarker analysis (Supplementary Fig. 1). Fifty-two patients had PD-L1 IHC results available; 63% (N = 33) were PD-L1 positive. Two patients with PD-L1 staining had no surgery. Among the 50 patients who completed surgery, patients who achieved pCR had nominally higher PD-L1 positivity rate, compared to those with RD, although this did not reach not statistical significance (74% (95% CI: 54–88%) vs. 52% (95% CI: 34–88%); p = 0.15), (Fig. 1a). The pCR rate was 55% (95% CI: 38–71%) in the PD-L1 positive group compared to 32% (95% CI: 12–56%) in the PD-L1 negative group, also not significantly different (p = 0.15; Fig. 2a). In the same tissues, a parallel study with quantitative measurement of PD-L1 using immunofluorescence showed a statistically significant association between PD-L1 expression as a continuous variable and pCR, which is reported separately14.Fig. 1 PD-L1 positivity and stromal TILs (sTILs) by pathologic response category.
a PD-L1-positivity rate by SP263 antibody in the pathologic complete response (pCR, 74%, n = 14), and residual disease (RD, 52%, n = 13) groups, respectively, p = 0.148 (two-sided Fisher’s exact test). b The percentage of manual stromal tumor-infiltrating lymphocytes (sTILs) and the median (horizontal line) in the pCR (median: 20%) and RD groups (median: 5%), error bars represent 95% confidence intervals, p = 0.0167 (Mann–Whitney U test).
Fig. 2 Distribution of pCR rate by PD-L1 status and manual stromal TILs (sTILs).
a pCR rates in the PD-L1-positive (55%; 95% CI: 0.38–0.71) and -negative (32%; 95% CI: 0.15–0.54) groups, p = 0.148 (two-sided Fisher’s exact test). b pCR rates in cancers with ≥30% sTIL (pCR 57%), 29–10% sTIL (pCR 60%), and <10% sTIL (pCR 29%) groups, p = 0.099 (two-sided Fisher’s exact test). c PD-L1 positivity rates in cancers with sTIL >30%, sTIL 29%–10%, and sTIL <10%, were 100%, 71% and 42%, respectively, p = 0.00015 (two-sided Fisher’s exact test). On all panels error bars represent standard deviations (s.d.).
Manual sTIL counts were available on 54 patients including the 2 patients who did not complete surgery. All patients with evaluable sTIL counts had at least 1% sTILs and 14 of the 52 patients (27%) had sTIL-high cancers defined as ≥30% sTILs. Figure 1b shows TIL counts in the pCR and RD groups. The pCR rates were 57%, 60%, and 29% among TIL-high (sTIL ≥ 30%), intermediate (sTIL 29–10%), and low (sTIL < 10%) groups, p = 0.099. (Fig. 2b). Forty-nine patients had both baseline sTIL and PD-L1 results available, Stromal TIL count was significantly higher in the PD-L1 positive group (median 27.5% vs. 5%; p < 0.001). In cancers with sTIL ≥30%, the PD-L1 positivity rate was 100%, in cancers with sTIL 11–29%, PD-L1 positivity was 71%, and in cancers with sTIL <10%, PD-L1 positivity was only 42% (p = 0.00015 (two-sided Fisher’s exact test); Fig. 2c). Patients whose tumors were PD-L1 positive and sTIL-high (≥30%) had a numerically higher pCR rate of 57% than those with PD-L1 positive but sTIL intermediate or low cancers (pCR rate 50%) or PD-L1 negative cancers (pCR rate 32%), but these differences did not reach statistical significance (p = 0.302, two-sided Fisher’s exact test).
In a multivariate analysis including PD-L1 expression (positive vs. negative), sTIL count (as a continuous variable), age, tumor size (T1 vs. T2/T3) NS nodal status (N− vs. N+), neither PD-L1 status (SP263 IHC) nor sTIL count was independently associated with pCR (Table 2).Table 2 Univariate and multivariate logistic regression analyses to identify possible independent predictors of pCR following neoadjuvant therapy.
Univariate analysis Multivariate analysisa
Variables OR (95% CI) p-value OR (95% CI) p-value
sTILs (continuous variable) 0.99 (0.98–1.01) 0.56 1.00 (0.98–1.01) 0.63
PD-L1 (POS vs. NEG) 2.63 (0.82–9.21) 0.11 2.62 (0.78–9.62) 0.13
Age (continuous variable) 1.00 (0.96–1.04) 0.94
T status (T1 vs. T2/3) 0.47 (0.15–1.44) 0.19
N status (N− vs. N+) 1.38 (0.49–4.00) 0.54
aCovariates included are age (as a continuous variable), T status (T1 vs. T2/3), and N status (N− vs. N+).
Safety and toxicity
All patients who received at least one dose of study-assigned therapy were evaluated for safety and toxicity. Overall, durvalumab was discontinued in 19 (32%) patients, including 2 patients in Phase I portion of the study. During nab-paclitaxel treatment durvalumab was discontinued in 9 patients, 5 due to local progression and 4 due to AEs, 3 of which were immune-related (irAE): one case each of autoimmune diabetes, Guillain–Barre syndrome (GBS), and optic neuritis. In addition, durvalumab was held in 3 patients for at least 1 cycle during nab-paclitaxel due to AEs—transaminitis, dermatitis, and fatigue—and was then continued with the AC portion of chemotherapy. During the AC portion of chemotherapy, durvalumab was discontinued in 9 patients, 7 due to AEs, 2 of which were irAEs: one pneumonitis and one dermatitis. In addition, 5 patients discontinued AC chemotherapy (one each for renal failure, fatigue, and rash, and two due to neutropenic fever) and proceeded to surgery before completing all the planned doses of durvalumab. Two patients were found to be ineligible for the AC portion of treatment due to underlying cardiac disease discovered during the study. Selected treatment-related and clinically relevant toxicities and immune-related adverse events reported within 180 days of the last investigational agent dose are summarized in Table 3. The irAEs observed have all previously been observed in the context of other clinical studies; no new safety concerns were identified. The most frequent irAEs reported were dermatitis and endocrinopathies, with thyroid dysfunction being the most common (hypo- and hyperthyroidism), occurring in 13% of patients including 4 patients who had hyperthyroidism that progressed to hypothyroidism. Adrenal insufficiency was observed in 1 patient. Two patients developed autoimmune diabetes characterized by low or undetectable C-peptide levels and in 1 of the 2 patients, autoantibodies against islet antigen 2 (IA-2).Table 3 Treatment-related adverse events occurring in ≥10% of patients, or grades 3–4 occurring in ≥2% of patients.
All grades Grades 3–4
Adverse event N (%)
Fatigue 50 (85) 1 (2)
Nausea 43 (73) 0 (0)
Alopecia 39 (66) 0 (0)
Anemia 35 (59) 4 (7)
Rash 35 (59) 1 (2)
Diarrhea 27 (46) 0 (0)
Peripheral sensory neuropathy 20 (37) 0 (0)
Leukopenia 16 (27) 3 (5)
Neutropenia 13 (22) 4 (7)
Vomiting 12 (20) 0 (0)
Anorexia 11 (19) 0 (0)
Dyspnea 9 (15) 1 (2)
Myalgia 9 (15) 0 (0)
Mucositis 7 (12) 1 (2)
ALT increased 7 (12) 0 (0)
Weight loss 7 (12) 0 (0)
Hypertension 6 (10) 0 (0)
Cough 6 (10) 0 (0)
Febrile neutropenia 3 (5) 3 (5)
Dehydration 3 (5) 2 (3)
Immune-related adverse events
Hypothyroidisma 8 (13) 0 (0)
Hyperthyroidismb 4 (7) 0 (0)
Adrenal insufficiency 1 (2) 0 (0)
Diabetes mellitus 2 (3) 2 (3)
Dermatitis 12 (20) 0 (0)
Colitis 4 (7) 2 (3)
Guillan–Barre syndrome 1 (2) 1 (2)
Optic neuritis 1 (2) 0 (0)
Pneumonitis 1 (2) 0 (0)
Arthritis 1 (2) 0 (0)
Parotitisc 1 (2)
SAE 14 n/a
SAE serious adverse event.
aTreatment-related adverse events were events that were attributed to a trial treatment by investigators.
bFour patients had both hyperthyroidism and hypothyroidism over the course of their treatment.
cImmune-related adverse event without a grade.
Two patients died. One discontinued therapy after one dose of durvalumab and two weekly treatments of nab-paclitaxel due to altered mental status attributed to Miller–Fisher variant of Guillain–Barre syndrome. Her mental status did not improve and the family opted for comfort care measures only. Her other co-morbid illnesses included hypertension, type 2 diabetes, and chronic obstructive pulmonary disease (COPD). The patient passed away several months later in a hospice. The other patient had completed 9 weekly treatments of nab-paclitaxel (further treatments were held because of peripheral neuropathy), 4 cycles of AC concurrent with durvalumab, and died of sudden death in her home before undergoing surgery. No autopsy was performed. Her other co-morbid illnesses included hypertension, hyperlipidemia, type 2 diabetes, history of coronary artery disease with a left ventricular ejection fraction (LVEF) of 50–55%.
Discussion
The addition of ten cycles of durvalumab (10 mg/kg every 2 weeks) to weekly nab-paclitaxel (100 mg/m2) and ddAC resulted in a pCR rate of 44% (95% CI: 30–57%) in patients with early-stage TNBC in our trial. An identical chemotherapy regimen demonstrated a pCR rate of 29% in TNBC in the SWOG S0800 trial11, while other sequential taxane anthracycline regimens reported pCR rates between 30 and 48% in TNBC15. Two randomized Phase II trials also compared durvalumab plus chemotherapy with chemotherapy alone as neoadjuvant therapy. The GeparNuevo trial in TNBC demonstrated a numerical but not statistically significant increase in pCR rate (53% vs. 44%, p = 0.287) when durvalumab (1500 mg every 4 weeks) was included with weekly nab-paclitaxel (125 mg/m2) and epirubicin/cyclophosphamide16. The Bayesian randomized I-SPY2 trial evaluated the combination of 1500 mg durvalumab every 4 weeks and olaparib 100 mg twice a day concurrent with weekly paclitaxel (80 mg/kg) followed by AC without durvalumab or olaparib vs. the same chemotherapy regimen alone and reported an increase in pCR rate from 27 to 47% in the TNBC population of the trial with a 98% probability that the experimental arm is superior to the control17. The 95% confidence interval of the pCR point estimate in our trial includes the pCR rates seen in the immunotherapy arms of both these randomized trials and therefore the results are consistent with an improvement in pCR rate with the inclusion of durvalumab.
The addition of pembrolizumab to neoadjuvant chemotherapy was also examined in two large randomized trials in TNBC. The KEYNOTE-522 trial showed a significant improvement in pCR rate with the inclusion of pembrolizumab with paclitaxel plus carboplatin followed by anthracycline/cyclophosphamide compared to the same chemotherapy plus placebo (65% vs. 51%, p < 0.001)18. Another, previously reported arm of the I-SPY2 trial, randomized patients to 4 cycles of pembrolizumab vs. placebo in combination with weekly paclitaxel followed by AC without pembrolizumab and reported a significant improvement in predicted pCR rates from 22% in the control arm to 60% in the pembrolizumab arm in TNBC19. Atezolizumab has also been evaluated in two neoadjuvant randomized trials in TNBC. The IMpassion-031 trial randomized patients to atezolizumab or placebo concurrent with nab-paclitaxel followed by doxorubicin/cyclophosphamide, the same chemotherapy regimen as in our current study, and showed a significant increase in pCR rate (58% vs. 41%, p = 0.0044)20. However, one randomized trial, the NeoTRIPaPDL1, that compared nab-paclitaxel/carboplatin with or without atezolizumab failed to show a significant improvement in pCR rate with the inclusion of atezolizumab (pCR rate 43% vs. 41%)21. One important difference is that NeoTRIPaPDL1, unlike all the other positive trials had no anthracycline component. However, it is difficult to attribute the lack of efficacy in this trial to the lack anthracyclines; (i) it is clear from multiple metastatic trials in breast cancer that immune checkpoint inhibitors are synergistic with single-agent nab-paclitaxel at similar doses as used in NeoTRIPaPDL1, (ii) the two immune checkpoint inhibitor arms of the ISPY trial demonstrated improvement in pCR even though immunotherapy was only administered during the paclitaxel phase of chemotherapy, (iii) in lung cancer and other cancers immune checkpoint inhibitors are clearly synergistic with taxane/carboplatin regimens, and finally (iv) a small, multi-arm, window of opportunity trial, TONIC22, randomized patients to nivolumab alone or with a brief concurrent induction therapy including either irradiation (3 × 8 Gy), or cyclophosphamide (50 mg orally daily for 2 weeks), or cisplatin (40 mg/m2 intravenously weekly × 2), or doxorubicin (15 mg intravenously weekly × 2) for 2 weeks, and reported the highest responses rates and upregulation of immune-related genes with cisplatin and with doxorubicin. While it remains unclear why the NeoTRIPaPDL1 trial was negative, overall, the majority of trials provide consistent evidence for an improvement in pCR rate when an immune checkpoint inhibitor is added to standard of care neoadjuvant chemotherapy in TNBC.
Next, we examined the relationship between TIL count and pCR rate and found that patients with pCR had significantly higher TIL counts than those with residual disease. TIL-high (i.e., TIL ≥ 30%) cancers (n = 14) had a pCR rate close to 60%. However, TIL count alone may not identify patients who selectively benefit from the inclusion of an immune checkpoint inhibitor in the neoadjuvant chemotherapy regimen, as it has been shown that immune-rich TNBC also has higher pCR rates with chemotherapy alone compared to immune-low cancers1–5. The pCR rate was also higher in PD-L1 positive tumors (55% vs. 32%) in our study; however, this difference was not statistically significant (p = 0.15). The lack of statistical significance is likely due to the small sample size (i.e., the same proportions of 17/31 pCR in PD-L1 positive and 6/19 pCR in PD-L1 negative cancers would have resulted in a p < 0.0001 in a 500-patient trial [corresponding numbers would be 170/310 and 60/190]). All other substantially larger randomized neoadjuvant immune checkpoint inhibitor trials have reported significantly higher pCR rates in PD-L1 positive TNBC, which was consistent across three different immune checkpoint inhibitors—pembrolizumab19, durvalumab16, and atezolizumab20,21 and three different IHC assays: 22C319, SP26316, and SP14221. However, these trials also showed that immune checkpoint therapy increases pCR rates even in PD-L1 negative cancers, and similar to TIL counts, PD-L1 status may not be useful in selecting patients for neoadjuvant immunotherapy.
The inability of PD-L1 protein expression, as determined by current assays, to identify patients who selectively benefit from immune checkpoint therapy in early-stage TNBC is very different from results obtained in metastatic TNBC where PD-L1 expression unequivocally identifies a subset of patients who have the potential to benefit from immune therapy. In the randomized IMpassion130 trial, only PD-L1 immune cell-positive patients (either with SP142, 22C3, or SP263 assays) showed improved progression-free survival (PFS) when atezolizumab was added to nab-paclitaxel as first-line therapy for metastatic TNBC23. In the KEYNOTE-119 trial, objective response rates and progression-free survival with single-agent pembrolizumab increased almost linearly as PD-L1 positivity increased (with 22C3 assay)24. The recently presented KEYNOTE 355 trial that compared pembrolizumab vs. placebo in addition to chemotherapy for metastatic TNBC in the first-line setting also demonstrated a statistically significant improvement in PFS in the pembrolizumab arm but only in PD-L1 positive cancers (CPS ≥ 10 using the 22C3 assay)25. The SAFIR-02 trial randomized patients with metastatic breast cancer who had a response or stable disease after 6 to 8 cycles of chemotherapy and had no actionable mutations, to maintenance single-agent durvalumab or continuation of chemotherapy. Maintenance durvalumab had inferior PFS in the entire population but demonstrated improved OS in the PD-L1 positive cancers (with SP142 assay)26. These results clearly demonstrate that unlike in stages I–III TNBC, PD-L1 positivity is required for the benefit of atezolizumab, pembrolizumab, and durvalumab in metastatic TNBC.
The biological reasons behind the distinct predictive functions of PD-L1 in metastatic vs. early-stage breast cancers are unclear. However, PD-L1 protein expression on immune cells, the primary cellular sources of PD-L1 expression in breast cancer, correlates closely with overall immune infiltration6–8 and metastatic lesions have been shown to have an overall more immune attenuated tissue microenvironment, even when immune cells are present, compared to primary tumors27–29. We hypothesize that in metastatic breast cancer, greater immune checkpoint inhibitor target expression (reflected by higher PD-L1 expression) may be required to obtain benefit from immune checkpoint inhibition, whereas low levels of the target (that may be missed by current PD-L1 IHC or TIL counting methods) may be sufficient to augment antitumor immune responses by immune checkpoint inhibitors in stages I–III TNBC. Indeed, in our study, all TNBCs had at least 1% sTILs but the PD-L1 positivity rate was only 42% in cancers with sTIL between 1 and 10%, compared to 100% positivity rate in cancers with sTIL ≥30%.
Immune-related adverse events were consistent with known adverse events of immune checkpoint inhibitors and no new safety concerns were identified. There were no perioperative complications. However, we did observe several severe irAEs including 2 patients (3%) with autoimmune type I diabetes. One patient presented with grade 3 hyperglycemia, diabetic ketoacidosis, low C-peptide, and increased islet antibody-2 (IA-2) after 4 cycles of durvalumab, requiring inpatient admission. She remains on long-term insulin treatment. The second patient presented with grade 4 hyperglycemia without diabetic ketoacidosis after completing 7 cycles of durvalumab. She had a history of metabolic syndrome (obesity, glucose intolerance) and was initially thought to have type II diabetes; however, her C-peptide level was low on presentation with a further decrease on follow-up testing 5 months later, indicating autoimmune type I-like diabetes. There were two deaths possibly related to treatment, one patient suffered a presumed cardiac arrest following completion of all study-related treatments but prior to undergoing surgery and one patient died after developing the Miller–Fisher variant of Guillain–Barre syndrome (GBS), a rare but previously reported neurologic complication of checkpoint inhibition characterized by ophthalmoplegia, ataxia, and hypersomnolence30. Notably, she developed GBS after only one dose of durvalumab. We recognize that our study had slightly higher than expected toxicity and mortality, we attribute this to more comorbidities in our study population than seen in the pivotal randomized trials. A growing number of randomized neoadjuvant trials with pembrolizumab, durvalumab, and atezolizumab including over 2000 patients with TNBC show good tolerability but also added immune-related toxicities. In the KEYNOTE-522 trial, 32% of patients experienced immune-related adverse events of any grade, and 12% had grade 3 or greater immune-related toxicities18. The most common were hypo-, and hyperthyroidism, and skin rash. Similar results were seen in Impassion-03120.
In summary, these results add to the growing literature that indicates the efficacy of immune checkpoint inhibitors in early-stage TNBC. Durvalumab concurrent with neoadjuvant nab-paclitaxel and ddAC chemotherapy resulted in a 44% pCR rate. Among the 62% of patients who had PD-L1 positive disease, the pCR rate was 55%, among PD-L1 negative cancers the pCR rate was 32%.
Methods
Study design
The primary objective of the Phase I part was to assess the safety of durvalumab concurrent with weekly nab-paclitaxel (100 mg/m2) × 12 treatments followed by doxorubicin (60 mg/m2) and cyclophosphamide (600 mg/m2) every 2 weeks (AC) × 4 treatments. Two dose levels, 3 mg/kg and 10 mg/kg, of durvalumab, administered every 2 weeks were explored following a 3 + 3 design. No steroid premedications were used during nab-paclitaxel treatment and durvalumab was administered immediately after completion of nab-paclitaxel. During AC, the first course of treatment was administered without dexamethasone pre-medication, but if clinically significant nausea or vomiting occurred subsequent courses were given with 20 mg dexamethasone. Approximately 24 h after administration of AC, 6 mg pegfilgrastim was administered followed by durvalumab. Dose-limiting toxicities (DLT) were monitored during the entire 20 weeks of therapy and for 4 weeks after completion of surgery before advancing to the next dose level. DLT was defined as any grade 4 immune-related adverse event (irAE), any grade 3 irAE that did not resolve to grade 2 within 3 days despite optimal management or did not resolve to ≤grade 1 within 14 days, and any ≥grade 3 non-irAE causally attributed to durvalumab. The primary efficacy objective was to assess pCR rate in patients who received the recommended Phase II dose including both the Phase I and phase II component. The efficacy study followed Simon’s two-stage design (p0 = 30%, p1 = 50%) with an interim efficacy analysis after the first 22 patients completed surgery and accrual was to be terminated if <7 patients experienced pCR, otherwise, accrual continued until 50 patients were evaluable for pCR. The maximum sample size was set to N = 61 allowing for replacement of non-evaluable patients. If >20 of 50 evaluable patients had pCR (40% observed pCR rate) the combination therapy would be recommended for further study. This was an investigator-initiated trial, and ethical approval was obtained from the Yale Human Investigations Committee (Yale University, HIC# 1409014537). Astra Zeneca provided study drug and funding for the trial but played no role in the study design, collection/analysis of data, or manuscript preparation.
Patients and assessments
The study was approved and was annually reviewed by the internal institutional review board and all patients provided a written consent form to join the study. All patients signed written informed consent prior to participation. Patients with clinical stages I–III, triple-negative breast cancer, defined as ER and PR < 1% positive and HER2 negative (IHC 0, 1+, or 2+, or FISH negative), for whom systemic chemotherapy was indicated according to NCCN treatment guidelines were eligible31. Exclusion criteria included contraindications for anthracycline, paclitaxel, or anti-PD-L1 therapies (e.g., active autoimmune disease, live vaccines within 30 days, prior transplants, immune deficiency, active immunosuppressive medications).
Adverse events (AE) were assessed every 2 weeks and graded according to NCI CTCAE v4.03. All patients who received at least one dose of durvalumab were included in toxicity analysis. Surgery was performed within 4 weeks of completion of neoadjuvant chemotherapy and the extent of residual cancer assessed by the local pathologist as part of routine care. Residual Cancer Burden was assessed centrally by a breast pathologist (E.R.)32.
Biomarker analysis
PD-L1 expression on formalin-fixed paraffin-embedded pretreatment biopsies was assessed with chromogenic immunohistochemistry (IHC) using the VENTANA PD-L1 (SP263) Assay performed according to the Federal Drug Administration (FDA) label. PD-L1 positivity was determined by consensus review of 2 pathologists (E.R., D.L.R.), and ≥1% staining on immune or tumor cells was considered positive. The percentage of stromal tumor-infiltrating lymphocytes (sTILs) was assessed on hematoxylin–eosin-stained slides and calculated as the area occupied by mononuclear inflammatory cells over the total intratumoral stromal area (E.R, K.S.). The association between pCR, PD-L1 expression, and sTILs along with clinicopathologic parameters (age, tumor size [T1 vs. T2/T3], nodal status [N0 vs. N1–N3]) was assessed using logistic regression. The pCR rates between PD-L1 positive and negative cohorts were compared using Fisher’s exact test. PD-L1 positivity rate in low, intermediate, and high sTIL cancers was assessed with a two-sided Fisher’s exact test. Median sTILs percent between cases with pCR and RD were compared using the Mann–Whitney U test.
Reporting summary
Further information on research design is available in the Nature Research Reporting Summary linked to this article.
Supplementary information
Supplementary Figure 1
Reporting Summary Checklist
Supplementary information
The online version contains supplementary material available at 10.1038/s41523-021-00219-7.
Acknowledgements
We thank the participating patients and their families, as well as the research nurses, trial coordinators, and operations staff, for their contributions, and we thank the investigators who enrolled patients in this trial. The research reported in this publication was supported by Astra Zeneca and grants from the National Cancer Institute (R01CA219647), the Breast Cancer Research Foundation, and the Susan Komen Foundation (SAC160076) to L.P.
Author contributions
Study design: L.P. Patient accrual: A.S., N.F., J.P., K.A., A.K., N.H., D.L., A.C., T.P., and L.P. Data analysis: J.F., M.M., E.R., K.S., C.F., T.B., E.I., T.Q., Y.B., K.B., D.R., and L.P. Manuscript writing: J.F., K.B., and L.P. Final review of manuscript: all authors.
Data availability
The data generated and analyzed during this study are described and shared openly in the following data record: 10.6084/m9.figshare.1336296833. The three data files containing all data are as follows. (1) Neoadjuvant Durvalumab Study_AEs_irAEs no dates.xlsx: Adverse events of all grades including detailed immune-related adverse events observed during our study. The file also includes data on the discontinuation of study drugs and the reason for those discontinuations. (2) Neoadjuvant Durvalumab Study_Demographics_Outcomes no dates.xlsx: Study participant demographics with no identifiable information and all dates removed from the data. Data includes baseline disease characteristics as well as outcomes in terms of survival and recurrence events up to the data cutoff of 8/15/2020. (3) Neoadjuvant Durvalumab Study_TIL counts_PDL1.xlsx - Tumor-infiltrating lymphocyte (TIL) counts (%) and PD-L1 status (positive vs. negative or unscorable) of patient’s tumors.
Competing interests
A.S. has received honoraria and consulting fees from Astra Zeneca. D.L.R. has served as an advisor and consultant for Amgen, Astra Zeneca, Biocept, BMS, Cell Signaling Technology, Cepheid, Daiichi Sankyo, GSK, Konica/Minolta, Merck, NanoString, NextCure, Odonate, Perkin Elmer, PAIGE.AI, Roche, Sanofi, Ventana, and Ultivue; received research funding from Amgen, Cepheid, NavigateBP, NextCure, Konica/Minolta, Lilly, and Ultivue; received instrument support from Akoya/Perkin Elmer, NanoString and Ventana; is a founder and equity holder of PixelGear, and received royalties from Rarecyte. L.P. has received consulting fees and honoraria from Astra Zeneca, Merck, Novartis, Bristol-Myers Squibb Genentech, Eisai, Pieris, Immunomedics, Seattle Genetics, Clovis, Syndax, H3Bio, and Daiichi. The remaining authors declare no competing interests.
Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. | 600 MILLIGRAM/SQ. METER | DrugDosageText | CC BY | 33558513 | 18,936,228 | 2021-02-08 |
What was the dosage of drug 'DURVALUMAB'? | Neoadjuvant durvalumab plus weekly nab-paclitaxel and dose-dense doxorubicin/cyclophosphamide in triple-negative breast cancer.
The goal of this Phase I/II trial is to assess the safety and efficacy of administering durvalumab concurrent with weekly nab-paclitaxel and dose-dense doxorubicin/cyclophosphamide (ddAC) neoadjuvant therapy for stages I-III triple-negative breast cancer. The primary endpoint is pathologic complete response (pCR:ypT0/is, ypN0). The response was correlated with PDL1 expression and stromal tumor-infiltrating lymphocytes (sTILs). Two dose levels of durvalumab (3 and 10 mg/kg) were assessed. PD-L1 was assessed using the SP263 antibody; ≥1% immune and tumor cell staining was considered positive; sTILs were calculated as the area occupied by mononuclear inflammatory cells over the total intratumoral stromal area. 59 patients were evaluable for toxicity and 55 for efficacy in the Phase II study (10 mg/kg dose). No dose-limiting toxicities were observed in Phase I. In Phase II, pCR rate was 44% (95% CI: 30-57%); 18 patients (31%) experienced grade 3/4 treatment-related adverse events (AE), most frequently neutropenia (n = 4) and anemia (n = 4). Immune-related grade 3/4 AEs included Guillain-Barre syndrome (n = 1), colitis (n = 2), and hyperglycemia (n = 2). Of the 50 evaluable patients for PD-L1, 31 (62%) were PD-L1 positive. pCR rates were 55% (95% CI: 0.38-0.71) and 32% (95% CI: 0.12-0.56) in the PD-L1 positive and negative groups (p = 0.15), respectively. sTIL counts were available on 52 patients and were significantly higher in the pCR group (p = 0.0167). Concomitant administration of durvalumab with sequential weekly nab-paclitaxel and ddAC neoadjuvant chemotherapy resulted in a pCR rate of 44%; pCR rates were higher in sTIL-high cancers.
pmcIntroduction
The presence of immune cells in the tumor microenvironment of triple-negative breast cancer (TNBC) is associated with a good prognosis with1 or without adjuvant chemotherapy2, and is also predictive of pathologic complete response (pCR, ypT0/is, ypN0) after neoadjuvant chemotherapy3. Animal models of cancer also demonstrated that immune cells in the tumor microenvironment, particularly activated cytotoxic T cells, partially mediate chemotherapy response4,5. The availability of immune checkpoint inhibitors in the clinic that target the programmed cell death protein-1 (PD-1) and its ligands allow us to directly test if removing an important inhibitory signal from the immune microenvironment can lead to a more effective antitumor immune response and increase chemotherapy sensitivity. PD-1 is expressed on the surface of T cells and causes T-cell inhibition when it binds to either of its two ligands, programmed death-ligand-1 (PD-L1) and -2 (PD-L2). PD-L1 is expressed on the cell surface of cancer cells, macrophages, dendritic cells, and T cells6,7. There is a strong positive correlation between PD-L1 expression, immune infiltration, and tumor-infiltrating lymphocyte count, which explains the paradoxical observations that high PD-L1 expression is associated with better prognosis and higher pCR rate in breast cancer8,9.
Durvalumab is a monoclonal human immunoglobulin G1κ antibody that binds to PD-L1 and inhibits its interaction with PD-1 and CD80 (B7.1)10. The antibody also contains mutations in the constant domain of the heavy chain that reduces binding to complement protein C1q and to Fcγ receptors to avoid complement- and antibody-mediated cytotoxicity. In this trial (NCT02489448), we tested the hypothesis that durvalumab administered concurrently with sequential weekly nab-paclitaxel and dose-dense AC (ddAC) neoadjuvant chemotherapy will increase pCR rate above the historical pCR rate of 30% observed with the same chemotherapy regimen in TNBC in an earlier trial (SWOG S0800, NCT00856492)11. Among the different neoadjuvant chemotherapy options that can be combined with checkpoint inhibitors, we selected Nab-paclitaxel because it did not require steroid premedications12. In addition, there is preclinical evidence suggesting that nab-paclitaxel can release tumor antigens from rapidly dying cells13, which in turn might be able to prime antitumor T cells, a response that might be further amplified by the addition of checkpoint inhibitors.
Results
Patient population
Sixty-nine patients were screened for enrollment at Yale Cancer Center and its regional care centers; 60 patients consented to the trial between December 18, 2015, and November 21, 2018. One patient subsequently withdrew consent. The baseline characteristics of the remaining 59 patients are shown in Table 1. Seven patients were included in Phase I part of the study, four at 3 mg/kg and three at 10 mg/kg dose. Fifty-two patients were enrolled in the Phase II part at a 10 mg/kg dose. Two patients did not proceed to surgery—one developed irreversible altered mental status attributed to Guillen Barre syndrome and family opted for comfort care, the other completed treatment but died of sudden death in her home before undergoing surgery.Table 1 Patients characteristics.
Characteristics N (%)
All patients 59 (100)
Age (median 50 years)
≤40 11 (19)
41–50 19 (32)
51–69 29 (49)
≥70 0 (0)
Race/ethnicity
White (non-Hispanic) 35 (59)
Hispanic/Latino 5 (8)
Black 11 (19)
Asian/American Indian 4 (6)
Unknown 4 (6)
Clinical tumor size
T1 21 (35)
T2 30 (51)
T3 8 (14)
Clinical nodal status
cN0 31 (52)
cN1 25 (42)
cN2 1 (2)
cN3 3 (4)
Clinical stage at diagnosis
I 12 (20)
II 33 (56)
III 14 (24)
Histologic tumor grade
G1 1 (2)
G2 12 (20)
G3 45 (76)
Unknown 1 (2)
Durvalumab dose level
3 mg/kg 4 (7)
10 mg/kg 55 (93)
Pathologic response
pCR 26 (44)
RD 31 (53)
No surgery 2 (3)
Residual cancer burden (RCB)
RCB-I 7 (12)
RCB-II 18 (31)
RCB-III 6 (10)
No surgery 2 (3)
PD-L1 IHC
Negative 19 (32)
Positive (≥1%) 33 (56)
Not available 7 (12)
Stromal TIL count
0–10% 28 (48)
11–29% 10 (17)
≥30% 16 (27)
Not available 5 (8)
TIL tumor-infiltrating lymphocytes, IHC immunohistochemistry.
Efficacy
In the total intention-to-treat population in the Phase II trial who received the recommended Phase II dose of 10 mg/kg durvalumab (N = 55), the pCR rate was 44% (N = 24, 95% CI: 30–57%). Of the 55 patients, 19 (34.5%) received less than the planned 10 treatments with durvalumab, including 7 patients who received less than six doses. Among the 36 patients who received all 10 treatments, 17 (47%) had a pCR. Four patients had clinical progression and underwent surgery or switched to other chemotherapy. One of these patients who subsequently received carboplatin had a pCR at the surgery.
Among the 57 patients who received durvalumab at any dose level and completed surgery, pCR rate was 46%, including 2 pCRs among the 4 patients who received 3 mg/kg durvalumab in the phase I part of the study. The RCB class distribution was RCB-0 (pCR): 46%, RCB-I: 12%, RCB-II: 31%, and RCB-III: 10%. At a median follow-up of 20 months, there have been no recurrences in cases that achieved a pCR. Among those with residual disease, there were nine metastatic and two local recurrences. Three patients died from metastatic disease.
Biomarker results
The consort diagram shows data availability for biomarker analysis (Supplementary Fig. 1). Fifty-two patients had PD-L1 IHC results available; 63% (N = 33) were PD-L1 positive. Two patients with PD-L1 staining had no surgery. Among the 50 patients who completed surgery, patients who achieved pCR had nominally higher PD-L1 positivity rate, compared to those with RD, although this did not reach not statistical significance (74% (95% CI: 54–88%) vs. 52% (95% CI: 34–88%); p = 0.15), (Fig. 1a). The pCR rate was 55% (95% CI: 38–71%) in the PD-L1 positive group compared to 32% (95% CI: 12–56%) in the PD-L1 negative group, also not significantly different (p = 0.15; Fig. 2a). In the same tissues, a parallel study with quantitative measurement of PD-L1 using immunofluorescence showed a statistically significant association between PD-L1 expression as a continuous variable and pCR, which is reported separately14.Fig. 1 PD-L1 positivity and stromal TILs (sTILs) by pathologic response category.
a PD-L1-positivity rate by SP263 antibody in the pathologic complete response (pCR, 74%, n = 14), and residual disease (RD, 52%, n = 13) groups, respectively, p = 0.148 (two-sided Fisher’s exact test). b The percentage of manual stromal tumor-infiltrating lymphocytes (sTILs) and the median (horizontal line) in the pCR (median: 20%) and RD groups (median: 5%), error bars represent 95% confidence intervals, p = 0.0167 (Mann–Whitney U test).
Fig. 2 Distribution of pCR rate by PD-L1 status and manual stromal TILs (sTILs).
a pCR rates in the PD-L1-positive (55%; 95% CI: 0.38–0.71) and -negative (32%; 95% CI: 0.15–0.54) groups, p = 0.148 (two-sided Fisher’s exact test). b pCR rates in cancers with ≥30% sTIL (pCR 57%), 29–10% sTIL (pCR 60%), and <10% sTIL (pCR 29%) groups, p = 0.099 (two-sided Fisher’s exact test). c PD-L1 positivity rates in cancers with sTIL >30%, sTIL 29%–10%, and sTIL <10%, were 100%, 71% and 42%, respectively, p = 0.00015 (two-sided Fisher’s exact test). On all panels error bars represent standard deviations (s.d.).
Manual sTIL counts were available on 54 patients including the 2 patients who did not complete surgery. All patients with evaluable sTIL counts had at least 1% sTILs and 14 of the 52 patients (27%) had sTIL-high cancers defined as ≥30% sTILs. Figure 1b shows TIL counts in the pCR and RD groups. The pCR rates were 57%, 60%, and 29% among TIL-high (sTIL ≥ 30%), intermediate (sTIL 29–10%), and low (sTIL < 10%) groups, p = 0.099. (Fig. 2b). Forty-nine patients had both baseline sTIL and PD-L1 results available, Stromal TIL count was significantly higher in the PD-L1 positive group (median 27.5% vs. 5%; p < 0.001). In cancers with sTIL ≥30%, the PD-L1 positivity rate was 100%, in cancers with sTIL 11–29%, PD-L1 positivity was 71%, and in cancers with sTIL <10%, PD-L1 positivity was only 42% (p = 0.00015 (two-sided Fisher’s exact test); Fig. 2c). Patients whose tumors were PD-L1 positive and sTIL-high (≥30%) had a numerically higher pCR rate of 57% than those with PD-L1 positive but sTIL intermediate or low cancers (pCR rate 50%) or PD-L1 negative cancers (pCR rate 32%), but these differences did not reach statistical significance (p = 0.302, two-sided Fisher’s exact test).
In a multivariate analysis including PD-L1 expression (positive vs. negative), sTIL count (as a continuous variable), age, tumor size (T1 vs. T2/T3) NS nodal status (N− vs. N+), neither PD-L1 status (SP263 IHC) nor sTIL count was independently associated with pCR (Table 2).Table 2 Univariate and multivariate logistic regression analyses to identify possible independent predictors of pCR following neoadjuvant therapy.
Univariate analysis Multivariate analysisa
Variables OR (95% CI) p-value OR (95% CI) p-value
sTILs (continuous variable) 0.99 (0.98–1.01) 0.56 1.00 (0.98–1.01) 0.63
PD-L1 (POS vs. NEG) 2.63 (0.82–9.21) 0.11 2.62 (0.78–9.62) 0.13
Age (continuous variable) 1.00 (0.96–1.04) 0.94
T status (T1 vs. T2/3) 0.47 (0.15–1.44) 0.19
N status (N− vs. N+) 1.38 (0.49–4.00) 0.54
aCovariates included are age (as a continuous variable), T status (T1 vs. T2/3), and N status (N− vs. N+).
Safety and toxicity
All patients who received at least one dose of study-assigned therapy were evaluated for safety and toxicity. Overall, durvalumab was discontinued in 19 (32%) patients, including 2 patients in Phase I portion of the study. During nab-paclitaxel treatment durvalumab was discontinued in 9 patients, 5 due to local progression and 4 due to AEs, 3 of which were immune-related (irAE): one case each of autoimmune diabetes, Guillain–Barre syndrome (GBS), and optic neuritis. In addition, durvalumab was held in 3 patients for at least 1 cycle during nab-paclitaxel due to AEs—transaminitis, dermatitis, and fatigue—and was then continued with the AC portion of chemotherapy. During the AC portion of chemotherapy, durvalumab was discontinued in 9 patients, 7 due to AEs, 2 of which were irAEs: one pneumonitis and one dermatitis. In addition, 5 patients discontinued AC chemotherapy (one each for renal failure, fatigue, and rash, and two due to neutropenic fever) and proceeded to surgery before completing all the planned doses of durvalumab. Two patients were found to be ineligible for the AC portion of treatment due to underlying cardiac disease discovered during the study. Selected treatment-related and clinically relevant toxicities and immune-related adverse events reported within 180 days of the last investigational agent dose are summarized in Table 3. The irAEs observed have all previously been observed in the context of other clinical studies; no new safety concerns were identified. The most frequent irAEs reported were dermatitis and endocrinopathies, with thyroid dysfunction being the most common (hypo- and hyperthyroidism), occurring in 13% of patients including 4 patients who had hyperthyroidism that progressed to hypothyroidism. Adrenal insufficiency was observed in 1 patient. Two patients developed autoimmune diabetes characterized by low or undetectable C-peptide levels and in 1 of the 2 patients, autoantibodies against islet antigen 2 (IA-2).Table 3 Treatment-related adverse events occurring in ≥10% of patients, or grades 3–4 occurring in ≥2% of patients.
All grades Grades 3–4
Adverse event N (%)
Fatigue 50 (85) 1 (2)
Nausea 43 (73) 0 (0)
Alopecia 39 (66) 0 (0)
Anemia 35 (59) 4 (7)
Rash 35 (59) 1 (2)
Diarrhea 27 (46) 0 (0)
Peripheral sensory neuropathy 20 (37) 0 (0)
Leukopenia 16 (27) 3 (5)
Neutropenia 13 (22) 4 (7)
Vomiting 12 (20) 0 (0)
Anorexia 11 (19) 0 (0)
Dyspnea 9 (15) 1 (2)
Myalgia 9 (15) 0 (0)
Mucositis 7 (12) 1 (2)
ALT increased 7 (12) 0 (0)
Weight loss 7 (12) 0 (0)
Hypertension 6 (10) 0 (0)
Cough 6 (10) 0 (0)
Febrile neutropenia 3 (5) 3 (5)
Dehydration 3 (5) 2 (3)
Immune-related adverse events
Hypothyroidisma 8 (13) 0 (0)
Hyperthyroidismb 4 (7) 0 (0)
Adrenal insufficiency 1 (2) 0 (0)
Diabetes mellitus 2 (3) 2 (3)
Dermatitis 12 (20) 0 (0)
Colitis 4 (7) 2 (3)
Guillan–Barre syndrome 1 (2) 1 (2)
Optic neuritis 1 (2) 0 (0)
Pneumonitis 1 (2) 0 (0)
Arthritis 1 (2) 0 (0)
Parotitisc 1 (2)
SAE 14 n/a
SAE serious adverse event.
aTreatment-related adverse events were events that were attributed to a trial treatment by investigators.
bFour patients had both hyperthyroidism and hypothyroidism over the course of their treatment.
cImmune-related adverse event without a grade.
Two patients died. One discontinued therapy after one dose of durvalumab and two weekly treatments of nab-paclitaxel due to altered mental status attributed to Miller–Fisher variant of Guillain–Barre syndrome. Her mental status did not improve and the family opted for comfort care measures only. Her other co-morbid illnesses included hypertension, type 2 diabetes, and chronic obstructive pulmonary disease (COPD). The patient passed away several months later in a hospice. The other patient had completed 9 weekly treatments of nab-paclitaxel (further treatments were held because of peripheral neuropathy), 4 cycles of AC concurrent with durvalumab, and died of sudden death in her home before undergoing surgery. No autopsy was performed. Her other co-morbid illnesses included hypertension, hyperlipidemia, type 2 diabetes, history of coronary artery disease with a left ventricular ejection fraction (LVEF) of 50–55%.
Discussion
The addition of ten cycles of durvalumab (10 mg/kg every 2 weeks) to weekly nab-paclitaxel (100 mg/m2) and ddAC resulted in a pCR rate of 44% (95% CI: 30–57%) in patients with early-stage TNBC in our trial. An identical chemotherapy regimen demonstrated a pCR rate of 29% in TNBC in the SWOG S0800 trial11, while other sequential taxane anthracycline regimens reported pCR rates between 30 and 48% in TNBC15. Two randomized Phase II trials also compared durvalumab plus chemotherapy with chemotherapy alone as neoadjuvant therapy. The GeparNuevo trial in TNBC demonstrated a numerical but not statistically significant increase in pCR rate (53% vs. 44%, p = 0.287) when durvalumab (1500 mg every 4 weeks) was included with weekly nab-paclitaxel (125 mg/m2) and epirubicin/cyclophosphamide16. The Bayesian randomized I-SPY2 trial evaluated the combination of 1500 mg durvalumab every 4 weeks and olaparib 100 mg twice a day concurrent with weekly paclitaxel (80 mg/kg) followed by AC without durvalumab or olaparib vs. the same chemotherapy regimen alone and reported an increase in pCR rate from 27 to 47% in the TNBC population of the trial with a 98% probability that the experimental arm is superior to the control17. The 95% confidence interval of the pCR point estimate in our trial includes the pCR rates seen in the immunotherapy arms of both these randomized trials and therefore the results are consistent with an improvement in pCR rate with the inclusion of durvalumab.
The addition of pembrolizumab to neoadjuvant chemotherapy was also examined in two large randomized trials in TNBC. The KEYNOTE-522 trial showed a significant improvement in pCR rate with the inclusion of pembrolizumab with paclitaxel plus carboplatin followed by anthracycline/cyclophosphamide compared to the same chemotherapy plus placebo (65% vs. 51%, p < 0.001)18. Another, previously reported arm of the I-SPY2 trial, randomized patients to 4 cycles of pembrolizumab vs. placebo in combination with weekly paclitaxel followed by AC without pembrolizumab and reported a significant improvement in predicted pCR rates from 22% in the control arm to 60% in the pembrolizumab arm in TNBC19. Atezolizumab has also been evaluated in two neoadjuvant randomized trials in TNBC. The IMpassion-031 trial randomized patients to atezolizumab or placebo concurrent with nab-paclitaxel followed by doxorubicin/cyclophosphamide, the same chemotherapy regimen as in our current study, and showed a significant increase in pCR rate (58% vs. 41%, p = 0.0044)20. However, one randomized trial, the NeoTRIPaPDL1, that compared nab-paclitaxel/carboplatin with or without atezolizumab failed to show a significant improvement in pCR rate with the inclusion of atezolizumab (pCR rate 43% vs. 41%)21. One important difference is that NeoTRIPaPDL1, unlike all the other positive trials had no anthracycline component. However, it is difficult to attribute the lack of efficacy in this trial to the lack anthracyclines; (i) it is clear from multiple metastatic trials in breast cancer that immune checkpoint inhibitors are synergistic with single-agent nab-paclitaxel at similar doses as used in NeoTRIPaPDL1, (ii) the two immune checkpoint inhibitor arms of the ISPY trial demonstrated improvement in pCR even though immunotherapy was only administered during the paclitaxel phase of chemotherapy, (iii) in lung cancer and other cancers immune checkpoint inhibitors are clearly synergistic with taxane/carboplatin regimens, and finally (iv) a small, multi-arm, window of opportunity trial, TONIC22, randomized patients to nivolumab alone or with a brief concurrent induction therapy including either irradiation (3 × 8 Gy), or cyclophosphamide (50 mg orally daily for 2 weeks), or cisplatin (40 mg/m2 intravenously weekly × 2), or doxorubicin (15 mg intravenously weekly × 2) for 2 weeks, and reported the highest responses rates and upregulation of immune-related genes with cisplatin and with doxorubicin. While it remains unclear why the NeoTRIPaPDL1 trial was negative, overall, the majority of trials provide consistent evidence for an improvement in pCR rate when an immune checkpoint inhibitor is added to standard of care neoadjuvant chemotherapy in TNBC.
Next, we examined the relationship between TIL count and pCR rate and found that patients with pCR had significantly higher TIL counts than those with residual disease. TIL-high (i.e., TIL ≥ 30%) cancers (n = 14) had a pCR rate close to 60%. However, TIL count alone may not identify patients who selectively benefit from the inclusion of an immune checkpoint inhibitor in the neoadjuvant chemotherapy regimen, as it has been shown that immune-rich TNBC also has higher pCR rates with chemotherapy alone compared to immune-low cancers1–5. The pCR rate was also higher in PD-L1 positive tumors (55% vs. 32%) in our study; however, this difference was not statistically significant (p = 0.15). The lack of statistical significance is likely due to the small sample size (i.e., the same proportions of 17/31 pCR in PD-L1 positive and 6/19 pCR in PD-L1 negative cancers would have resulted in a p < 0.0001 in a 500-patient trial [corresponding numbers would be 170/310 and 60/190]). All other substantially larger randomized neoadjuvant immune checkpoint inhibitor trials have reported significantly higher pCR rates in PD-L1 positive TNBC, which was consistent across three different immune checkpoint inhibitors—pembrolizumab19, durvalumab16, and atezolizumab20,21 and three different IHC assays: 22C319, SP26316, and SP14221. However, these trials also showed that immune checkpoint therapy increases pCR rates even in PD-L1 negative cancers, and similar to TIL counts, PD-L1 status may not be useful in selecting patients for neoadjuvant immunotherapy.
The inability of PD-L1 protein expression, as determined by current assays, to identify patients who selectively benefit from immune checkpoint therapy in early-stage TNBC is very different from results obtained in metastatic TNBC where PD-L1 expression unequivocally identifies a subset of patients who have the potential to benefit from immune therapy. In the randomized IMpassion130 trial, only PD-L1 immune cell-positive patients (either with SP142, 22C3, or SP263 assays) showed improved progression-free survival (PFS) when atezolizumab was added to nab-paclitaxel as first-line therapy for metastatic TNBC23. In the KEYNOTE-119 trial, objective response rates and progression-free survival with single-agent pembrolizumab increased almost linearly as PD-L1 positivity increased (with 22C3 assay)24. The recently presented KEYNOTE 355 trial that compared pembrolizumab vs. placebo in addition to chemotherapy for metastatic TNBC in the first-line setting also demonstrated a statistically significant improvement in PFS in the pembrolizumab arm but only in PD-L1 positive cancers (CPS ≥ 10 using the 22C3 assay)25. The SAFIR-02 trial randomized patients with metastatic breast cancer who had a response or stable disease after 6 to 8 cycles of chemotherapy and had no actionable mutations, to maintenance single-agent durvalumab or continuation of chemotherapy. Maintenance durvalumab had inferior PFS in the entire population but demonstrated improved OS in the PD-L1 positive cancers (with SP142 assay)26. These results clearly demonstrate that unlike in stages I–III TNBC, PD-L1 positivity is required for the benefit of atezolizumab, pembrolizumab, and durvalumab in metastatic TNBC.
The biological reasons behind the distinct predictive functions of PD-L1 in metastatic vs. early-stage breast cancers are unclear. However, PD-L1 protein expression on immune cells, the primary cellular sources of PD-L1 expression in breast cancer, correlates closely with overall immune infiltration6–8 and metastatic lesions have been shown to have an overall more immune attenuated tissue microenvironment, even when immune cells are present, compared to primary tumors27–29. We hypothesize that in metastatic breast cancer, greater immune checkpoint inhibitor target expression (reflected by higher PD-L1 expression) may be required to obtain benefit from immune checkpoint inhibition, whereas low levels of the target (that may be missed by current PD-L1 IHC or TIL counting methods) may be sufficient to augment antitumor immune responses by immune checkpoint inhibitors in stages I–III TNBC. Indeed, in our study, all TNBCs had at least 1% sTILs but the PD-L1 positivity rate was only 42% in cancers with sTIL between 1 and 10%, compared to 100% positivity rate in cancers with sTIL ≥30%.
Immune-related adverse events were consistent with known adverse events of immune checkpoint inhibitors and no new safety concerns were identified. There were no perioperative complications. However, we did observe several severe irAEs including 2 patients (3%) with autoimmune type I diabetes. One patient presented with grade 3 hyperglycemia, diabetic ketoacidosis, low C-peptide, and increased islet antibody-2 (IA-2) after 4 cycles of durvalumab, requiring inpatient admission. She remains on long-term insulin treatment. The second patient presented with grade 4 hyperglycemia without diabetic ketoacidosis after completing 7 cycles of durvalumab. She had a history of metabolic syndrome (obesity, glucose intolerance) and was initially thought to have type II diabetes; however, her C-peptide level was low on presentation with a further decrease on follow-up testing 5 months later, indicating autoimmune type I-like diabetes. There were two deaths possibly related to treatment, one patient suffered a presumed cardiac arrest following completion of all study-related treatments but prior to undergoing surgery and one patient died after developing the Miller–Fisher variant of Guillain–Barre syndrome (GBS), a rare but previously reported neurologic complication of checkpoint inhibition characterized by ophthalmoplegia, ataxia, and hypersomnolence30. Notably, she developed GBS after only one dose of durvalumab. We recognize that our study had slightly higher than expected toxicity and mortality, we attribute this to more comorbidities in our study population than seen in the pivotal randomized trials. A growing number of randomized neoadjuvant trials with pembrolizumab, durvalumab, and atezolizumab including over 2000 patients with TNBC show good tolerability but also added immune-related toxicities. In the KEYNOTE-522 trial, 32% of patients experienced immune-related adverse events of any grade, and 12% had grade 3 or greater immune-related toxicities18. The most common were hypo-, and hyperthyroidism, and skin rash. Similar results were seen in Impassion-03120.
In summary, these results add to the growing literature that indicates the efficacy of immune checkpoint inhibitors in early-stage TNBC. Durvalumab concurrent with neoadjuvant nab-paclitaxel and ddAC chemotherapy resulted in a 44% pCR rate. Among the 62% of patients who had PD-L1 positive disease, the pCR rate was 55%, among PD-L1 negative cancers the pCR rate was 32%.
Methods
Study design
The primary objective of the Phase I part was to assess the safety of durvalumab concurrent with weekly nab-paclitaxel (100 mg/m2) × 12 treatments followed by doxorubicin (60 mg/m2) and cyclophosphamide (600 mg/m2) every 2 weeks (AC) × 4 treatments. Two dose levels, 3 mg/kg and 10 mg/kg, of durvalumab, administered every 2 weeks were explored following a 3 + 3 design. No steroid premedications were used during nab-paclitaxel treatment and durvalumab was administered immediately after completion of nab-paclitaxel. During AC, the first course of treatment was administered without dexamethasone pre-medication, but if clinically significant nausea or vomiting occurred subsequent courses were given with 20 mg dexamethasone. Approximately 24 h after administration of AC, 6 mg pegfilgrastim was administered followed by durvalumab. Dose-limiting toxicities (DLT) were monitored during the entire 20 weeks of therapy and for 4 weeks after completion of surgery before advancing to the next dose level. DLT was defined as any grade 4 immune-related adverse event (irAE), any grade 3 irAE that did not resolve to grade 2 within 3 days despite optimal management or did not resolve to ≤grade 1 within 14 days, and any ≥grade 3 non-irAE causally attributed to durvalumab. The primary efficacy objective was to assess pCR rate in patients who received the recommended Phase II dose including both the Phase I and phase II component. The efficacy study followed Simon’s two-stage design (p0 = 30%, p1 = 50%) with an interim efficacy analysis after the first 22 patients completed surgery and accrual was to be terminated if <7 patients experienced pCR, otherwise, accrual continued until 50 patients were evaluable for pCR. The maximum sample size was set to N = 61 allowing for replacement of non-evaluable patients. If >20 of 50 evaluable patients had pCR (40% observed pCR rate) the combination therapy would be recommended for further study. This was an investigator-initiated trial, and ethical approval was obtained from the Yale Human Investigations Committee (Yale University, HIC# 1409014537). Astra Zeneca provided study drug and funding for the trial but played no role in the study design, collection/analysis of data, or manuscript preparation.
Patients and assessments
The study was approved and was annually reviewed by the internal institutional review board and all patients provided a written consent form to join the study. All patients signed written informed consent prior to participation. Patients with clinical stages I–III, triple-negative breast cancer, defined as ER and PR < 1% positive and HER2 negative (IHC 0, 1+, or 2+, or FISH negative), for whom systemic chemotherapy was indicated according to NCCN treatment guidelines were eligible31. Exclusion criteria included contraindications for anthracycline, paclitaxel, or anti-PD-L1 therapies (e.g., active autoimmune disease, live vaccines within 30 days, prior transplants, immune deficiency, active immunosuppressive medications).
Adverse events (AE) were assessed every 2 weeks and graded according to NCI CTCAE v4.03. All patients who received at least one dose of durvalumab were included in toxicity analysis. Surgery was performed within 4 weeks of completion of neoadjuvant chemotherapy and the extent of residual cancer assessed by the local pathologist as part of routine care. Residual Cancer Burden was assessed centrally by a breast pathologist (E.R.)32.
Biomarker analysis
PD-L1 expression on formalin-fixed paraffin-embedded pretreatment biopsies was assessed with chromogenic immunohistochemistry (IHC) using the VENTANA PD-L1 (SP263) Assay performed according to the Federal Drug Administration (FDA) label. PD-L1 positivity was determined by consensus review of 2 pathologists (E.R., D.L.R.), and ≥1% staining on immune or tumor cells was considered positive. The percentage of stromal tumor-infiltrating lymphocytes (sTILs) was assessed on hematoxylin–eosin-stained slides and calculated as the area occupied by mononuclear inflammatory cells over the total intratumoral stromal area (E.R, K.S.). The association between pCR, PD-L1 expression, and sTILs along with clinicopathologic parameters (age, tumor size [T1 vs. T2/T3], nodal status [N0 vs. N1–N3]) was assessed using logistic regression. The pCR rates between PD-L1 positive and negative cohorts were compared using Fisher’s exact test. PD-L1 positivity rate in low, intermediate, and high sTIL cancers was assessed with a two-sided Fisher’s exact test. Median sTILs percent between cases with pCR and RD were compared using the Mann–Whitney U test.
Reporting summary
Further information on research design is available in the Nature Research Reporting Summary linked to this article.
Supplementary information
Supplementary Figure 1
Reporting Summary Checklist
Supplementary information
The online version contains supplementary material available at 10.1038/s41523-021-00219-7.
Acknowledgements
We thank the participating patients and their families, as well as the research nurses, trial coordinators, and operations staff, for their contributions, and we thank the investigators who enrolled patients in this trial. The research reported in this publication was supported by Astra Zeneca and grants from the National Cancer Institute (R01CA219647), the Breast Cancer Research Foundation, and the Susan Komen Foundation (SAC160076) to L.P.
Author contributions
Study design: L.P. Patient accrual: A.S., N.F., J.P., K.A., A.K., N.H., D.L., A.C., T.P., and L.P. Data analysis: J.F., M.M., E.R., K.S., C.F., T.B., E.I., T.Q., Y.B., K.B., D.R., and L.P. Manuscript writing: J.F., K.B., and L.P. Final review of manuscript: all authors.
Data availability
The data generated and analyzed during this study are described and shared openly in the following data record: 10.6084/m9.figshare.1336296833. The three data files containing all data are as follows. (1) Neoadjuvant Durvalumab Study_AEs_irAEs no dates.xlsx: Adverse events of all grades including detailed immune-related adverse events observed during our study. The file also includes data on the discontinuation of study drugs and the reason for those discontinuations. (2) Neoadjuvant Durvalumab Study_Demographics_Outcomes no dates.xlsx: Study participant demographics with no identifiable information and all dates removed from the data. Data includes baseline disease characteristics as well as outcomes in terms of survival and recurrence events up to the data cutoff of 8/15/2020. (3) Neoadjuvant Durvalumab Study_TIL counts_PDL1.xlsx - Tumor-infiltrating lymphocyte (TIL) counts (%) and PD-L1 status (positive vs. negative or unscorable) of patient’s tumors.
Competing interests
A.S. has received honoraria and consulting fees from Astra Zeneca. D.L.R. has served as an advisor and consultant for Amgen, Astra Zeneca, Biocept, BMS, Cell Signaling Technology, Cepheid, Daiichi Sankyo, GSK, Konica/Minolta, Merck, NanoString, NextCure, Odonate, Perkin Elmer, PAIGE.AI, Roche, Sanofi, Ventana, and Ultivue; received research funding from Amgen, Cepheid, NavigateBP, NextCure, Konica/Minolta, Lilly, and Ultivue; received instrument support from Akoya/Perkin Elmer, NanoString and Ventana; is a founder and equity holder of PixelGear, and received royalties from Rarecyte. L.P. has received consulting fees and honoraria from Astra Zeneca, Merck, Novartis, Bristol-Myers Squibb Genentech, Eisai, Pieris, Immunomedics, Seattle Genetics, Clovis, Syndax, H3Bio, and Daiichi. The remaining authors declare no competing interests.
Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. | 10 MILLIGRAM/KILOGRAM | DrugDosageText | CC BY | 33558513 | 18,936,228 | 2021-02-08 |
What was the dosage of drug 'PACLITAXEL'? | Neoadjuvant durvalumab plus weekly nab-paclitaxel and dose-dense doxorubicin/cyclophosphamide in triple-negative breast cancer.
The goal of this Phase I/II trial is to assess the safety and efficacy of administering durvalumab concurrent with weekly nab-paclitaxel and dose-dense doxorubicin/cyclophosphamide (ddAC) neoadjuvant therapy for stages I-III triple-negative breast cancer. The primary endpoint is pathologic complete response (pCR:ypT0/is, ypN0). The response was correlated with PDL1 expression and stromal tumor-infiltrating lymphocytes (sTILs). Two dose levels of durvalumab (3 and 10 mg/kg) were assessed. PD-L1 was assessed using the SP263 antibody; ≥1% immune and tumor cell staining was considered positive; sTILs were calculated as the area occupied by mononuclear inflammatory cells over the total intratumoral stromal area. 59 patients were evaluable for toxicity and 55 for efficacy in the Phase II study (10 mg/kg dose). No dose-limiting toxicities were observed in Phase I. In Phase II, pCR rate was 44% (95% CI: 30-57%); 18 patients (31%) experienced grade 3/4 treatment-related adverse events (AE), most frequently neutropenia (n = 4) and anemia (n = 4). Immune-related grade 3/4 AEs included Guillain-Barre syndrome (n = 1), colitis (n = 2), and hyperglycemia (n = 2). Of the 50 evaluable patients for PD-L1, 31 (62%) were PD-L1 positive. pCR rates were 55% (95% CI: 0.38-0.71) and 32% (95% CI: 0.12-0.56) in the PD-L1 positive and negative groups (p = 0.15), respectively. sTIL counts were available on 52 patients and were significantly higher in the pCR group (p = 0.0167). Concomitant administration of durvalumab with sequential weekly nab-paclitaxel and ddAC neoadjuvant chemotherapy resulted in a pCR rate of 44%; pCR rates were higher in sTIL-high cancers.
pmcIntroduction
The presence of immune cells in the tumor microenvironment of triple-negative breast cancer (TNBC) is associated with a good prognosis with1 or without adjuvant chemotherapy2, and is also predictive of pathologic complete response (pCR, ypT0/is, ypN0) after neoadjuvant chemotherapy3. Animal models of cancer also demonstrated that immune cells in the tumor microenvironment, particularly activated cytotoxic T cells, partially mediate chemotherapy response4,5. The availability of immune checkpoint inhibitors in the clinic that target the programmed cell death protein-1 (PD-1) and its ligands allow us to directly test if removing an important inhibitory signal from the immune microenvironment can lead to a more effective antitumor immune response and increase chemotherapy sensitivity. PD-1 is expressed on the surface of T cells and causes T-cell inhibition when it binds to either of its two ligands, programmed death-ligand-1 (PD-L1) and -2 (PD-L2). PD-L1 is expressed on the cell surface of cancer cells, macrophages, dendritic cells, and T cells6,7. There is a strong positive correlation between PD-L1 expression, immune infiltration, and tumor-infiltrating lymphocyte count, which explains the paradoxical observations that high PD-L1 expression is associated with better prognosis and higher pCR rate in breast cancer8,9.
Durvalumab is a monoclonal human immunoglobulin G1κ antibody that binds to PD-L1 and inhibits its interaction with PD-1 and CD80 (B7.1)10. The antibody also contains mutations in the constant domain of the heavy chain that reduces binding to complement protein C1q and to Fcγ receptors to avoid complement- and antibody-mediated cytotoxicity. In this trial (NCT02489448), we tested the hypothesis that durvalumab administered concurrently with sequential weekly nab-paclitaxel and dose-dense AC (ddAC) neoadjuvant chemotherapy will increase pCR rate above the historical pCR rate of 30% observed with the same chemotherapy regimen in TNBC in an earlier trial (SWOG S0800, NCT00856492)11. Among the different neoadjuvant chemotherapy options that can be combined with checkpoint inhibitors, we selected Nab-paclitaxel because it did not require steroid premedications12. In addition, there is preclinical evidence suggesting that nab-paclitaxel can release tumor antigens from rapidly dying cells13, which in turn might be able to prime antitumor T cells, a response that might be further amplified by the addition of checkpoint inhibitors.
Results
Patient population
Sixty-nine patients were screened for enrollment at Yale Cancer Center and its regional care centers; 60 patients consented to the trial between December 18, 2015, and November 21, 2018. One patient subsequently withdrew consent. The baseline characteristics of the remaining 59 patients are shown in Table 1. Seven patients were included in Phase I part of the study, four at 3 mg/kg and three at 10 mg/kg dose. Fifty-two patients were enrolled in the Phase II part at a 10 mg/kg dose. Two patients did not proceed to surgery—one developed irreversible altered mental status attributed to Guillen Barre syndrome and family opted for comfort care, the other completed treatment but died of sudden death in her home before undergoing surgery.Table 1 Patients characteristics.
Characteristics N (%)
All patients 59 (100)
Age (median 50 years)
≤40 11 (19)
41–50 19 (32)
51–69 29 (49)
≥70 0 (0)
Race/ethnicity
White (non-Hispanic) 35 (59)
Hispanic/Latino 5 (8)
Black 11 (19)
Asian/American Indian 4 (6)
Unknown 4 (6)
Clinical tumor size
T1 21 (35)
T2 30 (51)
T3 8 (14)
Clinical nodal status
cN0 31 (52)
cN1 25 (42)
cN2 1 (2)
cN3 3 (4)
Clinical stage at diagnosis
I 12 (20)
II 33 (56)
III 14 (24)
Histologic tumor grade
G1 1 (2)
G2 12 (20)
G3 45 (76)
Unknown 1 (2)
Durvalumab dose level
3 mg/kg 4 (7)
10 mg/kg 55 (93)
Pathologic response
pCR 26 (44)
RD 31 (53)
No surgery 2 (3)
Residual cancer burden (RCB)
RCB-I 7 (12)
RCB-II 18 (31)
RCB-III 6 (10)
No surgery 2 (3)
PD-L1 IHC
Negative 19 (32)
Positive (≥1%) 33 (56)
Not available 7 (12)
Stromal TIL count
0–10% 28 (48)
11–29% 10 (17)
≥30% 16 (27)
Not available 5 (8)
TIL tumor-infiltrating lymphocytes, IHC immunohistochemistry.
Efficacy
In the total intention-to-treat population in the Phase II trial who received the recommended Phase II dose of 10 mg/kg durvalumab (N = 55), the pCR rate was 44% (N = 24, 95% CI: 30–57%). Of the 55 patients, 19 (34.5%) received less than the planned 10 treatments with durvalumab, including 7 patients who received less than six doses. Among the 36 patients who received all 10 treatments, 17 (47%) had a pCR. Four patients had clinical progression and underwent surgery or switched to other chemotherapy. One of these patients who subsequently received carboplatin had a pCR at the surgery.
Among the 57 patients who received durvalumab at any dose level and completed surgery, pCR rate was 46%, including 2 pCRs among the 4 patients who received 3 mg/kg durvalumab in the phase I part of the study. The RCB class distribution was RCB-0 (pCR): 46%, RCB-I: 12%, RCB-II: 31%, and RCB-III: 10%. At a median follow-up of 20 months, there have been no recurrences in cases that achieved a pCR. Among those with residual disease, there were nine metastatic and two local recurrences. Three patients died from metastatic disease.
Biomarker results
The consort diagram shows data availability for biomarker analysis (Supplementary Fig. 1). Fifty-two patients had PD-L1 IHC results available; 63% (N = 33) were PD-L1 positive. Two patients with PD-L1 staining had no surgery. Among the 50 patients who completed surgery, patients who achieved pCR had nominally higher PD-L1 positivity rate, compared to those with RD, although this did not reach not statistical significance (74% (95% CI: 54–88%) vs. 52% (95% CI: 34–88%); p = 0.15), (Fig. 1a). The pCR rate was 55% (95% CI: 38–71%) in the PD-L1 positive group compared to 32% (95% CI: 12–56%) in the PD-L1 negative group, also not significantly different (p = 0.15; Fig. 2a). In the same tissues, a parallel study with quantitative measurement of PD-L1 using immunofluorescence showed a statistically significant association between PD-L1 expression as a continuous variable and pCR, which is reported separately14.Fig. 1 PD-L1 positivity and stromal TILs (sTILs) by pathologic response category.
a PD-L1-positivity rate by SP263 antibody in the pathologic complete response (pCR, 74%, n = 14), and residual disease (RD, 52%, n = 13) groups, respectively, p = 0.148 (two-sided Fisher’s exact test). b The percentage of manual stromal tumor-infiltrating lymphocytes (sTILs) and the median (horizontal line) in the pCR (median: 20%) and RD groups (median: 5%), error bars represent 95% confidence intervals, p = 0.0167 (Mann–Whitney U test).
Fig. 2 Distribution of pCR rate by PD-L1 status and manual stromal TILs (sTILs).
a pCR rates in the PD-L1-positive (55%; 95% CI: 0.38–0.71) and -negative (32%; 95% CI: 0.15–0.54) groups, p = 0.148 (two-sided Fisher’s exact test). b pCR rates in cancers with ≥30% sTIL (pCR 57%), 29–10% sTIL (pCR 60%), and <10% sTIL (pCR 29%) groups, p = 0.099 (two-sided Fisher’s exact test). c PD-L1 positivity rates in cancers with sTIL >30%, sTIL 29%–10%, and sTIL <10%, were 100%, 71% and 42%, respectively, p = 0.00015 (two-sided Fisher’s exact test). On all panels error bars represent standard deviations (s.d.).
Manual sTIL counts were available on 54 patients including the 2 patients who did not complete surgery. All patients with evaluable sTIL counts had at least 1% sTILs and 14 of the 52 patients (27%) had sTIL-high cancers defined as ≥30% sTILs. Figure 1b shows TIL counts in the pCR and RD groups. The pCR rates were 57%, 60%, and 29% among TIL-high (sTIL ≥ 30%), intermediate (sTIL 29–10%), and low (sTIL < 10%) groups, p = 0.099. (Fig. 2b). Forty-nine patients had both baseline sTIL and PD-L1 results available, Stromal TIL count was significantly higher in the PD-L1 positive group (median 27.5% vs. 5%; p < 0.001). In cancers with sTIL ≥30%, the PD-L1 positivity rate was 100%, in cancers with sTIL 11–29%, PD-L1 positivity was 71%, and in cancers with sTIL <10%, PD-L1 positivity was only 42% (p = 0.00015 (two-sided Fisher’s exact test); Fig. 2c). Patients whose tumors were PD-L1 positive and sTIL-high (≥30%) had a numerically higher pCR rate of 57% than those with PD-L1 positive but sTIL intermediate or low cancers (pCR rate 50%) or PD-L1 negative cancers (pCR rate 32%), but these differences did not reach statistical significance (p = 0.302, two-sided Fisher’s exact test).
In a multivariate analysis including PD-L1 expression (positive vs. negative), sTIL count (as a continuous variable), age, tumor size (T1 vs. T2/T3) NS nodal status (N− vs. N+), neither PD-L1 status (SP263 IHC) nor sTIL count was independently associated with pCR (Table 2).Table 2 Univariate and multivariate logistic regression analyses to identify possible independent predictors of pCR following neoadjuvant therapy.
Univariate analysis Multivariate analysisa
Variables OR (95% CI) p-value OR (95% CI) p-value
sTILs (continuous variable) 0.99 (0.98–1.01) 0.56 1.00 (0.98–1.01) 0.63
PD-L1 (POS vs. NEG) 2.63 (0.82–9.21) 0.11 2.62 (0.78–9.62) 0.13
Age (continuous variable) 1.00 (0.96–1.04) 0.94
T status (T1 vs. T2/3) 0.47 (0.15–1.44) 0.19
N status (N− vs. N+) 1.38 (0.49–4.00) 0.54
aCovariates included are age (as a continuous variable), T status (T1 vs. T2/3), and N status (N− vs. N+).
Safety and toxicity
All patients who received at least one dose of study-assigned therapy were evaluated for safety and toxicity. Overall, durvalumab was discontinued in 19 (32%) patients, including 2 patients in Phase I portion of the study. During nab-paclitaxel treatment durvalumab was discontinued in 9 patients, 5 due to local progression and 4 due to AEs, 3 of which were immune-related (irAE): one case each of autoimmune diabetes, Guillain–Barre syndrome (GBS), and optic neuritis. In addition, durvalumab was held in 3 patients for at least 1 cycle during nab-paclitaxel due to AEs—transaminitis, dermatitis, and fatigue—and was then continued with the AC portion of chemotherapy. During the AC portion of chemotherapy, durvalumab was discontinued in 9 patients, 7 due to AEs, 2 of which were irAEs: one pneumonitis and one dermatitis. In addition, 5 patients discontinued AC chemotherapy (one each for renal failure, fatigue, and rash, and two due to neutropenic fever) and proceeded to surgery before completing all the planned doses of durvalumab. Two patients were found to be ineligible for the AC portion of treatment due to underlying cardiac disease discovered during the study. Selected treatment-related and clinically relevant toxicities and immune-related adverse events reported within 180 days of the last investigational agent dose are summarized in Table 3. The irAEs observed have all previously been observed in the context of other clinical studies; no new safety concerns were identified. The most frequent irAEs reported were dermatitis and endocrinopathies, with thyroid dysfunction being the most common (hypo- and hyperthyroidism), occurring in 13% of patients including 4 patients who had hyperthyroidism that progressed to hypothyroidism. Adrenal insufficiency was observed in 1 patient. Two patients developed autoimmune diabetes characterized by low or undetectable C-peptide levels and in 1 of the 2 patients, autoantibodies against islet antigen 2 (IA-2).Table 3 Treatment-related adverse events occurring in ≥10% of patients, or grades 3–4 occurring in ≥2% of patients.
All grades Grades 3–4
Adverse event N (%)
Fatigue 50 (85) 1 (2)
Nausea 43 (73) 0 (0)
Alopecia 39 (66) 0 (0)
Anemia 35 (59) 4 (7)
Rash 35 (59) 1 (2)
Diarrhea 27 (46) 0 (0)
Peripheral sensory neuropathy 20 (37) 0 (0)
Leukopenia 16 (27) 3 (5)
Neutropenia 13 (22) 4 (7)
Vomiting 12 (20) 0 (0)
Anorexia 11 (19) 0 (0)
Dyspnea 9 (15) 1 (2)
Myalgia 9 (15) 0 (0)
Mucositis 7 (12) 1 (2)
ALT increased 7 (12) 0 (0)
Weight loss 7 (12) 0 (0)
Hypertension 6 (10) 0 (0)
Cough 6 (10) 0 (0)
Febrile neutropenia 3 (5) 3 (5)
Dehydration 3 (5) 2 (3)
Immune-related adverse events
Hypothyroidisma 8 (13) 0 (0)
Hyperthyroidismb 4 (7) 0 (0)
Adrenal insufficiency 1 (2) 0 (0)
Diabetes mellitus 2 (3) 2 (3)
Dermatitis 12 (20) 0 (0)
Colitis 4 (7) 2 (3)
Guillan–Barre syndrome 1 (2) 1 (2)
Optic neuritis 1 (2) 0 (0)
Pneumonitis 1 (2) 0 (0)
Arthritis 1 (2) 0 (0)
Parotitisc 1 (2)
SAE 14 n/a
SAE serious adverse event.
aTreatment-related adverse events were events that were attributed to a trial treatment by investigators.
bFour patients had both hyperthyroidism and hypothyroidism over the course of their treatment.
cImmune-related adverse event without a grade.
Two patients died. One discontinued therapy after one dose of durvalumab and two weekly treatments of nab-paclitaxel due to altered mental status attributed to Miller–Fisher variant of Guillain–Barre syndrome. Her mental status did not improve and the family opted for comfort care measures only. Her other co-morbid illnesses included hypertension, type 2 diabetes, and chronic obstructive pulmonary disease (COPD). The patient passed away several months later in a hospice. The other patient had completed 9 weekly treatments of nab-paclitaxel (further treatments were held because of peripheral neuropathy), 4 cycles of AC concurrent with durvalumab, and died of sudden death in her home before undergoing surgery. No autopsy was performed. Her other co-morbid illnesses included hypertension, hyperlipidemia, type 2 diabetes, history of coronary artery disease with a left ventricular ejection fraction (LVEF) of 50–55%.
Discussion
The addition of ten cycles of durvalumab (10 mg/kg every 2 weeks) to weekly nab-paclitaxel (100 mg/m2) and ddAC resulted in a pCR rate of 44% (95% CI: 30–57%) in patients with early-stage TNBC in our trial. An identical chemotherapy regimen demonstrated a pCR rate of 29% in TNBC in the SWOG S0800 trial11, while other sequential taxane anthracycline regimens reported pCR rates between 30 and 48% in TNBC15. Two randomized Phase II trials also compared durvalumab plus chemotherapy with chemotherapy alone as neoadjuvant therapy. The GeparNuevo trial in TNBC demonstrated a numerical but not statistically significant increase in pCR rate (53% vs. 44%, p = 0.287) when durvalumab (1500 mg every 4 weeks) was included with weekly nab-paclitaxel (125 mg/m2) and epirubicin/cyclophosphamide16. The Bayesian randomized I-SPY2 trial evaluated the combination of 1500 mg durvalumab every 4 weeks and olaparib 100 mg twice a day concurrent with weekly paclitaxel (80 mg/kg) followed by AC without durvalumab or olaparib vs. the same chemotherapy regimen alone and reported an increase in pCR rate from 27 to 47% in the TNBC population of the trial with a 98% probability that the experimental arm is superior to the control17. The 95% confidence interval of the pCR point estimate in our trial includes the pCR rates seen in the immunotherapy arms of both these randomized trials and therefore the results are consistent with an improvement in pCR rate with the inclusion of durvalumab.
The addition of pembrolizumab to neoadjuvant chemotherapy was also examined in two large randomized trials in TNBC. The KEYNOTE-522 trial showed a significant improvement in pCR rate with the inclusion of pembrolizumab with paclitaxel plus carboplatin followed by anthracycline/cyclophosphamide compared to the same chemotherapy plus placebo (65% vs. 51%, p < 0.001)18. Another, previously reported arm of the I-SPY2 trial, randomized patients to 4 cycles of pembrolizumab vs. placebo in combination with weekly paclitaxel followed by AC without pembrolizumab and reported a significant improvement in predicted pCR rates from 22% in the control arm to 60% in the pembrolizumab arm in TNBC19. Atezolizumab has also been evaluated in two neoadjuvant randomized trials in TNBC. The IMpassion-031 trial randomized patients to atezolizumab or placebo concurrent with nab-paclitaxel followed by doxorubicin/cyclophosphamide, the same chemotherapy regimen as in our current study, and showed a significant increase in pCR rate (58% vs. 41%, p = 0.0044)20. However, one randomized trial, the NeoTRIPaPDL1, that compared nab-paclitaxel/carboplatin with or without atezolizumab failed to show a significant improvement in pCR rate with the inclusion of atezolizumab (pCR rate 43% vs. 41%)21. One important difference is that NeoTRIPaPDL1, unlike all the other positive trials had no anthracycline component. However, it is difficult to attribute the lack of efficacy in this trial to the lack anthracyclines; (i) it is clear from multiple metastatic trials in breast cancer that immune checkpoint inhibitors are synergistic with single-agent nab-paclitaxel at similar doses as used in NeoTRIPaPDL1, (ii) the two immune checkpoint inhibitor arms of the ISPY trial demonstrated improvement in pCR even though immunotherapy was only administered during the paclitaxel phase of chemotherapy, (iii) in lung cancer and other cancers immune checkpoint inhibitors are clearly synergistic with taxane/carboplatin regimens, and finally (iv) a small, multi-arm, window of opportunity trial, TONIC22, randomized patients to nivolumab alone or with a brief concurrent induction therapy including either irradiation (3 × 8 Gy), or cyclophosphamide (50 mg orally daily for 2 weeks), or cisplatin (40 mg/m2 intravenously weekly × 2), or doxorubicin (15 mg intravenously weekly × 2) for 2 weeks, and reported the highest responses rates and upregulation of immune-related genes with cisplatin and with doxorubicin. While it remains unclear why the NeoTRIPaPDL1 trial was negative, overall, the majority of trials provide consistent evidence for an improvement in pCR rate when an immune checkpoint inhibitor is added to standard of care neoadjuvant chemotherapy in TNBC.
Next, we examined the relationship between TIL count and pCR rate and found that patients with pCR had significantly higher TIL counts than those with residual disease. TIL-high (i.e., TIL ≥ 30%) cancers (n = 14) had a pCR rate close to 60%. However, TIL count alone may not identify patients who selectively benefit from the inclusion of an immune checkpoint inhibitor in the neoadjuvant chemotherapy regimen, as it has been shown that immune-rich TNBC also has higher pCR rates with chemotherapy alone compared to immune-low cancers1–5. The pCR rate was also higher in PD-L1 positive tumors (55% vs. 32%) in our study; however, this difference was not statistically significant (p = 0.15). The lack of statistical significance is likely due to the small sample size (i.e., the same proportions of 17/31 pCR in PD-L1 positive and 6/19 pCR in PD-L1 negative cancers would have resulted in a p < 0.0001 in a 500-patient trial [corresponding numbers would be 170/310 and 60/190]). All other substantially larger randomized neoadjuvant immune checkpoint inhibitor trials have reported significantly higher pCR rates in PD-L1 positive TNBC, which was consistent across three different immune checkpoint inhibitors—pembrolizumab19, durvalumab16, and atezolizumab20,21 and three different IHC assays: 22C319, SP26316, and SP14221. However, these trials also showed that immune checkpoint therapy increases pCR rates even in PD-L1 negative cancers, and similar to TIL counts, PD-L1 status may not be useful in selecting patients for neoadjuvant immunotherapy.
The inability of PD-L1 protein expression, as determined by current assays, to identify patients who selectively benefit from immune checkpoint therapy in early-stage TNBC is very different from results obtained in metastatic TNBC where PD-L1 expression unequivocally identifies a subset of patients who have the potential to benefit from immune therapy. In the randomized IMpassion130 trial, only PD-L1 immune cell-positive patients (either with SP142, 22C3, or SP263 assays) showed improved progression-free survival (PFS) when atezolizumab was added to nab-paclitaxel as first-line therapy for metastatic TNBC23. In the KEYNOTE-119 trial, objective response rates and progression-free survival with single-agent pembrolizumab increased almost linearly as PD-L1 positivity increased (with 22C3 assay)24. The recently presented KEYNOTE 355 trial that compared pembrolizumab vs. placebo in addition to chemotherapy for metastatic TNBC in the first-line setting also demonstrated a statistically significant improvement in PFS in the pembrolizumab arm but only in PD-L1 positive cancers (CPS ≥ 10 using the 22C3 assay)25. The SAFIR-02 trial randomized patients with metastatic breast cancer who had a response or stable disease after 6 to 8 cycles of chemotherapy and had no actionable mutations, to maintenance single-agent durvalumab or continuation of chemotherapy. Maintenance durvalumab had inferior PFS in the entire population but demonstrated improved OS in the PD-L1 positive cancers (with SP142 assay)26. These results clearly demonstrate that unlike in stages I–III TNBC, PD-L1 positivity is required for the benefit of atezolizumab, pembrolizumab, and durvalumab in metastatic TNBC.
The biological reasons behind the distinct predictive functions of PD-L1 in metastatic vs. early-stage breast cancers are unclear. However, PD-L1 protein expression on immune cells, the primary cellular sources of PD-L1 expression in breast cancer, correlates closely with overall immune infiltration6–8 and metastatic lesions have been shown to have an overall more immune attenuated tissue microenvironment, even when immune cells are present, compared to primary tumors27–29. We hypothesize that in metastatic breast cancer, greater immune checkpoint inhibitor target expression (reflected by higher PD-L1 expression) may be required to obtain benefit from immune checkpoint inhibition, whereas low levels of the target (that may be missed by current PD-L1 IHC or TIL counting methods) may be sufficient to augment antitumor immune responses by immune checkpoint inhibitors in stages I–III TNBC. Indeed, in our study, all TNBCs had at least 1% sTILs but the PD-L1 positivity rate was only 42% in cancers with sTIL between 1 and 10%, compared to 100% positivity rate in cancers with sTIL ≥30%.
Immune-related adverse events were consistent with known adverse events of immune checkpoint inhibitors and no new safety concerns were identified. There were no perioperative complications. However, we did observe several severe irAEs including 2 patients (3%) with autoimmune type I diabetes. One patient presented with grade 3 hyperglycemia, diabetic ketoacidosis, low C-peptide, and increased islet antibody-2 (IA-2) after 4 cycles of durvalumab, requiring inpatient admission. She remains on long-term insulin treatment. The second patient presented with grade 4 hyperglycemia without diabetic ketoacidosis after completing 7 cycles of durvalumab. She had a history of metabolic syndrome (obesity, glucose intolerance) and was initially thought to have type II diabetes; however, her C-peptide level was low on presentation with a further decrease on follow-up testing 5 months later, indicating autoimmune type I-like diabetes. There were two deaths possibly related to treatment, one patient suffered a presumed cardiac arrest following completion of all study-related treatments but prior to undergoing surgery and one patient died after developing the Miller–Fisher variant of Guillain–Barre syndrome (GBS), a rare but previously reported neurologic complication of checkpoint inhibition characterized by ophthalmoplegia, ataxia, and hypersomnolence30. Notably, she developed GBS after only one dose of durvalumab. We recognize that our study had slightly higher than expected toxicity and mortality, we attribute this to more comorbidities in our study population than seen in the pivotal randomized trials. A growing number of randomized neoadjuvant trials with pembrolizumab, durvalumab, and atezolizumab including over 2000 patients with TNBC show good tolerability but also added immune-related toxicities. In the KEYNOTE-522 trial, 32% of patients experienced immune-related adverse events of any grade, and 12% had grade 3 or greater immune-related toxicities18. The most common were hypo-, and hyperthyroidism, and skin rash. Similar results were seen in Impassion-03120.
In summary, these results add to the growing literature that indicates the efficacy of immune checkpoint inhibitors in early-stage TNBC. Durvalumab concurrent with neoadjuvant nab-paclitaxel and ddAC chemotherapy resulted in a 44% pCR rate. Among the 62% of patients who had PD-L1 positive disease, the pCR rate was 55%, among PD-L1 negative cancers the pCR rate was 32%.
Methods
Study design
The primary objective of the Phase I part was to assess the safety of durvalumab concurrent with weekly nab-paclitaxel (100 mg/m2) × 12 treatments followed by doxorubicin (60 mg/m2) and cyclophosphamide (600 mg/m2) every 2 weeks (AC) × 4 treatments. Two dose levels, 3 mg/kg and 10 mg/kg, of durvalumab, administered every 2 weeks were explored following a 3 + 3 design. No steroid premedications were used during nab-paclitaxel treatment and durvalumab was administered immediately after completion of nab-paclitaxel. During AC, the first course of treatment was administered without dexamethasone pre-medication, but if clinically significant nausea or vomiting occurred subsequent courses were given with 20 mg dexamethasone. Approximately 24 h after administration of AC, 6 mg pegfilgrastim was administered followed by durvalumab. Dose-limiting toxicities (DLT) were monitored during the entire 20 weeks of therapy and for 4 weeks after completion of surgery before advancing to the next dose level. DLT was defined as any grade 4 immune-related adverse event (irAE), any grade 3 irAE that did not resolve to grade 2 within 3 days despite optimal management or did not resolve to ≤grade 1 within 14 days, and any ≥grade 3 non-irAE causally attributed to durvalumab. The primary efficacy objective was to assess pCR rate in patients who received the recommended Phase II dose including both the Phase I and phase II component. The efficacy study followed Simon’s two-stage design (p0 = 30%, p1 = 50%) with an interim efficacy analysis after the first 22 patients completed surgery and accrual was to be terminated if <7 patients experienced pCR, otherwise, accrual continued until 50 patients were evaluable for pCR. The maximum sample size was set to N = 61 allowing for replacement of non-evaluable patients. If >20 of 50 evaluable patients had pCR (40% observed pCR rate) the combination therapy would be recommended for further study. This was an investigator-initiated trial, and ethical approval was obtained from the Yale Human Investigations Committee (Yale University, HIC# 1409014537). Astra Zeneca provided study drug and funding for the trial but played no role in the study design, collection/analysis of data, or manuscript preparation.
Patients and assessments
The study was approved and was annually reviewed by the internal institutional review board and all patients provided a written consent form to join the study. All patients signed written informed consent prior to participation. Patients with clinical stages I–III, triple-negative breast cancer, defined as ER and PR < 1% positive and HER2 negative (IHC 0, 1+, or 2+, or FISH negative), for whom systemic chemotherapy was indicated according to NCCN treatment guidelines were eligible31. Exclusion criteria included contraindications for anthracycline, paclitaxel, or anti-PD-L1 therapies (e.g., active autoimmune disease, live vaccines within 30 days, prior transplants, immune deficiency, active immunosuppressive medications).
Adverse events (AE) were assessed every 2 weeks and graded according to NCI CTCAE v4.03. All patients who received at least one dose of durvalumab were included in toxicity analysis. Surgery was performed within 4 weeks of completion of neoadjuvant chemotherapy and the extent of residual cancer assessed by the local pathologist as part of routine care. Residual Cancer Burden was assessed centrally by a breast pathologist (E.R.)32.
Biomarker analysis
PD-L1 expression on formalin-fixed paraffin-embedded pretreatment biopsies was assessed with chromogenic immunohistochemistry (IHC) using the VENTANA PD-L1 (SP263) Assay performed according to the Federal Drug Administration (FDA) label. PD-L1 positivity was determined by consensus review of 2 pathologists (E.R., D.L.R.), and ≥1% staining on immune or tumor cells was considered positive. The percentage of stromal tumor-infiltrating lymphocytes (sTILs) was assessed on hematoxylin–eosin-stained slides and calculated as the area occupied by mononuclear inflammatory cells over the total intratumoral stromal area (E.R, K.S.). The association between pCR, PD-L1 expression, and sTILs along with clinicopathologic parameters (age, tumor size [T1 vs. T2/T3], nodal status [N0 vs. N1–N3]) was assessed using logistic regression. The pCR rates between PD-L1 positive and negative cohorts were compared using Fisher’s exact test. PD-L1 positivity rate in low, intermediate, and high sTIL cancers was assessed with a two-sided Fisher’s exact test. Median sTILs percent between cases with pCR and RD were compared using the Mann–Whitney U test.
Reporting summary
Further information on research design is available in the Nature Research Reporting Summary linked to this article.
Supplementary information
Supplementary Figure 1
Reporting Summary Checklist
Supplementary information
The online version contains supplementary material available at 10.1038/s41523-021-00219-7.
Acknowledgements
We thank the participating patients and their families, as well as the research nurses, trial coordinators, and operations staff, for their contributions, and we thank the investigators who enrolled patients in this trial. The research reported in this publication was supported by Astra Zeneca and grants from the National Cancer Institute (R01CA219647), the Breast Cancer Research Foundation, and the Susan Komen Foundation (SAC160076) to L.P.
Author contributions
Study design: L.P. Patient accrual: A.S., N.F., J.P., K.A., A.K., N.H., D.L., A.C., T.P., and L.P. Data analysis: J.F., M.M., E.R., K.S., C.F., T.B., E.I., T.Q., Y.B., K.B., D.R., and L.P. Manuscript writing: J.F., K.B., and L.P. Final review of manuscript: all authors.
Data availability
The data generated and analyzed during this study are described and shared openly in the following data record: 10.6084/m9.figshare.1336296833. The three data files containing all data are as follows. (1) Neoadjuvant Durvalumab Study_AEs_irAEs no dates.xlsx: Adverse events of all grades including detailed immune-related adverse events observed during our study. The file also includes data on the discontinuation of study drugs and the reason for those discontinuations. (2) Neoadjuvant Durvalumab Study_Demographics_Outcomes no dates.xlsx: Study participant demographics with no identifiable information and all dates removed from the data. Data includes baseline disease characteristics as well as outcomes in terms of survival and recurrence events up to the data cutoff of 8/15/2020. (3) Neoadjuvant Durvalumab Study_TIL counts_PDL1.xlsx - Tumor-infiltrating lymphocyte (TIL) counts (%) and PD-L1 status (positive vs. negative or unscorable) of patient’s tumors.
Competing interests
A.S. has received honoraria and consulting fees from Astra Zeneca. D.L.R. has served as an advisor and consultant for Amgen, Astra Zeneca, Biocept, BMS, Cell Signaling Technology, Cepheid, Daiichi Sankyo, GSK, Konica/Minolta, Merck, NanoString, NextCure, Odonate, Perkin Elmer, PAIGE.AI, Roche, Sanofi, Ventana, and Ultivue; received research funding from Amgen, Cepheid, NavigateBP, NextCure, Konica/Minolta, Lilly, and Ultivue; received instrument support from Akoya/Perkin Elmer, NanoString and Ventana; is a founder and equity holder of PixelGear, and received royalties from Rarecyte. L.P. has received consulting fees and honoraria from Astra Zeneca, Merck, Novartis, Bristol-Myers Squibb Genentech, Eisai, Pieris, Immunomedics, Seattle Genetics, Clovis, Syndax, H3Bio, and Daiichi. The remaining authors declare no competing interests.
Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. | 100 MILLIGRAM/SQ. METER | DrugDosageText | CC BY | 33558513 | 18,936,228 | 2021-02-08 |
Give an alphabetized list of all active substances of drugs taken by the patient who experienced 'Intentional overdose'. | Subcortical Structure Disruption in Diffusion Tensor Tractography of the Patient With the Syndrome of Irreversible Lithium-Effectuated Neurotoxicity Combined With Neuroleptic Malignant Syndrome: A Case Report.
BACKGROUND
Lithium can cause not only acute neurotoxicity but also chronic and persistent neurotoxicity known as syndrome of irreversible lithium-effectuated neurotoxicity (SILENT). The combined use of lithium and antipsychotics increases the possibility of SILENT. Neuroleptic malignant syndrome (NMS) is a reversible, idiosyncratic, and potentially life-threatening reaction, which is usually caused by antipsychotics and other agents, such as mood stabilizers (eg, lithium and metoclopramide). Neuroleptic malignant syndrome is characterized by hyperpyrexia, muscle rigidity, and altered mental status. We describe a case of SILENT combined with NMS in this case report.
METHODS
A 46-year-old man who had been treated with lithium for bipolar II disorder since 2008 was prescribed lorazepam, lithium, and aripiprazole at his last outpatient visit. The patient experienced financial difficulties (bankruptcy) and suffered severe emotional stress. Subsequently, he overused lorazepam, lithium, and aripiprazole. Two days after the overdose, he experienced a high fever, confused mental status, and rhabdomyolysis and was diagnosed with NMS. However, even after resolution of NMS-related symptoms, quadriplegia, visual field defects, ataxia, and severe dysarthria persisted. A positron emission tomography-computed tomography brain scan showed decreased 15F-fludeoxyglucose uptake in bilateral primary motor cortices and in the thalamus, midbrain, and cerebellum. Brain magnetic resonance imaging diffusion tensor imaging and diffusion tensor tractography of the subcortical tracts revealed structural disruptions, especially in the corticospinal tract, dentatorubrothalamic tract, and optic radiation, which seemed to be correlated with the clinical symptoms of the patient.
CONCLUSIONS
This case suggests that the clinical use of diffusion tensor tractography could be helpful to explain the clinical features in the case of SILENT combined with NMS.
The use of lithium as a treatment for bipolar disorder has increased recently. Because of its narrow therapeutic window, it is important to check the serum dose. Since lithium was first introduced in the field of psychiatry in 1949, a number of cases of lithium neurotoxicity and potentially life-threatening complications have been reported.1–3 Among neurotoxic complications of lithium, there are reported cases of acute and reversible neurotoxicity.4,5 Adityanjee6 reported 55 cases of chronic and persistent neurotoxicity and sequelae associated with the use of lithium. In these cases, the main sequelae of the patients were persistent cerebellar symptoms. Adityanjee7 was the first to propose the name syndrome of irreversible lithium-effectuated neurotoxicity (SILENT) to represent persistent neurotoxic sequelae of lithium. Lithium intoxication is associated with several neurological symptoms, such as tremor, ataxia, encephalopathy, comatous mental change, and dysarthria.8 Also, SILENT mostly induces cerebellar and extrapyramidal symptoms.8
Neuroleptic malignant syndrome (NMS) is an idiosyncratic and potentially life-threatening reaction, characterized by hyperpyrexia, muscle rigidity, autonomic dysfunction, mental status change, tremors, leukocytosis, and creatinine kinase (CK) elevation.9–11 Although the reported incidence of NMS is reported to be just 0.01% to 0.02%, it is responsible for a significant portion of morbidity and mortality in patients who use antipsychotics.11–13 In terms of pathophysiological aspects, NMS is thought to be a subcortical motor syndrome caused by dopaminergic dysregulation.14 Neuroleptic malignant syndrome is associated with the use of conventional, old-generation antipsychotics. Recently, the development of newer generation antipsychotic agents has decreased the incidence of NMS.
Catatonia, which refers to cortical psychomotor immobility and abnormal behavior, shares similar features with NMS, but it is the result of GABAergic dysregulation.14 In some previous cases, the initial presentation of NMS was catatonia.10,14,15
We describe the case of a 46-year-old man with bipolar disorder who was diagnosed with SILENT and NMS by the clinical symptoms after drug intoxication, such as persistent catatonia and quadriplegia, tremor, ataxia, and dysarthria. Moreover, imaging analysis by using diffusion tensor tractography (DTT) in this case was also performed.
CASE REPORT
A 46-year-old man had received treatment for bipolar II disorder since 2008. In September 2018, he suffered severe emotional stress due to bankruptcy. In October 2018, he visited the outpatient clinic of a university hospital and was prescribed lorazepam, lithium, and aripiprazole. The same day, he took a massive overdose of the medication. He became delirious 1 day later and exhibited abnormal behaviors, including confusion. He developed a high fever (40°C) 2 days later, with concomitant aggravation of his mental status. A laboratory study showed CK elevation (over 40,000 IU/L; reference value = 44–245 IU/L) and metabolic acidosis. At that time, his serum lithium level was 1.63 mmol/L (reference value = 0.6–1.2 mmol/L). Subsequently, oliguria with azotemia due to acute kidney injury after rhabdomyolysis and hemodynamic instability developed. Continuous renal replacement therapy was administered, with intensive care unit management for 8 days. Blood, sputum, and urine culture, in addition to abdomen and pelvic computed tomography (CT), cerebrospinal fluid tapping, and brain imaging, including magnetic resonance imaging (MRI) (Fig. 1) and CT, were performed, none of which revealed any significant findings. Due to the suspicion of NMS, the patient was treated with dantrolene via the intravenous route. Seven days after the administration of dantrolene, the patient's CK level began to decrease.
FIGURE 1 Brain MRI T2 Axial and T2 FLAIR Sagittal (2019.1.18). There was no remarkable finding.
However, even after resolution of rhabdomyolysis and acute kidney injury, catatonia, limb and trunk ataxia, visual field defects, and severe dysarthria remained. To rule out possible organic problems, electroencephalography and brain positron emission tomography (PET) were performed. The electroencephalography showed sharply formed diffuse theta and delta and theta dominant waves, which suggested mild nonspecific diffuse cerebral dysfunction. A PET brain scan taken in May 2019 revealed decreased 15F-fludeoxyglucose (FDG) uptake in bilateral primary motor cortices and the thalamus, midbrain, and cerebellum (Fig. 2).
FIGURE 2 PET-CT brain scan (2019.5.15). Decreased FDG uptake in bilateral primary motor cortices (red arrow), thalamus (white arrow), midbrain (red arrowhead), and cerebellum (white arrowhead) was shown.
In June 2019, the patient was admitted to our hospital. In a neurological examination at that time, his Mini-Mental Status Examination score was 28 points, with slight time disorientation and attention deficit detected. In the manual muscle test using the Medical Research Council (MRC) scale, the patient was grade III to IV for both the upper and lower extremities. Brain MRI was performed twice. Both times, structural brain MRI sequences, including T1WI, T2WI, T2 FLAIR, SWI, MPR, and DWI, showed no abnormalities (lesions) (Fig. 3).
FIGURE 3 Brain MRI T2 FLAIR Axial and T1 Sagittal (2019.6.14). There was no remarkable finding. Compared with a previous study (2019.1.8), no interval change was observed.
Diffusion tensor imaging (DTI) was performed using a 3.0 T system (Philips Achieva TX, Best, Netherlands). The DTI sequence parameters were as follows: repetition time = 7,958.5 ms and echo time = 71 ms. After this DTI sequence, a DTI diffusion scheme was used, and 32 diffusion sampling directions were acquired. The b-value was 600 s/mm2. The in-plane resolution was 1.91071 mm. The slice thickness was 2 mm. The b-table was checked using an automatic quality control routine to ensure its accuracy.16 To obtain the spin distribution function,17 the diffusion data were reconstructed in the Montreal Neurological Institute space using q-space diffeomorphic reconstruction.18 A diffusion sampling length ratio of 1.25 was used, with isotropic output resolution of 2 mm. The restricted diffusion was quantified using restricted diffusion imaging.19
Then, the DSI Studio software (http://dsi-studio.labsolver.org/) was used to visualize the subcortical tracts. The DSI Studio software has auto-tracking tools for most subcortical tracts, including the corticospinal tract (CST), rubrospinal tract, and spinothalamic tract. However, some tracts, such as the dentatorubrothalamic tract (DRTT), which is associated with motor planning and initiation of movement, motor coordination, verbal fluency, and working memory,20,21 could not be obtained using the auto-tracking tools. Anatomically, DRTT arises from deep cerebellar nuclei, mainly the dentate nucleus, passing through the superior cerebellar peduncle, and then decussates to the contralateral red nucleus to ascend to the thalamus and brain cortex.22 In this case, DRTT fiber tracking was conducted using deterministic fiber-tracking algorithm based on Human Connectome Project (Q1–Q3 release, WU-Minn HCP consortium).20,23
We obtained DTT of each subcortical tracts, including the CST, arcuate fasciculus, rubrospinal tract, corpus callosum, optic radiation, and DRTT. Diffusion tensor tractography of the subcortical tracts revealed subtle impairment of the bilateral CST (Figs. 4A, B, C) and substantial structural impairment of left optic radiation compared with the right side (Fig. 4D). In addition, DRTT showed severe subcortical disruption (Figs. 4E, F) that seemed to be correlated with the quadriplegic, ataxic, catatonic symptoms, and dysarthria of the patient.
FIGURE 4 DTT of CST (A, B, C), optic radiation (d), and DRTT (E, F) (June 14, 2019). Subcortical disruptions were observed. (Arrows and arrowheads: suspected disruption of each tracts) (red: left, blue: right).
The patient received intensive rehabilitation, including physiotherapy (30 min/session, 2 sessions/d, 5 times/wk), occupational therapy (30 min/session, 2 sessions/d, 5 times/wk), and speech therapy (40 min/session, 2–3 three times/wk) until July 2019. In the manual muscle test, his muscle power increased from MRC grade I in November 2018 to MRC grade III to IV in July 2019. In terms of hand function, pinch and grasp power of both hands improved, but fine motor function of his left hand showed no improvement (Table 1). The patient’s Functional Independence Measure score improved from 38 in January 2019 to 71 in July 2019. Correspondingly, his modified Barthel Index score improved from 0 in January 2019 to 49 in July 2019. In a speech evaluation, articulation and pronunciation improved slightly, but his speech remained very slow (Table 2). Ataxia-related features also improved, with the CARS score declining from 72 in June 2019 to 60 in July 2019 (Table 3).
TABLE 1 Hand Function Test
January 2019 July 2019
Pinch power (kg)
Tip pinch
Rt. 1.6 5.5
Lt. NT NT
Lateral pinch
Rt. 3.8 9
Lt. 1 3.5
Palmar pinch
Rt. 2.5 8.5
Lt. NT NT
Box and block (/min)
Rt. 14 13
Lt. NT 6
Grip power (kg)
Rt. 4 26
Lt. NT 9
NT indicates not testable; Rt., right; Lt., left.
TABLE 2 Speech Test (Paradise K-WAB)
January 2019 May 2019 June 2019
AQ 92.4 94.5 96.2
LQ — 92.5 94.6
MPT 2.45 s 20.83 s 10.44 s
DDK
AMR
“/pa/” 8 times/5 s 13 times/5 s
AMR
“/ta/” 6 times/5 s 13.7times/5 s
AMR
“/ka/” 5 times/5 s 12 times/5 s
SMR
“/pataka/” 2 times/5 s 4 times/5 s
K-WAB indicates Korean version—the Western Aphasia Battery; AQ, aphasia quotient; LQ, language quotient; MPT, maximum phonation time; DDK, diadochokinetic rate; AMR, alterate motion rate; SMR, sequencing motion rate.
TABLE 3 International Cooperative Ataxia Rating Scale (ICARS)
June 2019 July 2019
Posture and gait disturbances
Walking capacities 8 8
Gait speed 4 4
Standing capacities, eyes open 5 5
Spread of feet in natural position/s support, eyes open 4 2
Body sway with feet together, eyes open 4 3
Body sway with feet together, eyes closed 4 4
Quality of sitting position 1 0
Kinetic functions
Knee-tibia test (decomposition of movement and intention tremor) 3/4 3/3
Action tremor in the heel to knee test 3/3 2/2
Finger to nose test: decomposition and dysmetria 2/3 2/3
Finger to nose test: intention tremor of finger 2/3 2/2
Finger-finger test (action tremor and/or instability) 2/3 2/2
Pronation supination alternating movements 2/3 1/2
Drawing of Archimedes' spiral on a predrawn pattern 2 1
Speech disorders
Dysarthria: fluency of speech 3 3
Dysarthria: clarity of speech 2 2
Oculomotor disorders
Gaze-evoked nystagmus 1 1
Abnormalities of ocular pursuit 1 1
Dysmetria of saccade 0 0
Total 72/100 60/100
DISCUSSION
Neuroleptic malignant syndrome is a rare but potentially life-threatening complication associated with the use of antipsychotics.12 The characteristic symptom triad of NMS includes hyperpyrexia, rigidity, and altered mental status.24 Other clinical features include tremor, urinary incontinence, dysphagia, elevated CK, and leukocytosis.24
Over 75% of patients with long-term use of lithium experience some kind of toxicity because of its narrow therapeutic dose.25 Lithium toxicity is associated with confusion, lethargy, slurred speech, tremor, and gait difficulties.26 Before 1987, the majority of reported lithium toxicity cases involved acute neurotoxicity, which was reversible.4,5 In 1987, the first case report of SILENT, which represents persistent and irreversible neurotoxic sequelae of lithium, was described.6–8 In a literature review, SILENT was mostly associated with extrapyramidal features and cerebellar symptoms.8,27
In the present case, the persistent catatonic features of the patient raised the suspicion of NMS. However, other than in the acute phase of his illness, the patient did not exhibit abrupt onset of mutism, negativism, immobility, or rigidity, all of which are part of the clinical presentation of catatonia. A number of studies have reported chronic neurological sequelae (SILENT) resulting from lithium intoxication.6–8 In the present case, we assumed that the chronic neurological sequelae were attributed to SILENT rather than persistent catatonia after NMS.
Our patient made some recovery, although extrapyramidal features, cerebellar ataxia, severe dysarthria, and autonomic instability remained. Thus, in this case of lithium toxicity, the patient appeared to exhibit not only NMS-related features in the acute stage but also SILENT-type features in the chronic stage. This case emphasizes the need to consider the possibility of SILENT, especially in cases of combined use of lithium and antipsychotics.8,28 Furthermore, we propose the possibility that SILENT might be a chronic subtype of NMS.10,15
In this case, after the diagnosis of SILENT combined with NMS, we performed imaging studies in an effort to identify possible causes of the patient’s symptoms. Among the imaging studies performed, a PET brain scan showed decreased FDG uptake in bilateral primary motor cortices and in the thalamus, midbrain, and cerebellum. Routine brain structural MRI revealed no lesions that could explain the patient's symptoms. As a PET CT brain scan provides only biochemical evidence, we performed DTI to assess the subcortical structure.
To acquire DTI, in addition to the three-dimensional gradient magnetic field, which is already used in the diffusion-weighted image sequence, an extra magnetic field is used to measure the motion of water molecules. If the water molecules in a specific space take same probability of diffusion in any direction, this is called Brownian motion, and it is defined as “isotropic diffusion.” On the other hand, if the diffusion of water molecules shows a specific direction, such as in a white matter tract, this is called as “anisotropic diffusion.” Therefore, DTI is helpful to analyze the white matter structure and injury of this structure.29,30 Practically, there are 2 methods to detect injury of white matter tracts. One is to analyze the diffusion tensor parameters of the region of interest, and the other is to reconstruct the region of interest of each tract using DTT.31–33 In contrast to DTI analysis and diffusion tensor parameter, DTT provides visual information of each tracts. Diffusion tensor tractography can be considered an objective, reproducible, and reliable method to ascertain the structural integrity of white matter tracts.34–39
The DTT analysis revealed structural disruptions of the CST and optic radiation, which were, respectively, correlated with quadriplegia and visual field defects. In particular, DTT showed severe structural disruption of the DRTT, which is associated with motor planning and initiation of movement. This disruption was not visible on routine brain MRI.
CONCLUSIONS
In the present case, although brain MRI sequences revealed no specific abnormal findings, DTT derived from the DTI sequence revealed severe subcortical disruption of the CST, optic radiation and DRTT, all of which seemed to be correlated with the patient's clinical symptoms. Therefore, the DTI sequence and DTT appear to be useful in evaluating and correlating neurological symptoms of patients with SILENT combined with NMS.
Conflicts of Interest and Source of Funding: The authors have no conflicts of interest to declare. | ARIPIPRAZOLE, LITHIUM, LORAZEPAM | DrugsGivenReaction | CC BY-NC-ND | 33560007 | 20,232,558 | 2021 |
Give an alphabetized list of all active substances of drugs taken by the patient who experienced 'Neuroleptic malignant syndrome'. | Subcortical Structure Disruption in Diffusion Tensor Tractography of the Patient With the Syndrome of Irreversible Lithium-Effectuated Neurotoxicity Combined With Neuroleptic Malignant Syndrome: A Case Report.
BACKGROUND
Lithium can cause not only acute neurotoxicity but also chronic and persistent neurotoxicity known as syndrome of irreversible lithium-effectuated neurotoxicity (SILENT). The combined use of lithium and antipsychotics increases the possibility of SILENT. Neuroleptic malignant syndrome (NMS) is a reversible, idiosyncratic, and potentially life-threatening reaction, which is usually caused by antipsychotics and other agents, such as mood stabilizers (eg, lithium and metoclopramide). Neuroleptic malignant syndrome is characterized by hyperpyrexia, muscle rigidity, and altered mental status. We describe a case of SILENT combined with NMS in this case report.
METHODS
A 46-year-old man who had been treated with lithium for bipolar II disorder since 2008 was prescribed lorazepam, lithium, and aripiprazole at his last outpatient visit. The patient experienced financial difficulties (bankruptcy) and suffered severe emotional stress. Subsequently, he overused lorazepam, lithium, and aripiprazole. Two days after the overdose, he experienced a high fever, confused mental status, and rhabdomyolysis and was diagnosed with NMS. However, even after resolution of NMS-related symptoms, quadriplegia, visual field defects, ataxia, and severe dysarthria persisted. A positron emission tomography-computed tomography brain scan showed decreased 15F-fludeoxyglucose uptake in bilateral primary motor cortices and in the thalamus, midbrain, and cerebellum. Brain magnetic resonance imaging diffusion tensor imaging and diffusion tensor tractography of the subcortical tracts revealed structural disruptions, especially in the corticospinal tract, dentatorubrothalamic tract, and optic radiation, which seemed to be correlated with the clinical symptoms of the patient.
CONCLUSIONS
This case suggests that the clinical use of diffusion tensor tractography could be helpful to explain the clinical features in the case of SILENT combined with NMS.
The use of lithium as a treatment for bipolar disorder has increased recently. Because of its narrow therapeutic window, it is important to check the serum dose. Since lithium was first introduced in the field of psychiatry in 1949, a number of cases of lithium neurotoxicity and potentially life-threatening complications have been reported.1–3 Among neurotoxic complications of lithium, there are reported cases of acute and reversible neurotoxicity.4,5 Adityanjee6 reported 55 cases of chronic and persistent neurotoxicity and sequelae associated with the use of lithium. In these cases, the main sequelae of the patients were persistent cerebellar symptoms. Adityanjee7 was the first to propose the name syndrome of irreversible lithium-effectuated neurotoxicity (SILENT) to represent persistent neurotoxic sequelae of lithium. Lithium intoxication is associated with several neurological symptoms, such as tremor, ataxia, encephalopathy, comatous mental change, and dysarthria.8 Also, SILENT mostly induces cerebellar and extrapyramidal symptoms.8
Neuroleptic malignant syndrome (NMS) is an idiosyncratic and potentially life-threatening reaction, characterized by hyperpyrexia, muscle rigidity, autonomic dysfunction, mental status change, tremors, leukocytosis, and creatinine kinase (CK) elevation.9–11 Although the reported incidence of NMS is reported to be just 0.01% to 0.02%, it is responsible for a significant portion of morbidity and mortality in patients who use antipsychotics.11–13 In terms of pathophysiological aspects, NMS is thought to be a subcortical motor syndrome caused by dopaminergic dysregulation.14 Neuroleptic malignant syndrome is associated with the use of conventional, old-generation antipsychotics. Recently, the development of newer generation antipsychotic agents has decreased the incidence of NMS.
Catatonia, which refers to cortical psychomotor immobility and abnormal behavior, shares similar features with NMS, but it is the result of GABAergic dysregulation.14 In some previous cases, the initial presentation of NMS was catatonia.10,14,15
We describe the case of a 46-year-old man with bipolar disorder who was diagnosed with SILENT and NMS by the clinical symptoms after drug intoxication, such as persistent catatonia and quadriplegia, tremor, ataxia, and dysarthria. Moreover, imaging analysis by using diffusion tensor tractography (DTT) in this case was also performed.
CASE REPORT
A 46-year-old man had received treatment for bipolar II disorder since 2008. In September 2018, he suffered severe emotional stress due to bankruptcy. In October 2018, he visited the outpatient clinic of a university hospital and was prescribed lorazepam, lithium, and aripiprazole. The same day, he took a massive overdose of the medication. He became delirious 1 day later and exhibited abnormal behaviors, including confusion. He developed a high fever (40°C) 2 days later, with concomitant aggravation of his mental status. A laboratory study showed CK elevation (over 40,000 IU/L; reference value = 44–245 IU/L) and metabolic acidosis. At that time, his serum lithium level was 1.63 mmol/L (reference value = 0.6–1.2 mmol/L). Subsequently, oliguria with azotemia due to acute kidney injury after rhabdomyolysis and hemodynamic instability developed. Continuous renal replacement therapy was administered, with intensive care unit management for 8 days. Blood, sputum, and urine culture, in addition to abdomen and pelvic computed tomography (CT), cerebrospinal fluid tapping, and brain imaging, including magnetic resonance imaging (MRI) (Fig. 1) and CT, were performed, none of which revealed any significant findings. Due to the suspicion of NMS, the patient was treated with dantrolene via the intravenous route. Seven days after the administration of dantrolene, the patient's CK level began to decrease.
FIGURE 1 Brain MRI T2 Axial and T2 FLAIR Sagittal (2019.1.18). There was no remarkable finding.
However, even after resolution of rhabdomyolysis and acute kidney injury, catatonia, limb and trunk ataxia, visual field defects, and severe dysarthria remained. To rule out possible organic problems, electroencephalography and brain positron emission tomography (PET) were performed. The electroencephalography showed sharply formed diffuse theta and delta and theta dominant waves, which suggested mild nonspecific diffuse cerebral dysfunction. A PET brain scan taken in May 2019 revealed decreased 15F-fludeoxyglucose (FDG) uptake in bilateral primary motor cortices and the thalamus, midbrain, and cerebellum (Fig. 2).
FIGURE 2 PET-CT brain scan (2019.5.15). Decreased FDG uptake in bilateral primary motor cortices (red arrow), thalamus (white arrow), midbrain (red arrowhead), and cerebellum (white arrowhead) was shown.
In June 2019, the patient was admitted to our hospital. In a neurological examination at that time, his Mini-Mental Status Examination score was 28 points, with slight time disorientation and attention deficit detected. In the manual muscle test using the Medical Research Council (MRC) scale, the patient was grade III to IV for both the upper and lower extremities. Brain MRI was performed twice. Both times, structural brain MRI sequences, including T1WI, T2WI, T2 FLAIR, SWI, MPR, and DWI, showed no abnormalities (lesions) (Fig. 3).
FIGURE 3 Brain MRI T2 FLAIR Axial and T1 Sagittal (2019.6.14). There was no remarkable finding. Compared with a previous study (2019.1.8), no interval change was observed.
Diffusion tensor imaging (DTI) was performed using a 3.0 T system (Philips Achieva TX, Best, Netherlands). The DTI sequence parameters were as follows: repetition time = 7,958.5 ms and echo time = 71 ms. After this DTI sequence, a DTI diffusion scheme was used, and 32 diffusion sampling directions were acquired. The b-value was 600 s/mm2. The in-plane resolution was 1.91071 mm. The slice thickness was 2 mm. The b-table was checked using an automatic quality control routine to ensure its accuracy.16 To obtain the spin distribution function,17 the diffusion data were reconstructed in the Montreal Neurological Institute space using q-space diffeomorphic reconstruction.18 A diffusion sampling length ratio of 1.25 was used, with isotropic output resolution of 2 mm. The restricted diffusion was quantified using restricted diffusion imaging.19
Then, the DSI Studio software (http://dsi-studio.labsolver.org/) was used to visualize the subcortical tracts. The DSI Studio software has auto-tracking tools for most subcortical tracts, including the corticospinal tract (CST), rubrospinal tract, and spinothalamic tract. However, some tracts, such as the dentatorubrothalamic tract (DRTT), which is associated with motor planning and initiation of movement, motor coordination, verbal fluency, and working memory,20,21 could not be obtained using the auto-tracking tools. Anatomically, DRTT arises from deep cerebellar nuclei, mainly the dentate nucleus, passing through the superior cerebellar peduncle, and then decussates to the contralateral red nucleus to ascend to the thalamus and brain cortex.22 In this case, DRTT fiber tracking was conducted using deterministic fiber-tracking algorithm based on Human Connectome Project (Q1–Q3 release, WU-Minn HCP consortium).20,23
We obtained DTT of each subcortical tracts, including the CST, arcuate fasciculus, rubrospinal tract, corpus callosum, optic radiation, and DRTT. Diffusion tensor tractography of the subcortical tracts revealed subtle impairment of the bilateral CST (Figs. 4A, B, C) and substantial structural impairment of left optic radiation compared with the right side (Fig. 4D). In addition, DRTT showed severe subcortical disruption (Figs. 4E, F) that seemed to be correlated with the quadriplegic, ataxic, catatonic symptoms, and dysarthria of the patient.
FIGURE 4 DTT of CST (A, B, C), optic radiation (d), and DRTT (E, F) (June 14, 2019). Subcortical disruptions were observed. (Arrows and arrowheads: suspected disruption of each tracts) (red: left, blue: right).
The patient received intensive rehabilitation, including physiotherapy (30 min/session, 2 sessions/d, 5 times/wk), occupational therapy (30 min/session, 2 sessions/d, 5 times/wk), and speech therapy (40 min/session, 2–3 three times/wk) until July 2019. In the manual muscle test, his muscle power increased from MRC grade I in November 2018 to MRC grade III to IV in July 2019. In terms of hand function, pinch and grasp power of both hands improved, but fine motor function of his left hand showed no improvement (Table 1). The patient’s Functional Independence Measure score improved from 38 in January 2019 to 71 in July 2019. Correspondingly, his modified Barthel Index score improved from 0 in January 2019 to 49 in July 2019. In a speech evaluation, articulation and pronunciation improved slightly, but his speech remained very slow (Table 2). Ataxia-related features also improved, with the CARS score declining from 72 in June 2019 to 60 in July 2019 (Table 3).
TABLE 1 Hand Function Test
January 2019 July 2019
Pinch power (kg)
Tip pinch
Rt. 1.6 5.5
Lt. NT NT
Lateral pinch
Rt. 3.8 9
Lt. 1 3.5
Palmar pinch
Rt. 2.5 8.5
Lt. NT NT
Box and block (/min)
Rt. 14 13
Lt. NT 6
Grip power (kg)
Rt. 4 26
Lt. NT 9
NT indicates not testable; Rt., right; Lt., left.
TABLE 2 Speech Test (Paradise K-WAB)
January 2019 May 2019 June 2019
AQ 92.4 94.5 96.2
LQ — 92.5 94.6
MPT 2.45 s 20.83 s 10.44 s
DDK
AMR
“/pa/” 8 times/5 s 13 times/5 s
AMR
“/ta/” 6 times/5 s 13.7times/5 s
AMR
“/ka/” 5 times/5 s 12 times/5 s
SMR
“/pataka/” 2 times/5 s 4 times/5 s
K-WAB indicates Korean version—the Western Aphasia Battery; AQ, aphasia quotient; LQ, language quotient; MPT, maximum phonation time; DDK, diadochokinetic rate; AMR, alterate motion rate; SMR, sequencing motion rate.
TABLE 3 International Cooperative Ataxia Rating Scale (ICARS)
June 2019 July 2019
Posture and gait disturbances
Walking capacities 8 8
Gait speed 4 4
Standing capacities, eyes open 5 5
Spread of feet in natural position/s support, eyes open 4 2
Body sway with feet together, eyes open 4 3
Body sway with feet together, eyes closed 4 4
Quality of sitting position 1 0
Kinetic functions
Knee-tibia test (decomposition of movement and intention tremor) 3/4 3/3
Action tremor in the heel to knee test 3/3 2/2
Finger to nose test: decomposition and dysmetria 2/3 2/3
Finger to nose test: intention tremor of finger 2/3 2/2
Finger-finger test (action tremor and/or instability) 2/3 2/2
Pronation supination alternating movements 2/3 1/2
Drawing of Archimedes' spiral on a predrawn pattern 2 1
Speech disorders
Dysarthria: fluency of speech 3 3
Dysarthria: clarity of speech 2 2
Oculomotor disorders
Gaze-evoked nystagmus 1 1
Abnormalities of ocular pursuit 1 1
Dysmetria of saccade 0 0
Total 72/100 60/100
DISCUSSION
Neuroleptic malignant syndrome is a rare but potentially life-threatening complication associated with the use of antipsychotics.12 The characteristic symptom triad of NMS includes hyperpyrexia, rigidity, and altered mental status.24 Other clinical features include tremor, urinary incontinence, dysphagia, elevated CK, and leukocytosis.24
Over 75% of patients with long-term use of lithium experience some kind of toxicity because of its narrow therapeutic dose.25 Lithium toxicity is associated with confusion, lethargy, slurred speech, tremor, and gait difficulties.26 Before 1987, the majority of reported lithium toxicity cases involved acute neurotoxicity, which was reversible.4,5 In 1987, the first case report of SILENT, which represents persistent and irreversible neurotoxic sequelae of lithium, was described.6–8 In a literature review, SILENT was mostly associated with extrapyramidal features and cerebellar symptoms.8,27
In the present case, the persistent catatonic features of the patient raised the suspicion of NMS. However, other than in the acute phase of his illness, the patient did not exhibit abrupt onset of mutism, negativism, immobility, or rigidity, all of which are part of the clinical presentation of catatonia. A number of studies have reported chronic neurological sequelae (SILENT) resulting from lithium intoxication.6–8 In the present case, we assumed that the chronic neurological sequelae were attributed to SILENT rather than persistent catatonia after NMS.
Our patient made some recovery, although extrapyramidal features, cerebellar ataxia, severe dysarthria, and autonomic instability remained. Thus, in this case of lithium toxicity, the patient appeared to exhibit not only NMS-related features in the acute stage but also SILENT-type features in the chronic stage. This case emphasizes the need to consider the possibility of SILENT, especially in cases of combined use of lithium and antipsychotics.8,28 Furthermore, we propose the possibility that SILENT might be a chronic subtype of NMS.10,15
In this case, after the diagnosis of SILENT combined with NMS, we performed imaging studies in an effort to identify possible causes of the patient’s symptoms. Among the imaging studies performed, a PET brain scan showed decreased FDG uptake in bilateral primary motor cortices and in the thalamus, midbrain, and cerebellum. Routine brain structural MRI revealed no lesions that could explain the patient's symptoms. As a PET CT brain scan provides only biochemical evidence, we performed DTI to assess the subcortical structure.
To acquire DTI, in addition to the three-dimensional gradient magnetic field, which is already used in the diffusion-weighted image sequence, an extra magnetic field is used to measure the motion of water molecules. If the water molecules in a specific space take same probability of diffusion in any direction, this is called Brownian motion, and it is defined as “isotropic diffusion.” On the other hand, if the diffusion of water molecules shows a specific direction, such as in a white matter tract, this is called as “anisotropic diffusion.” Therefore, DTI is helpful to analyze the white matter structure and injury of this structure.29,30 Practically, there are 2 methods to detect injury of white matter tracts. One is to analyze the diffusion tensor parameters of the region of interest, and the other is to reconstruct the region of interest of each tract using DTT.31–33 In contrast to DTI analysis and diffusion tensor parameter, DTT provides visual information of each tracts. Diffusion tensor tractography can be considered an objective, reproducible, and reliable method to ascertain the structural integrity of white matter tracts.34–39
The DTT analysis revealed structural disruptions of the CST and optic radiation, which were, respectively, correlated with quadriplegia and visual field defects. In particular, DTT showed severe structural disruption of the DRTT, which is associated with motor planning and initiation of movement. This disruption was not visible on routine brain MRI.
CONCLUSIONS
In the present case, although brain MRI sequences revealed no specific abnormal findings, DTT derived from the DTI sequence revealed severe subcortical disruption of the CST, optic radiation and DRTT, all of which seemed to be correlated with the patient's clinical symptoms. Therefore, the DTI sequence and DTT appear to be useful in evaluating and correlating neurological symptoms of patients with SILENT combined with NMS.
Conflicts of Interest and Source of Funding: The authors have no conflicts of interest to declare. | ARIPIPRAZOLE, LITHIUM, LORAZEPAM | DrugsGivenReaction | CC BY-NC-ND | 33560007 | 20,232,558 | 2021 |
Give an alphabetized list of all active substances of drugs taken by the patient who experienced 'Toxicity to various agents'. | Subcortical Structure Disruption in Diffusion Tensor Tractography of the Patient With the Syndrome of Irreversible Lithium-Effectuated Neurotoxicity Combined With Neuroleptic Malignant Syndrome: A Case Report.
BACKGROUND
Lithium can cause not only acute neurotoxicity but also chronic and persistent neurotoxicity known as syndrome of irreversible lithium-effectuated neurotoxicity (SILENT). The combined use of lithium and antipsychotics increases the possibility of SILENT. Neuroleptic malignant syndrome (NMS) is a reversible, idiosyncratic, and potentially life-threatening reaction, which is usually caused by antipsychotics and other agents, such as mood stabilizers (eg, lithium and metoclopramide). Neuroleptic malignant syndrome is characterized by hyperpyrexia, muscle rigidity, and altered mental status. We describe a case of SILENT combined with NMS in this case report.
METHODS
A 46-year-old man who had been treated with lithium for bipolar II disorder since 2008 was prescribed lorazepam, lithium, and aripiprazole at his last outpatient visit. The patient experienced financial difficulties (bankruptcy) and suffered severe emotional stress. Subsequently, he overused lorazepam, lithium, and aripiprazole. Two days after the overdose, he experienced a high fever, confused mental status, and rhabdomyolysis and was diagnosed with NMS. However, even after resolution of NMS-related symptoms, quadriplegia, visual field defects, ataxia, and severe dysarthria persisted. A positron emission tomography-computed tomography brain scan showed decreased 15F-fludeoxyglucose uptake in bilateral primary motor cortices and in the thalamus, midbrain, and cerebellum. Brain magnetic resonance imaging diffusion tensor imaging and diffusion tensor tractography of the subcortical tracts revealed structural disruptions, especially in the corticospinal tract, dentatorubrothalamic tract, and optic radiation, which seemed to be correlated with the clinical symptoms of the patient.
CONCLUSIONS
This case suggests that the clinical use of diffusion tensor tractography could be helpful to explain the clinical features in the case of SILENT combined with NMS.
The use of lithium as a treatment for bipolar disorder has increased recently. Because of its narrow therapeutic window, it is important to check the serum dose. Since lithium was first introduced in the field of psychiatry in 1949, a number of cases of lithium neurotoxicity and potentially life-threatening complications have been reported.1–3 Among neurotoxic complications of lithium, there are reported cases of acute and reversible neurotoxicity.4,5 Adityanjee6 reported 55 cases of chronic and persistent neurotoxicity and sequelae associated with the use of lithium. In these cases, the main sequelae of the patients were persistent cerebellar symptoms. Adityanjee7 was the first to propose the name syndrome of irreversible lithium-effectuated neurotoxicity (SILENT) to represent persistent neurotoxic sequelae of lithium. Lithium intoxication is associated with several neurological symptoms, such as tremor, ataxia, encephalopathy, comatous mental change, and dysarthria.8 Also, SILENT mostly induces cerebellar and extrapyramidal symptoms.8
Neuroleptic malignant syndrome (NMS) is an idiosyncratic and potentially life-threatening reaction, characterized by hyperpyrexia, muscle rigidity, autonomic dysfunction, mental status change, tremors, leukocytosis, and creatinine kinase (CK) elevation.9–11 Although the reported incidence of NMS is reported to be just 0.01% to 0.02%, it is responsible for a significant portion of morbidity and mortality in patients who use antipsychotics.11–13 In terms of pathophysiological aspects, NMS is thought to be a subcortical motor syndrome caused by dopaminergic dysregulation.14 Neuroleptic malignant syndrome is associated with the use of conventional, old-generation antipsychotics. Recently, the development of newer generation antipsychotic agents has decreased the incidence of NMS.
Catatonia, which refers to cortical psychomotor immobility and abnormal behavior, shares similar features with NMS, but it is the result of GABAergic dysregulation.14 In some previous cases, the initial presentation of NMS was catatonia.10,14,15
We describe the case of a 46-year-old man with bipolar disorder who was diagnosed with SILENT and NMS by the clinical symptoms after drug intoxication, such as persistent catatonia and quadriplegia, tremor, ataxia, and dysarthria. Moreover, imaging analysis by using diffusion tensor tractography (DTT) in this case was also performed.
CASE REPORT
A 46-year-old man had received treatment for bipolar II disorder since 2008. In September 2018, he suffered severe emotional stress due to bankruptcy. In October 2018, he visited the outpatient clinic of a university hospital and was prescribed lorazepam, lithium, and aripiprazole. The same day, he took a massive overdose of the medication. He became delirious 1 day later and exhibited abnormal behaviors, including confusion. He developed a high fever (40°C) 2 days later, with concomitant aggravation of his mental status. A laboratory study showed CK elevation (over 40,000 IU/L; reference value = 44–245 IU/L) and metabolic acidosis. At that time, his serum lithium level was 1.63 mmol/L (reference value = 0.6–1.2 mmol/L). Subsequently, oliguria with azotemia due to acute kidney injury after rhabdomyolysis and hemodynamic instability developed. Continuous renal replacement therapy was administered, with intensive care unit management for 8 days. Blood, sputum, and urine culture, in addition to abdomen and pelvic computed tomography (CT), cerebrospinal fluid tapping, and brain imaging, including magnetic resonance imaging (MRI) (Fig. 1) and CT, were performed, none of which revealed any significant findings. Due to the suspicion of NMS, the patient was treated with dantrolene via the intravenous route. Seven days after the administration of dantrolene, the patient's CK level began to decrease.
FIGURE 1 Brain MRI T2 Axial and T2 FLAIR Sagittal (2019.1.18). There was no remarkable finding.
However, even after resolution of rhabdomyolysis and acute kidney injury, catatonia, limb and trunk ataxia, visual field defects, and severe dysarthria remained. To rule out possible organic problems, electroencephalography and brain positron emission tomography (PET) were performed. The electroencephalography showed sharply formed diffuse theta and delta and theta dominant waves, which suggested mild nonspecific diffuse cerebral dysfunction. A PET brain scan taken in May 2019 revealed decreased 15F-fludeoxyglucose (FDG) uptake in bilateral primary motor cortices and the thalamus, midbrain, and cerebellum (Fig. 2).
FIGURE 2 PET-CT brain scan (2019.5.15). Decreased FDG uptake in bilateral primary motor cortices (red arrow), thalamus (white arrow), midbrain (red arrowhead), and cerebellum (white arrowhead) was shown.
In June 2019, the patient was admitted to our hospital. In a neurological examination at that time, his Mini-Mental Status Examination score was 28 points, with slight time disorientation and attention deficit detected. In the manual muscle test using the Medical Research Council (MRC) scale, the patient was grade III to IV for both the upper and lower extremities. Brain MRI was performed twice. Both times, structural brain MRI sequences, including T1WI, T2WI, T2 FLAIR, SWI, MPR, and DWI, showed no abnormalities (lesions) (Fig. 3).
FIGURE 3 Brain MRI T2 FLAIR Axial and T1 Sagittal (2019.6.14). There was no remarkable finding. Compared with a previous study (2019.1.8), no interval change was observed.
Diffusion tensor imaging (DTI) was performed using a 3.0 T system (Philips Achieva TX, Best, Netherlands). The DTI sequence parameters were as follows: repetition time = 7,958.5 ms and echo time = 71 ms. After this DTI sequence, a DTI diffusion scheme was used, and 32 diffusion sampling directions were acquired. The b-value was 600 s/mm2. The in-plane resolution was 1.91071 mm. The slice thickness was 2 mm. The b-table was checked using an automatic quality control routine to ensure its accuracy.16 To obtain the spin distribution function,17 the diffusion data were reconstructed in the Montreal Neurological Institute space using q-space diffeomorphic reconstruction.18 A diffusion sampling length ratio of 1.25 was used, with isotropic output resolution of 2 mm. The restricted diffusion was quantified using restricted diffusion imaging.19
Then, the DSI Studio software (http://dsi-studio.labsolver.org/) was used to visualize the subcortical tracts. The DSI Studio software has auto-tracking tools for most subcortical tracts, including the corticospinal tract (CST), rubrospinal tract, and spinothalamic tract. However, some tracts, such as the dentatorubrothalamic tract (DRTT), which is associated with motor planning and initiation of movement, motor coordination, verbal fluency, and working memory,20,21 could not be obtained using the auto-tracking tools. Anatomically, DRTT arises from deep cerebellar nuclei, mainly the dentate nucleus, passing through the superior cerebellar peduncle, and then decussates to the contralateral red nucleus to ascend to the thalamus and brain cortex.22 In this case, DRTT fiber tracking was conducted using deterministic fiber-tracking algorithm based on Human Connectome Project (Q1–Q3 release, WU-Minn HCP consortium).20,23
We obtained DTT of each subcortical tracts, including the CST, arcuate fasciculus, rubrospinal tract, corpus callosum, optic radiation, and DRTT. Diffusion tensor tractography of the subcortical tracts revealed subtle impairment of the bilateral CST (Figs. 4A, B, C) and substantial structural impairment of left optic radiation compared with the right side (Fig. 4D). In addition, DRTT showed severe subcortical disruption (Figs. 4E, F) that seemed to be correlated with the quadriplegic, ataxic, catatonic symptoms, and dysarthria of the patient.
FIGURE 4 DTT of CST (A, B, C), optic radiation (d), and DRTT (E, F) (June 14, 2019). Subcortical disruptions were observed. (Arrows and arrowheads: suspected disruption of each tracts) (red: left, blue: right).
The patient received intensive rehabilitation, including physiotherapy (30 min/session, 2 sessions/d, 5 times/wk), occupational therapy (30 min/session, 2 sessions/d, 5 times/wk), and speech therapy (40 min/session, 2–3 three times/wk) until July 2019. In the manual muscle test, his muscle power increased from MRC grade I in November 2018 to MRC grade III to IV in July 2019. In terms of hand function, pinch and grasp power of both hands improved, but fine motor function of his left hand showed no improvement (Table 1). The patient’s Functional Independence Measure score improved from 38 in January 2019 to 71 in July 2019. Correspondingly, his modified Barthel Index score improved from 0 in January 2019 to 49 in July 2019. In a speech evaluation, articulation and pronunciation improved slightly, but his speech remained very slow (Table 2). Ataxia-related features also improved, with the CARS score declining from 72 in June 2019 to 60 in July 2019 (Table 3).
TABLE 1 Hand Function Test
January 2019 July 2019
Pinch power (kg)
Tip pinch
Rt. 1.6 5.5
Lt. NT NT
Lateral pinch
Rt. 3.8 9
Lt. 1 3.5
Palmar pinch
Rt. 2.5 8.5
Lt. NT NT
Box and block (/min)
Rt. 14 13
Lt. NT 6
Grip power (kg)
Rt. 4 26
Lt. NT 9
NT indicates not testable; Rt., right; Lt., left.
TABLE 2 Speech Test (Paradise K-WAB)
January 2019 May 2019 June 2019
AQ 92.4 94.5 96.2
LQ — 92.5 94.6
MPT 2.45 s 20.83 s 10.44 s
DDK
AMR
“/pa/” 8 times/5 s 13 times/5 s
AMR
“/ta/” 6 times/5 s 13.7times/5 s
AMR
“/ka/” 5 times/5 s 12 times/5 s
SMR
“/pataka/” 2 times/5 s 4 times/5 s
K-WAB indicates Korean version—the Western Aphasia Battery; AQ, aphasia quotient; LQ, language quotient; MPT, maximum phonation time; DDK, diadochokinetic rate; AMR, alterate motion rate; SMR, sequencing motion rate.
TABLE 3 International Cooperative Ataxia Rating Scale (ICARS)
June 2019 July 2019
Posture and gait disturbances
Walking capacities 8 8
Gait speed 4 4
Standing capacities, eyes open 5 5
Spread of feet in natural position/s support, eyes open 4 2
Body sway with feet together, eyes open 4 3
Body sway with feet together, eyes closed 4 4
Quality of sitting position 1 0
Kinetic functions
Knee-tibia test (decomposition of movement and intention tremor) 3/4 3/3
Action tremor in the heel to knee test 3/3 2/2
Finger to nose test: decomposition and dysmetria 2/3 2/3
Finger to nose test: intention tremor of finger 2/3 2/2
Finger-finger test (action tremor and/or instability) 2/3 2/2
Pronation supination alternating movements 2/3 1/2
Drawing of Archimedes' spiral on a predrawn pattern 2 1
Speech disorders
Dysarthria: fluency of speech 3 3
Dysarthria: clarity of speech 2 2
Oculomotor disorders
Gaze-evoked nystagmus 1 1
Abnormalities of ocular pursuit 1 1
Dysmetria of saccade 0 0
Total 72/100 60/100
DISCUSSION
Neuroleptic malignant syndrome is a rare but potentially life-threatening complication associated with the use of antipsychotics.12 The characteristic symptom triad of NMS includes hyperpyrexia, rigidity, and altered mental status.24 Other clinical features include tremor, urinary incontinence, dysphagia, elevated CK, and leukocytosis.24
Over 75% of patients with long-term use of lithium experience some kind of toxicity because of its narrow therapeutic dose.25 Lithium toxicity is associated with confusion, lethargy, slurred speech, tremor, and gait difficulties.26 Before 1987, the majority of reported lithium toxicity cases involved acute neurotoxicity, which was reversible.4,5 In 1987, the first case report of SILENT, which represents persistent and irreversible neurotoxic sequelae of lithium, was described.6–8 In a literature review, SILENT was mostly associated with extrapyramidal features and cerebellar symptoms.8,27
In the present case, the persistent catatonic features of the patient raised the suspicion of NMS. However, other than in the acute phase of his illness, the patient did not exhibit abrupt onset of mutism, negativism, immobility, or rigidity, all of which are part of the clinical presentation of catatonia. A number of studies have reported chronic neurological sequelae (SILENT) resulting from lithium intoxication.6–8 In the present case, we assumed that the chronic neurological sequelae were attributed to SILENT rather than persistent catatonia after NMS.
Our patient made some recovery, although extrapyramidal features, cerebellar ataxia, severe dysarthria, and autonomic instability remained. Thus, in this case of lithium toxicity, the patient appeared to exhibit not only NMS-related features in the acute stage but also SILENT-type features in the chronic stage. This case emphasizes the need to consider the possibility of SILENT, especially in cases of combined use of lithium and antipsychotics.8,28 Furthermore, we propose the possibility that SILENT might be a chronic subtype of NMS.10,15
In this case, after the diagnosis of SILENT combined with NMS, we performed imaging studies in an effort to identify possible causes of the patient’s symptoms. Among the imaging studies performed, a PET brain scan showed decreased FDG uptake in bilateral primary motor cortices and in the thalamus, midbrain, and cerebellum. Routine brain structural MRI revealed no lesions that could explain the patient's symptoms. As a PET CT brain scan provides only biochemical evidence, we performed DTI to assess the subcortical structure.
To acquire DTI, in addition to the three-dimensional gradient magnetic field, which is already used in the diffusion-weighted image sequence, an extra magnetic field is used to measure the motion of water molecules. If the water molecules in a specific space take same probability of diffusion in any direction, this is called Brownian motion, and it is defined as “isotropic diffusion.” On the other hand, if the diffusion of water molecules shows a specific direction, such as in a white matter tract, this is called as “anisotropic diffusion.” Therefore, DTI is helpful to analyze the white matter structure and injury of this structure.29,30 Practically, there are 2 methods to detect injury of white matter tracts. One is to analyze the diffusion tensor parameters of the region of interest, and the other is to reconstruct the region of interest of each tract using DTT.31–33 In contrast to DTI analysis and diffusion tensor parameter, DTT provides visual information of each tracts. Diffusion tensor tractography can be considered an objective, reproducible, and reliable method to ascertain the structural integrity of white matter tracts.34–39
The DTT analysis revealed structural disruptions of the CST and optic radiation, which were, respectively, correlated with quadriplegia and visual field defects. In particular, DTT showed severe structural disruption of the DRTT, which is associated with motor planning and initiation of movement. This disruption was not visible on routine brain MRI.
CONCLUSIONS
In the present case, although brain MRI sequences revealed no specific abnormal findings, DTT derived from the DTI sequence revealed severe subcortical disruption of the CST, optic radiation and DRTT, all of which seemed to be correlated with the patient's clinical symptoms. Therefore, the DTI sequence and DTT appear to be useful in evaluating and correlating neurological symptoms of patients with SILENT combined with NMS.
Conflicts of Interest and Source of Funding: The authors have no conflicts of interest to declare. | ARIPIPRAZOLE, LITHIUM, LORAZEPAM | DrugsGivenReaction | CC BY-NC-ND | 33560007 | 20,232,558 | 2021 |
What was the outcome of reaction 'Neuroleptic malignant syndrome'? | Subcortical Structure Disruption in Diffusion Tensor Tractography of the Patient With the Syndrome of Irreversible Lithium-Effectuated Neurotoxicity Combined With Neuroleptic Malignant Syndrome: A Case Report.
BACKGROUND
Lithium can cause not only acute neurotoxicity but also chronic and persistent neurotoxicity known as syndrome of irreversible lithium-effectuated neurotoxicity (SILENT). The combined use of lithium and antipsychotics increases the possibility of SILENT. Neuroleptic malignant syndrome (NMS) is a reversible, idiosyncratic, and potentially life-threatening reaction, which is usually caused by antipsychotics and other agents, such as mood stabilizers (eg, lithium and metoclopramide). Neuroleptic malignant syndrome is characterized by hyperpyrexia, muscle rigidity, and altered mental status. We describe a case of SILENT combined with NMS in this case report.
METHODS
A 46-year-old man who had been treated with lithium for bipolar II disorder since 2008 was prescribed lorazepam, lithium, and aripiprazole at his last outpatient visit. The patient experienced financial difficulties (bankruptcy) and suffered severe emotional stress. Subsequently, he overused lorazepam, lithium, and aripiprazole. Two days after the overdose, he experienced a high fever, confused mental status, and rhabdomyolysis and was diagnosed with NMS. However, even after resolution of NMS-related symptoms, quadriplegia, visual field defects, ataxia, and severe dysarthria persisted. A positron emission tomography-computed tomography brain scan showed decreased 15F-fludeoxyglucose uptake in bilateral primary motor cortices and in the thalamus, midbrain, and cerebellum. Brain magnetic resonance imaging diffusion tensor imaging and diffusion tensor tractography of the subcortical tracts revealed structural disruptions, especially in the corticospinal tract, dentatorubrothalamic tract, and optic radiation, which seemed to be correlated with the clinical symptoms of the patient.
CONCLUSIONS
This case suggests that the clinical use of diffusion tensor tractography could be helpful to explain the clinical features in the case of SILENT combined with NMS.
The use of lithium as a treatment for bipolar disorder has increased recently. Because of its narrow therapeutic window, it is important to check the serum dose. Since lithium was first introduced in the field of psychiatry in 1949, a number of cases of lithium neurotoxicity and potentially life-threatening complications have been reported.1–3 Among neurotoxic complications of lithium, there are reported cases of acute and reversible neurotoxicity.4,5 Adityanjee6 reported 55 cases of chronic and persistent neurotoxicity and sequelae associated with the use of lithium. In these cases, the main sequelae of the patients were persistent cerebellar symptoms. Adityanjee7 was the first to propose the name syndrome of irreversible lithium-effectuated neurotoxicity (SILENT) to represent persistent neurotoxic sequelae of lithium. Lithium intoxication is associated with several neurological symptoms, such as tremor, ataxia, encephalopathy, comatous mental change, and dysarthria.8 Also, SILENT mostly induces cerebellar and extrapyramidal symptoms.8
Neuroleptic malignant syndrome (NMS) is an idiosyncratic and potentially life-threatening reaction, characterized by hyperpyrexia, muscle rigidity, autonomic dysfunction, mental status change, tremors, leukocytosis, and creatinine kinase (CK) elevation.9–11 Although the reported incidence of NMS is reported to be just 0.01% to 0.02%, it is responsible for a significant portion of morbidity and mortality in patients who use antipsychotics.11–13 In terms of pathophysiological aspects, NMS is thought to be a subcortical motor syndrome caused by dopaminergic dysregulation.14 Neuroleptic malignant syndrome is associated with the use of conventional, old-generation antipsychotics. Recently, the development of newer generation antipsychotic agents has decreased the incidence of NMS.
Catatonia, which refers to cortical psychomotor immobility and abnormal behavior, shares similar features with NMS, but it is the result of GABAergic dysregulation.14 In some previous cases, the initial presentation of NMS was catatonia.10,14,15
We describe the case of a 46-year-old man with bipolar disorder who was diagnosed with SILENT and NMS by the clinical symptoms after drug intoxication, such as persistent catatonia and quadriplegia, tremor, ataxia, and dysarthria. Moreover, imaging analysis by using diffusion tensor tractography (DTT) in this case was also performed.
CASE REPORT
A 46-year-old man had received treatment for bipolar II disorder since 2008. In September 2018, he suffered severe emotional stress due to bankruptcy. In October 2018, he visited the outpatient clinic of a university hospital and was prescribed lorazepam, lithium, and aripiprazole. The same day, he took a massive overdose of the medication. He became delirious 1 day later and exhibited abnormal behaviors, including confusion. He developed a high fever (40°C) 2 days later, with concomitant aggravation of his mental status. A laboratory study showed CK elevation (over 40,000 IU/L; reference value = 44–245 IU/L) and metabolic acidosis. At that time, his serum lithium level was 1.63 mmol/L (reference value = 0.6–1.2 mmol/L). Subsequently, oliguria with azotemia due to acute kidney injury after rhabdomyolysis and hemodynamic instability developed. Continuous renal replacement therapy was administered, with intensive care unit management for 8 days. Blood, sputum, and urine culture, in addition to abdomen and pelvic computed tomography (CT), cerebrospinal fluid tapping, and brain imaging, including magnetic resonance imaging (MRI) (Fig. 1) and CT, were performed, none of which revealed any significant findings. Due to the suspicion of NMS, the patient was treated with dantrolene via the intravenous route. Seven days after the administration of dantrolene, the patient's CK level began to decrease.
FIGURE 1 Brain MRI T2 Axial and T2 FLAIR Sagittal (2019.1.18). There was no remarkable finding.
However, even after resolution of rhabdomyolysis and acute kidney injury, catatonia, limb and trunk ataxia, visual field defects, and severe dysarthria remained. To rule out possible organic problems, electroencephalography and brain positron emission tomography (PET) were performed. The electroencephalography showed sharply formed diffuse theta and delta and theta dominant waves, which suggested mild nonspecific diffuse cerebral dysfunction. A PET brain scan taken in May 2019 revealed decreased 15F-fludeoxyglucose (FDG) uptake in bilateral primary motor cortices and the thalamus, midbrain, and cerebellum (Fig. 2).
FIGURE 2 PET-CT brain scan (2019.5.15). Decreased FDG uptake in bilateral primary motor cortices (red arrow), thalamus (white arrow), midbrain (red arrowhead), and cerebellum (white arrowhead) was shown.
In June 2019, the patient was admitted to our hospital. In a neurological examination at that time, his Mini-Mental Status Examination score was 28 points, with slight time disorientation and attention deficit detected. In the manual muscle test using the Medical Research Council (MRC) scale, the patient was grade III to IV for both the upper and lower extremities. Brain MRI was performed twice. Both times, structural brain MRI sequences, including T1WI, T2WI, T2 FLAIR, SWI, MPR, and DWI, showed no abnormalities (lesions) (Fig. 3).
FIGURE 3 Brain MRI T2 FLAIR Axial and T1 Sagittal (2019.6.14). There was no remarkable finding. Compared with a previous study (2019.1.8), no interval change was observed.
Diffusion tensor imaging (DTI) was performed using a 3.0 T system (Philips Achieva TX, Best, Netherlands). The DTI sequence parameters were as follows: repetition time = 7,958.5 ms and echo time = 71 ms. After this DTI sequence, a DTI diffusion scheme was used, and 32 diffusion sampling directions were acquired. The b-value was 600 s/mm2. The in-plane resolution was 1.91071 mm. The slice thickness was 2 mm. The b-table was checked using an automatic quality control routine to ensure its accuracy.16 To obtain the spin distribution function,17 the diffusion data were reconstructed in the Montreal Neurological Institute space using q-space diffeomorphic reconstruction.18 A diffusion sampling length ratio of 1.25 was used, with isotropic output resolution of 2 mm. The restricted diffusion was quantified using restricted diffusion imaging.19
Then, the DSI Studio software (http://dsi-studio.labsolver.org/) was used to visualize the subcortical tracts. The DSI Studio software has auto-tracking tools for most subcortical tracts, including the corticospinal tract (CST), rubrospinal tract, and spinothalamic tract. However, some tracts, such as the dentatorubrothalamic tract (DRTT), which is associated with motor planning and initiation of movement, motor coordination, verbal fluency, and working memory,20,21 could not be obtained using the auto-tracking tools. Anatomically, DRTT arises from deep cerebellar nuclei, mainly the dentate nucleus, passing through the superior cerebellar peduncle, and then decussates to the contralateral red nucleus to ascend to the thalamus and brain cortex.22 In this case, DRTT fiber tracking was conducted using deterministic fiber-tracking algorithm based on Human Connectome Project (Q1–Q3 release, WU-Minn HCP consortium).20,23
We obtained DTT of each subcortical tracts, including the CST, arcuate fasciculus, rubrospinal tract, corpus callosum, optic radiation, and DRTT. Diffusion tensor tractography of the subcortical tracts revealed subtle impairment of the bilateral CST (Figs. 4A, B, C) and substantial structural impairment of left optic radiation compared with the right side (Fig. 4D). In addition, DRTT showed severe subcortical disruption (Figs. 4E, F) that seemed to be correlated with the quadriplegic, ataxic, catatonic symptoms, and dysarthria of the patient.
FIGURE 4 DTT of CST (A, B, C), optic radiation (d), and DRTT (E, F) (June 14, 2019). Subcortical disruptions were observed. (Arrows and arrowheads: suspected disruption of each tracts) (red: left, blue: right).
The patient received intensive rehabilitation, including physiotherapy (30 min/session, 2 sessions/d, 5 times/wk), occupational therapy (30 min/session, 2 sessions/d, 5 times/wk), and speech therapy (40 min/session, 2–3 three times/wk) until July 2019. In the manual muscle test, his muscle power increased from MRC grade I in November 2018 to MRC grade III to IV in July 2019. In terms of hand function, pinch and grasp power of both hands improved, but fine motor function of his left hand showed no improvement (Table 1). The patient’s Functional Independence Measure score improved from 38 in January 2019 to 71 in July 2019. Correspondingly, his modified Barthel Index score improved from 0 in January 2019 to 49 in July 2019. In a speech evaluation, articulation and pronunciation improved slightly, but his speech remained very slow (Table 2). Ataxia-related features also improved, with the CARS score declining from 72 in June 2019 to 60 in July 2019 (Table 3).
TABLE 1 Hand Function Test
January 2019 July 2019
Pinch power (kg)
Tip pinch
Rt. 1.6 5.5
Lt. NT NT
Lateral pinch
Rt. 3.8 9
Lt. 1 3.5
Palmar pinch
Rt. 2.5 8.5
Lt. NT NT
Box and block (/min)
Rt. 14 13
Lt. NT 6
Grip power (kg)
Rt. 4 26
Lt. NT 9
NT indicates not testable; Rt., right; Lt., left.
TABLE 2 Speech Test (Paradise K-WAB)
January 2019 May 2019 June 2019
AQ 92.4 94.5 96.2
LQ — 92.5 94.6
MPT 2.45 s 20.83 s 10.44 s
DDK
AMR
“/pa/” 8 times/5 s 13 times/5 s
AMR
“/ta/” 6 times/5 s 13.7times/5 s
AMR
“/ka/” 5 times/5 s 12 times/5 s
SMR
“/pataka/” 2 times/5 s 4 times/5 s
K-WAB indicates Korean version—the Western Aphasia Battery; AQ, aphasia quotient; LQ, language quotient; MPT, maximum phonation time; DDK, diadochokinetic rate; AMR, alterate motion rate; SMR, sequencing motion rate.
TABLE 3 International Cooperative Ataxia Rating Scale (ICARS)
June 2019 July 2019
Posture and gait disturbances
Walking capacities 8 8
Gait speed 4 4
Standing capacities, eyes open 5 5
Spread of feet in natural position/s support, eyes open 4 2
Body sway with feet together, eyes open 4 3
Body sway with feet together, eyes closed 4 4
Quality of sitting position 1 0
Kinetic functions
Knee-tibia test (decomposition of movement and intention tremor) 3/4 3/3
Action tremor in the heel to knee test 3/3 2/2
Finger to nose test: decomposition and dysmetria 2/3 2/3
Finger to nose test: intention tremor of finger 2/3 2/2
Finger-finger test (action tremor and/or instability) 2/3 2/2
Pronation supination alternating movements 2/3 1/2
Drawing of Archimedes' spiral on a predrawn pattern 2 1
Speech disorders
Dysarthria: fluency of speech 3 3
Dysarthria: clarity of speech 2 2
Oculomotor disorders
Gaze-evoked nystagmus 1 1
Abnormalities of ocular pursuit 1 1
Dysmetria of saccade 0 0
Total 72/100 60/100
DISCUSSION
Neuroleptic malignant syndrome is a rare but potentially life-threatening complication associated with the use of antipsychotics.12 The characteristic symptom triad of NMS includes hyperpyrexia, rigidity, and altered mental status.24 Other clinical features include tremor, urinary incontinence, dysphagia, elevated CK, and leukocytosis.24
Over 75% of patients with long-term use of lithium experience some kind of toxicity because of its narrow therapeutic dose.25 Lithium toxicity is associated with confusion, lethargy, slurred speech, tremor, and gait difficulties.26 Before 1987, the majority of reported lithium toxicity cases involved acute neurotoxicity, which was reversible.4,5 In 1987, the first case report of SILENT, which represents persistent and irreversible neurotoxic sequelae of lithium, was described.6–8 In a literature review, SILENT was mostly associated with extrapyramidal features and cerebellar symptoms.8,27
In the present case, the persistent catatonic features of the patient raised the suspicion of NMS. However, other than in the acute phase of his illness, the patient did not exhibit abrupt onset of mutism, negativism, immobility, or rigidity, all of which are part of the clinical presentation of catatonia. A number of studies have reported chronic neurological sequelae (SILENT) resulting from lithium intoxication.6–8 In the present case, we assumed that the chronic neurological sequelae were attributed to SILENT rather than persistent catatonia after NMS.
Our patient made some recovery, although extrapyramidal features, cerebellar ataxia, severe dysarthria, and autonomic instability remained. Thus, in this case of lithium toxicity, the patient appeared to exhibit not only NMS-related features in the acute stage but also SILENT-type features in the chronic stage. This case emphasizes the need to consider the possibility of SILENT, especially in cases of combined use of lithium and antipsychotics.8,28 Furthermore, we propose the possibility that SILENT might be a chronic subtype of NMS.10,15
In this case, after the diagnosis of SILENT combined with NMS, we performed imaging studies in an effort to identify possible causes of the patient’s symptoms. Among the imaging studies performed, a PET brain scan showed decreased FDG uptake in bilateral primary motor cortices and in the thalamus, midbrain, and cerebellum. Routine brain structural MRI revealed no lesions that could explain the patient's symptoms. As a PET CT brain scan provides only biochemical evidence, we performed DTI to assess the subcortical structure.
To acquire DTI, in addition to the three-dimensional gradient magnetic field, which is already used in the diffusion-weighted image sequence, an extra magnetic field is used to measure the motion of water molecules. If the water molecules in a specific space take same probability of diffusion in any direction, this is called Brownian motion, and it is defined as “isotropic diffusion.” On the other hand, if the diffusion of water molecules shows a specific direction, such as in a white matter tract, this is called as “anisotropic diffusion.” Therefore, DTI is helpful to analyze the white matter structure and injury of this structure.29,30 Practically, there are 2 methods to detect injury of white matter tracts. One is to analyze the diffusion tensor parameters of the region of interest, and the other is to reconstruct the region of interest of each tract using DTT.31–33 In contrast to DTI analysis and diffusion tensor parameter, DTT provides visual information of each tracts. Diffusion tensor tractography can be considered an objective, reproducible, and reliable method to ascertain the structural integrity of white matter tracts.34–39
The DTT analysis revealed structural disruptions of the CST and optic radiation, which were, respectively, correlated with quadriplegia and visual field defects. In particular, DTT showed severe structural disruption of the DRTT, which is associated with motor planning and initiation of movement. This disruption was not visible on routine brain MRI.
CONCLUSIONS
In the present case, although brain MRI sequences revealed no specific abnormal findings, DTT derived from the DTI sequence revealed severe subcortical disruption of the CST, optic radiation and DRTT, all of which seemed to be correlated with the patient's clinical symptoms. Therefore, the DTI sequence and DTT appear to be useful in evaluating and correlating neurological symptoms of patients with SILENT combined with NMS.
Conflicts of Interest and Source of Funding: The authors have no conflicts of interest to declare. | Recovering | ReactionOutcome | CC BY-NC-ND | 33560007 | 20,232,558 | 2021 |
What was the outcome of reaction 'Toxicity to various agents'? | Subcortical Structure Disruption in Diffusion Tensor Tractography of the Patient With the Syndrome of Irreversible Lithium-Effectuated Neurotoxicity Combined With Neuroleptic Malignant Syndrome: A Case Report.
BACKGROUND
Lithium can cause not only acute neurotoxicity but also chronic and persistent neurotoxicity known as syndrome of irreversible lithium-effectuated neurotoxicity (SILENT). The combined use of lithium and antipsychotics increases the possibility of SILENT. Neuroleptic malignant syndrome (NMS) is a reversible, idiosyncratic, and potentially life-threatening reaction, which is usually caused by antipsychotics and other agents, such as mood stabilizers (eg, lithium and metoclopramide). Neuroleptic malignant syndrome is characterized by hyperpyrexia, muscle rigidity, and altered mental status. We describe a case of SILENT combined with NMS in this case report.
METHODS
A 46-year-old man who had been treated with lithium for bipolar II disorder since 2008 was prescribed lorazepam, lithium, and aripiprazole at his last outpatient visit. The patient experienced financial difficulties (bankruptcy) and suffered severe emotional stress. Subsequently, he overused lorazepam, lithium, and aripiprazole. Two days after the overdose, he experienced a high fever, confused mental status, and rhabdomyolysis and was diagnosed with NMS. However, even after resolution of NMS-related symptoms, quadriplegia, visual field defects, ataxia, and severe dysarthria persisted. A positron emission tomography-computed tomography brain scan showed decreased 15F-fludeoxyglucose uptake in bilateral primary motor cortices and in the thalamus, midbrain, and cerebellum. Brain magnetic resonance imaging diffusion tensor imaging and diffusion tensor tractography of the subcortical tracts revealed structural disruptions, especially in the corticospinal tract, dentatorubrothalamic tract, and optic radiation, which seemed to be correlated with the clinical symptoms of the patient.
CONCLUSIONS
This case suggests that the clinical use of diffusion tensor tractography could be helpful to explain the clinical features in the case of SILENT combined with NMS.
The use of lithium as a treatment for bipolar disorder has increased recently. Because of its narrow therapeutic window, it is important to check the serum dose. Since lithium was first introduced in the field of psychiatry in 1949, a number of cases of lithium neurotoxicity and potentially life-threatening complications have been reported.1–3 Among neurotoxic complications of lithium, there are reported cases of acute and reversible neurotoxicity.4,5 Adityanjee6 reported 55 cases of chronic and persistent neurotoxicity and sequelae associated with the use of lithium. In these cases, the main sequelae of the patients were persistent cerebellar symptoms. Adityanjee7 was the first to propose the name syndrome of irreversible lithium-effectuated neurotoxicity (SILENT) to represent persistent neurotoxic sequelae of lithium. Lithium intoxication is associated with several neurological symptoms, such as tremor, ataxia, encephalopathy, comatous mental change, and dysarthria.8 Also, SILENT mostly induces cerebellar and extrapyramidal symptoms.8
Neuroleptic malignant syndrome (NMS) is an idiosyncratic and potentially life-threatening reaction, characterized by hyperpyrexia, muscle rigidity, autonomic dysfunction, mental status change, tremors, leukocytosis, and creatinine kinase (CK) elevation.9–11 Although the reported incidence of NMS is reported to be just 0.01% to 0.02%, it is responsible for a significant portion of morbidity and mortality in patients who use antipsychotics.11–13 In terms of pathophysiological aspects, NMS is thought to be a subcortical motor syndrome caused by dopaminergic dysregulation.14 Neuroleptic malignant syndrome is associated with the use of conventional, old-generation antipsychotics. Recently, the development of newer generation antipsychotic agents has decreased the incidence of NMS.
Catatonia, which refers to cortical psychomotor immobility and abnormal behavior, shares similar features with NMS, but it is the result of GABAergic dysregulation.14 In some previous cases, the initial presentation of NMS was catatonia.10,14,15
We describe the case of a 46-year-old man with bipolar disorder who was diagnosed with SILENT and NMS by the clinical symptoms after drug intoxication, such as persistent catatonia and quadriplegia, tremor, ataxia, and dysarthria. Moreover, imaging analysis by using diffusion tensor tractography (DTT) in this case was also performed.
CASE REPORT
A 46-year-old man had received treatment for bipolar II disorder since 2008. In September 2018, he suffered severe emotional stress due to bankruptcy. In October 2018, he visited the outpatient clinic of a university hospital and was prescribed lorazepam, lithium, and aripiprazole. The same day, he took a massive overdose of the medication. He became delirious 1 day later and exhibited abnormal behaviors, including confusion. He developed a high fever (40°C) 2 days later, with concomitant aggravation of his mental status. A laboratory study showed CK elevation (over 40,000 IU/L; reference value = 44–245 IU/L) and metabolic acidosis. At that time, his serum lithium level was 1.63 mmol/L (reference value = 0.6–1.2 mmol/L). Subsequently, oliguria with azotemia due to acute kidney injury after rhabdomyolysis and hemodynamic instability developed. Continuous renal replacement therapy was administered, with intensive care unit management for 8 days. Blood, sputum, and urine culture, in addition to abdomen and pelvic computed tomography (CT), cerebrospinal fluid tapping, and brain imaging, including magnetic resonance imaging (MRI) (Fig. 1) and CT, were performed, none of which revealed any significant findings. Due to the suspicion of NMS, the patient was treated with dantrolene via the intravenous route. Seven days after the administration of dantrolene, the patient's CK level began to decrease.
FIGURE 1 Brain MRI T2 Axial and T2 FLAIR Sagittal (2019.1.18). There was no remarkable finding.
However, even after resolution of rhabdomyolysis and acute kidney injury, catatonia, limb and trunk ataxia, visual field defects, and severe dysarthria remained. To rule out possible organic problems, electroencephalography and brain positron emission tomography (PET) were performed. The electroencephalography showed sharply formed diffuse theta and delta and theta dominant waves, which suggested mild nonspecific diffuse cerebral dysfunction. A PET brain scan taken in May 2019 revealed decreased 15F-fludeoxyglucose (FDG) uptake in bilateral primary motor cortices and the thalamus, midbrain, and cerebellum (Fig. 2).
FIGURE 2 PET-CT brain scan (2019.5.15). Decreased FDG uptake in bilateral primary motor cortices (red arrow), thalamus (white arrow), midbrain (red arrowhead), and cerebellum (white arrowhead) was shown.
In June 2019, the patient was admitted to our hospital. In a neurological examination at that time, his Mini-Mental Status Examination score was 28 points, with slight time disorientation and attention deficit detected. In the manual muscle test using the Medical Research Council (MRC) scale, the patient was grade III to IV for both the upper and lower extremities. Brain MRI was performed twice. Both times, structural brain MRI sequences, including T1WI, T2WI, T2 FLAIR, SWI, MPR, and DWI, showed no abnormalities (lesions) (Fig. 3).
FIGURE 3 Brain MRI T2 FLAIR Axial and T1 Sagittal (2019.6.14). There was no remarkable finding. Compared with a previous study (2019.1.8), no interval change was observed.
Diffusion tensor imaging (DTI) was performed using a 3.0 T system (Philips Achieva TX, Best, Netherlands). The DTI sequence parameters were as follows: repetition time = 7,958.5 ms and echo time = 71 ms. After this DTI sequence, a DTI diffusion scheme was used, and 32 diffusion sampling directions were acquired. The b-value was 600 s/mm2. The in-plane resolution was 1.91071 mm. The slice thickness was 2 mm. The b-table was checked using an automatic quality control routine to ensure its accuracy.16 To obtain the spin distribution function,17 the diffusion data were reconstructed in the Montreal Neurological Institute space using q-space diffeomorphic reconstruction.18 A diffusion sampling length ratio of 1.25 was used, with isotropic output resolution of 2 mm. The restricted diffusion was quantified using restricted diffusion imaging.19
Then, the DSI Studio software (http://dsi-studio.labsolver.org/) was used to visualize the subcortical tracts. The DSI Studio software has auto-tracking tools for most subcortical tracts, including the corticospinal tract (CST), rubrospinal tract, and spinothalamic tract. However, some tracts, such as the dentatorubrothalamic tract (DRTT), which is associated with motor planning and initiation of movement, motor coordination, verbal fluency, and working memory,20,21 could not be obtained using the auto-tracking tools. Anatomically, DRTT arises from deep cerebellar nuclei, mainly the dentate nucleus, passing through the superior cerebellar peduncle, and then decussates to the contralateral red nucleus to ascend to the thalamus and brain cortex.22 In this case, DRTT fiber tracking was conducted using deterministic fiber-tracking algorithm based on Human Connectome Project (Q1–Q3 release, WU-Minn HCP consortium).20,23
We obtained DTT of each subcortical tracts, including the CST, arcuate fasciculus, rubrospinal tract, corpus callosum, optic radiation, and DRTT. Diffusion tensor tractography of the subcortical tracts revealed subtle impairment of the bilateral CST (Figs. 4A, B, C) and substantial structural impairment of left optic radiation compared with the right side (Fig. 4D). In addition, DRTT showed severe subcortical disruption (Figs. 4E, F) that seemed to be correlated with the quadriplegic, ataxic, catatonic symptoms, and dysarthria of the patient.
FIGURE 4 DTT of CST (A, B, C), optic radiation (d), and DRTT (E, F) (June 14, 2019). Subcortical disruptions were observed. (Arrows and arrowheads: suspected disruption of each tracts) (red: left, blue: right).
The patient received intensive rehabilitation, including physiotherapy (30 min/session, 2 sessions/d, 5 times/wk), occupational therapy (30 min/session, 2 sessions/d, 5 times/wk), and speech therapy (40 min/session, 2–3 three times/wk) until July 2019. In the manual muscle test, his muscle power increased from MRC grade I in November 2018 to MRC grade III to IV in July 2019. In terms of hand function, pinch and grasp power of both hands improved, but fine motor function of his left hand showed no improvement (Table 1). The patient’s Functional Independence Measure score improved from 38 in January 2019 to 71 in July 2019. Correspondingly, his modified Barthel Index score improved from 0 in January 2019 to 49 in July 2019. In a speech evaluation, articulation and pronunciation improved slightly, but his speech remained very slow (Table 2). Ataxia-related features also improved, with the CARS score declining from 72 in June 2019 to 60 in July 2019 (Table 3).
TABLE 1 Hand Function Test
January 2019 July 2019
Pinch power (kg)
Tip pinch
Rt. 1.6 5.5
Lt. NT NT
Lateral pinch
Rt. 3.8 9
Lt. 1 3.5
Palmar pinch
Rt. 2.5 8.5
Lt. NT NT
Box and block (/min)
Rt. 14 13
Lt. NT 6
Grip power (kg)
Rt. 4 26
Lt. NT 9
NT indicates not testable; Rt., right; Lt., left.
TABLE 2 Speech Test (Paradise K-WAB)
January 2019 May 2019 June 2019
AQ 92.4 94.5 96.2
LQ — 92.5 94.6
MPT 2.45 s 20.83 s 10.44 s
DDK
AMR
“/pa/” 8 times/5 s 13 times/5 s
AMR
“/ta/” 6 times/5 s 13.7times/5 s
AMR
“/ka/” 5 times/5 s 12 times/5 s
SMR
“/pataka/” 2 times/5 s 4 times/5 s
K-WAB indicates Korean version—the Western Aphasia Battery; AQ, aphasia quotient; LQ, language quotient; MPT, maximum phonation time; DDK, diadochokinetic rate; AMR, alterate motion rate; SMR, sequencing motion rate.
TABLE 3 International Cooperative Ataxia Rating Scale (ICARS)
June 2019 July 2019
Posture and gait disturbances
Walking capacities 8 8
Gait speed 4 4
Standing capacities, eyes open 5 5
Spread of feet in natural position/s support, eyes open 4 2
Body sway with feet together, eyes open 4 3
Body sway with feet together, eyes closed 4 4
Quality of sitting position 1 0
Kinetic functions
Knee-tibia test (decomposition of movement and intention tremor) 3/4 3/3
Action tremor in the heel to knee test 3/3 2/2
Finger to nose test: decomposition and dysmetria 2/3 2/3
Finger to nose test: intention tremor of finger 2/3 2/2
Finger-finger test (action tremor and/or instability) 2/3 2/2
Pronation supination alternating movements 2/3 1/2
Drawing of Archimedes' spiral on a predrawn pattern 2 1
Speech disorders
Dysarthria: fluency of speech 3 3
Dysarthria: clarity of speech 2 2
Oculomotor disorders
Gaze-evoked nystagmus 1 1
Abnormalities of ocular pursuit 1 1
Dysmetria of saccade 0 0
Total 72/100 60/100
DISCUSSION
Neuroleptic malignant syndrome is a rare but potentially life-threatening complication associated with the use of antipsychotics.12 The characteristic symptom triad of NMS includes hyperpyrexia, rigidity, and altered mental status.24 Other clinical features include tremor, urinary incontinence, dysphagia, elevated CK, and leukocytosis.24
Over 75% of patients with long-term use of lithium experience some kind of toxicity because of its narrow therapeutic dose.25 Lithium toxicity is associated with confusion, lethargy, slurred speech, tremor, and gait difficulties.26 Before 1987, the majority of reported lithium toxicity cases involved acute neurotoxicity, which was reversible.4,5 In 1987, the first case report of SILENT, which represents persistent and irreversible neurotoxic sequelae of lithium, was described.6–8 In a literature review, SILENT was mostly associated with extrapyramidal features and cerebellar symptoms.8,27
In the present case, the persistent catatonic features of the patient raised the suspicion of NMS. However, other than in the acute phase of his illness, the patient did not exhibit abrupt onset of mutism, negativism, immobility, or rigidity, all of which are part of the clinical presentation of catatonia. A number of studies have reported chronic neurological sequelae (SILENT) resulting from lithium intoxication.6–8 In the present case, we assumed that the chronic neurological sequelae were attributed to SILENT rather than persistent catatonia after NMS.
Our patient made some recovery, although extrapyramidal features, cerebellar ataxia, severe dysarthria, and autonomic instability remained. Thus, in this case of lithium toxicity, the patient appeared to exhibit not only NMS-related features in the acute stage but also SILENT-type features in the chronic stage. This case emphasizes the need to consider the possibility of SILENT, especially in cases of combined use of lithium and antipsychotics.8,28 Furthermore, we propose the possibility that SILENT might be a chronic subtype of NMS.10,15
In this case, after the diagnosis of SILENT combined with NMS, we performed imaging studies in an effort to identify possible causes of the patient’s symptoms. Among the imaging studies performed, a PET brain scan showed decreased FDG uptake in bilateral primary motor cortices and in the thalamus, midbrain, and cerebellum. Routine brain structural MRI revealed no lesions that could explain the patient's symptoms. As a PET CT brain scan provides only biochemical evidence, we performed DTI to assess the subcortical structure.
To acquire DTI, in addition to the three-dimensional gradient magnetic field, which is already used in the diffusion-weighted image sequence, an extra magnetic field is used to measure the motion of water molecules. If the water molecules in a specific space take same probability of diffusion in any direction, this is called Brownian motion, and it is defined as “isotropic diffusion.” On the other hand, if the diffusion of water molecules shows a specific direction, such as in a white matter tract, this is called as “anisotropic diffusion.” Therefore, DTI is helpful to analyze the white matter structure and injury of this structure.29,30 Practically, there are 2 methods to detect injury of white matter tracts. One is to analyze the diffusion tensor parameters of the region of interest, and the other is to reconstruct the region of interest of each tract using DTT.31–33 In contrast to DTI analysis and diffusion tensor parameter, DTT provides visual information of each tracts. Diffusion tensor tractography can be considered an objective, reproducible, and reliable method to ascertain the structural integrity of white matter tracts.34–39
The DTT analysis revealed structural disruptions of the CST and optic radiation, which were, respectively, correlated with quadriplegia and visual field defects. In particular, DTT showed severe structural disruption of the DRTT, which is associated with motor planning and initiation of movement. This disruption was not visible on routine brain MRI.
CONCLUSIONS
In the present case, although brain MRI sequences revealed no specific abnormal findings, DTT derived from the DTI sequence revealed severe subcortical disruption of the CST, optic radiation and DRTT, all of which seemed to be correlated with the patient's clinical symptoms. Therefore, the DTI sequence and DTT appear to be useful in evaluating and correlating neurological symptoms of patients with SILENT combined with NMS.
Conflicts of Interest and Source of Funding: The authors have no conflicts of interest to declare. | Recovering | ReactionOutcome | CC BY-NC-ND | 33560007 | 20,232,558 | 2021 |
Give an alphabetized list of all active substances of drugs taken by the patient who experienced 'Drug ineffective for unapproved indication'. | Nebulized Nitroglycerin for Coronavirus Disease 2019-Associated Acute Respiratory Distress Syndrome: A Case Report.
We present a case where nitroglycerin tablets dissolved in saline and intravenous nitroglycerin solution were nebulized as surrogates for inhaled nitric oxide (iNO) after our iNO supply was depleted during the coronavirus disease 2019 (COVID-19) surge in New York. We gave this treatment to a COVID-19 patient with severe acute respiratory distress syndrome (ARDS) and hypercarbia. In response, the patient had immediate and clinically meaningful improvement in multiple organ systems despite no other interventions or ventilator changes.
Coronavirus disease 2019 (COVID-19) can result in profound lung pathology with potentially large fractions of dead space ventilation. Given this and the growing evidence for microvascular occlusions of the pulmonary vessels, inhaled pulmonary vasodilators are suggested as a potential therapy.1 The surge of COVID-19 patients in New York in 2020 exhausted of our hospital’s supply of nitric oxide (ie, the preferred pulmonary vasodilator), and epoprostenol (ie, a synthetic analog of prostacyclin that is also a pulmonary vasodilator) was not available. Previous studies in humans have demonstrated that nebulized intravenous nitroglycerin solution is an effective pulmonary vasodilator.2,3 It is readily absorbed into the pulmonary vasculature and quickly converted into nitric oxide, resulting in improved ventilation/perfusion (V/Q) matching and reduced right heart afterload with minimal systemic side effects.
Given the scarcity of pulmonary vasodilators and the potential for benefit in a patient with acute pulmonary failure, we trialed a form of inhaled pulmonary vasodilator therapy that has not been reported previously. We dissolved nitroglycerin tablets in saline and nebulized the resulting solution as a surrogate for traditional pulmonary vasodilators. We administered this therapy to a patient with COVID-19 and multiorgan failure, that included COVID-19–associated acute respiratory distress syndrome (C-ARDS) with profound hypercarbia. Without any changes to the ventilator, there was an immediate and clinically meaningful improvement in the patient’s hypercarbia as well as in several other organ functions.
This case report reflects the potential role for pulmonary vasodilators in C-ARDS, the feasibility of inhaled nitroglycerin as a pulmonary vasodilator, and the need for ingenuity and creativity in the face of resource scarcity during a pandemic.
Written Health Insurance Portability and Accountability Act authorization and consent for this case report was obtained from the patient’s family. All personal health information identifiers have been removed.
CASE DESCRIPTION
A 58-year-old man with COVID-19 had been hospitalized for 22 days and intubated and mechanically ventilated for 18 days. For a majority of that time, he had severe C-ARDS and multiorgan failure. For more than 48 hours, the patient’s Paco2 was >91 mm Hg, with the highest value being 154 mm Hg. He also required 100% inspired oxygen to maintain a pulse oximetry saturation (Spo2) of 90%. Despite heavy sedation, he demonstrated significant ventilator dyssynchrony and was pharmacologically paralyzed for approximately two-thirds of these 48 hours. He received scheduled acetaminophen (1000 mg every 6 hours intravenously) and cold packs to decrease his core temperature (bladder temperature consistently kept <38°C) and lessen CO2 production. His ventilator settings were adjusted numerous times, eventually increasing to a ventilatory rate of 35 times/min with a tidal volume of 450 mL (resulting in an expired minute ventilation of approximately 16 L/min), but his Paco2 remained significantly elevated at 104 mm Hg with an arterial pH of 7.14 (Figure 1). As his CO2 became more difficult to manage, he needed increasing doses of norepinephrine to maintain a mean arterial pressure of 65 mm Hg, eventually requiring the addition of epinephrine and vasopressin infusions. His heart rate was 100–110 beats/min. Coinciding with increasing vasopressor needs, the patient’s urine output declined to <0.5 mL/kg/h for over 6 hours. Given his pathology, we thought a pulmonary vasodilator would benefit him, but the hospital’s supply of inhaled nitric oxide (iNO) was exhausted due to the surge of COVID-19 patients and it was unknown when additional supplies would arrive. Inhaled epoprostenol was also not available. The patient was not an extracorporeal membrane oxygenation (ECMO) candidate given his prolonged mechanical ventilation with high pressures and fraction of inspired oxygen (Fio2) and regional resource constraints on ECMO during the pandemic.
Figure 1. Serial arterial blood gases over the course of 14 h. Column 4 shows a hypercarbic and acidotic blood gas with lactate increased from 1.4 to 5.5 mmol/L approximately 4.5 h earlier. Column 3 shows a blood gas taken immediately after trialing nebulized nitroglycerin tablets diluted in 0.9% normal saline with a decreased Paco2 and improved Pao2. Column 2 shows a stable Paco2 reduction after transitioning to a nebulized intravenous nitroglycerin solution. And column 1 shows a persistently reduced Paco2 with lactate decreased from 5.5 to 1.7 mmol/L after starting nebulized nitroglycerin approximately 5 h earlier.
We decided to trial inhaled nitroglycerin. There was initial difficulty procuring intravenous nitroglycerin, so we dissolved three 0.3 mg nitroglycerine tablets (the form intended for sublingual use) with 3 mL of 0.9% normal saline. This mixture was placed into a vibrating mesh nebulizer and incorporated into the airway circuit (Figure 2). After approximately 10–15 minutes, the solution was exhausted, and an arterial blood gas showed that the Paco2 had decreased from 104 to 60 mm Hg—a 44 mm Hg decrease—despite no changes to the ventilator (Figure 1). Concurrently, arterial pH increased from 7.14 to 7.41, and Pao2 increased from 80 to 144 mm Hg on 100% Fio2.
Figure 2. An intravenous nitroglycerin solution bottle is connected via intravenous tubing and a 3-way stopcock to a vibrating mesh nebulizer to facilitate delivery of inhaled nitroglycerin.
Given this success, we attempted to create another solution of a higher nitroglycerin concentration by placing 6 tablets in 3 mL of 0.9% saline, but the tablets did not appear to fully dissolve. Additionally, we had no way to regulate the rate of aerosolization, that is, whatever was placed into the aerosolization chamber was delivered at a constant rate. Because our mixture needed redosing every 10–15 minutes and each mixture required 3 tablets, we potentially needed over 430 tablets for one 24-hour period. There was also significant labor associated with constantly dissolving and replenishing the nitroglycerin tablet solution. Fortunately, we were able to procure a bottle of intravenous nitroglycerin solution (concentration 100 µg/mL) approximately 1 hour after trialing the nebulized nitroglycerin. Intravenous tubing and a 3-way stopcock were used to continuously transfer the solution into the nebulizer chamber (Figure 2), with the rate of transfer adjusted using a roller clamp. Because the aerosolization chamber was always full and the aerosolization rate was constant, we were not able to increase the delivered dose of nebulized nitroglycerin. Approximately 1 hour after starting the continuously nebulized intravenous nitroglycerin solution, Paco2 remained stable at 63 mm Hg and arterial pH was 7.40 (Figure 1).
During the initial 4 hours of nebulized nitroglycerin, the epinephrine and vasopressin infusions that had been started 10 hours previously were successfully weaned off, with a resulting mean arterial pressure of 65 mm Hg. The urine output increased to over 1 mL/kg and lactate decreased from 5.5 to 1.7 mmol/L. Fio2 was decreased from 100% to 80% while the Spo2 remained approximately 90%. Despite these initial improvements, the patient’s multiorgan failure and C-ARDS continued to worsen and he eventually died 5 days later from hypoxemic respiratory failure.
DISCUSSION
Pulmonary vasodilators are important therapeutic interventions in ARDS, a condition partially characterized by increased right ventricular afterload and disruption of normal V/Q matching. Inhaled administration of pulmonary vasodilators are favored over intravenous administration in ARDS because they selectively act on the pulmonary circulation to improve gas exchange while limiting systemic side effects.4 By preferentially improving pulmonary blood flow in well-ventilated regions, inhaled vasodilators preserve or improve V/Q matching and reduce pulmonary vascular resistance, leading to improved cardiac output.5 iNO is more effective at improving oxygenation than other inhaled vasodilators such as prostacyclin and milrinone.6 Unfortunately, inhaled pulmonary vasodilators have failed to decrease mortality, as was true for our described patient.7 Despite this lack of mortality benefit, inhaled pulmonary vasodilators remain useful tools when caring for patients with ARDS, refractory hypoxemia, and depressed right ventricular function.
Inhaled nitroglycerin is quickly metabolized to nitric oxide, making it an effective pulmonary vasodilator that decreases both mean pulmonary artery pressure and pulmonary vascular resistance while improving V/Q matching.2,3,8 Reports of its use are mainly limited to cardiac surgery. Because nitroglycerin is readily available and does not require special equipment, it may be preferred in resource-limited environments. While inhaled pulmonary vasodilators demonstrate improved right heart function compared to intravenous forms, there are no trials comparing iNO to inhaled nitroglycerin.9,10 Wang et al11 compared inhaled nitroglycerin to inhaled milrinone and found similar decreases in pulmonary vascular resistance, although the effects of nitroglycerin were more transient.
Before the COVID-19 pandemic, the Food and Drug Administration (FDA) estimated that 56% of US community hospitals had drug shortages that changed or delayed patient care.12 This has worsened with the COVID-19 pandemic. Since April 2020, the FDA has declared shortages of critical drugs such as dexmedetomidine, propofol, midazolam, cisatracurium, fentanyl, hydromorphone, furosemide, and continuous renal replacement therapy fluid.13 Shortages of ventilators have prompted physicians, respiratory therapists, and ventilator production companies to collaborate on ways to safely ventilate multiple patients with a single device.14 Our case demonstrates yet another example of ingenuity bred by resource constraints. We used existing supplies to make an improvised form of inhaled nitroglycerin as a surrogate for nitric oxide in a New York hospital during the height of the COVID-19 pandemic when conventional pulmonary vasodilators were unavailable. The result of our efforts proved safe, efficacious, and inspiring to many health care workers in our intensive care unit.
DISCLOSURES
Name: Benjamin T. Daxon, MD.
Contribution: This author coordinated all efforts and wrote the abstract and case description.
Name: Erin Lark, NP.
Contribution: This author helped retrieve patient information and family contact information for consent.
Name: Luke J. Matzek, MD.
Contribution: This author helped research pertinent literature and wrote part of the discussion.
Name: Amanda R. Fields, MD.
Contribution: This author helped research pertinent literature and wrote part of the discussion.
Name: Kyle J. Haselton, MD.
Contribution: This author helped research pertinent literature and wrote part of the discussion.
This manuscript was handled by: BobbieJean Sweitzer, MD, FACP.
GLOSSARY
ARDS acute respiratory distress syndrome
C-ARDS COVID-19–associated acute respiratory distress syndrome
COVID-19 coronavirus disease 2019
ECMO extracorporeal membrane oxygenation
FDA Food and Drug Administration
Fio2 fraction of inspired oxygen
iNO inhaled nitric oxide
Spo2 pulse oximetry saturation
V/Q ventilation/perfusion
Funding: None.
The authors declare no conflicts of interest. | ACETAMINOPHEN, EPINEPHRINE, NITROGLYCERIN, NOREPINEPHRINE BITARTRATE, VASOPRESSIN | DrugsGivenReaction | CC BY-NC-ND | 33560642 | 18,997,573 | 2021-02-05 |
Give an alphabetized list of all active substances of drugs taken by the patient who experienced 'Multiple organ dysfunction syndrome'. | Nebulized Nitroglycerin for Coronavirus Disease 2019-Associated Acute Respiratory Distress Syndrome: A Case Report.
We present a case where nitroglycerin tablets dissolved in saline and intravenous nitroglycerin solution were nebulized as surrogates for inhaled nitric oxide (iNO) after our iNO supply was depleted during the coronavirus disease 2019 (COVID-19) surge in New York. We gave this treatment to a COVID-19 patient with severe acute respiratory distress syndrome (ARDS) and hypercarbia. In response, the patient had immediate and clinically meaningful improvement in multiple organ systems despite no other interventions or ventilator changes.
Coronavirus disease 2019 (COVID-19) can result in profound lung pathology with potentially large fractions of dead space ventilation. Given this and the growing evidence for microvascular occlusions of the pulmonary vessels, inhaled pulmonary vasodilators are suggested as a potential therapy.1 The surge of COVID-19 patients in New York in 2020 exhausted of our hospital’s supply of nitric oxide (ie, the preferred pulmonary vasodilator), and epoprostenol (ie, a synthetic analog of prostacyclin that is also a pulmonary vasodilator) was not available. Previous studies in humans have demonstrated that nebulized intravenous nitroglycerin solution is an effective pulmonary vasodilator.2,3 It is readily absorbed into the pulmonary vasculature and quickly converted into nitric oxide, resulting in improved ventilation/perfusion (V/Q) matching and reduced right heart afterload with minimal systemic side effects.
Given the scarcity of pulmonary vasodilators and the potential for benefit in a patient with acute pulmonary failure, we trialed a form of inhaled pulmonary vasodilator therapy that has not been reported previously. We dissolved nitroglycerin tablets in saline and nebulized the resulting solution as a surrogate for traditional pulmonary vasodilators. We administered this therapy to a patient with COVID-19 and multiorgan failure, that included COVID-19–associated acute respiratory distress syndrome (C-ARDS) with profound hypercarbia. Without any changes to the ventilator, there was an immediate and clinically meaningful improvement in the patient’s hypercarbia as well as in several other organ functions.
This case report reflects the potential role for pulmonary vasodilators in C-ARDS, the feasibility of inhaled nitroglycerin as a pulmonary vasodilator, and the need for ingenuity and creativity in the face of resource scarcity during a pandemic.
Written Health Insurance Portability and Accountability Act authorization and consent for this case report was obtained from the patient’s family. All personal health information identifiers have been removed.
CASE DESCRIPTION
A 58-year-old man with COVID-19 had been hospitalized for 22 days and intubated and mechanically ventilated for 18 days. For a majority of that time, he had severe C-ARDS and multiorgan failure. For more than 48 hours, the patient’s Paco2 was >91 mm Hg, with the highest value being 154 mm Hg. He also required 100% inspired oxygen to maintain a pulse oximetry saturation (Spo2) of 90%. Despite heavy sedation, he demonstrated significant ventilator dyssynchrony and was pharmacologically paralyzed for approximately two-thirds of these 48 hours. He received scheduled acetaminophen (1000 mg every 6 hours intravenously) and cold packs to decrease his core temperature (bladder temperature consistently kept <38°C) and lessen CO2 production. His ventilator settings were adjusted numerous times, eventually increasing to a ventilatory rate of 35 times/min with a tidal volume of 450 mL (resulting in an expired minute ventilation of approximately 16 L/min), but his Paco2 remained significantly elevated at 104 mm Hg with an arterial pH of 7.14 (Figure 1). As his CO2 became more difficult to manage, he needed increasing doses of norepinephrine to maintain a mean arterial pressure of 65 mm Hg, eventually requiring the addition of epinephrine and vasopressin infusions. His heart rate was 100–110 beats/min. Coinciding with increasing vasopressor needs, the patient’s urine output declined to <0.5 mL/kg/h for over 6 hours. Given his pathology, we thought a pulmonary vasodilator would benefit him, but the hospital’s supply of inhaled nitric oxide (iNO) was exhausted due to the surge of COVID-19 patients and it was unknown when additional supplies would arrive. Inhaled epoprostenol was also not available. The patient was not an extracorporeal membrane oxygenation (ECMO) candidate given his prolonged mechanical ventilation with high pressures and fraction of inspired oxygen (Fio2) and regional resource constraints on ECMO during the pandemic.
Figure 1. Serial arterial blood gases over the course of 14 h. Column 4 shows a hypercarbic and acidotic blood gas with lactate increased from 1.4 to 5.5 mmol/L approximately 4.5 h earlier. Column 3 shows a blood gas taken immediately after trialing nebulized nitroglycerin tablets diluted in 0.9% normal saline with a decreased Paco2 and improved Pao2. Column 2 shows a stable Paco2 reduction after transitioning to a nebulized intravenous nitroglycerin solution. And column 1 shows a persistently reduced Paco2 with lactate decreased from 5.5 to 1.7 mmol/L after starting nebulized nitroglycerin approximately 5 h earlier.
We decided to trial inhaled nitroglycerin. There was initial difficulty procuring intravenous nitroglycerin, so we dissolved three 0.3 mg nitroglycerine tablets (the form intended for sublingual use) with 3 mL of 0.9% normal saline. This mixture was placed into a vibrating mesh nebulizer and incorporated into the airway circuit (Figure 2). After approximately 10–15 minutes, the solution was exhausted, and an arterial blood gas showed that the Paco2 had decreased from 104 to 60 mm Hg—a 44 mm Hg decrease—despite no changes to the ventilator (Figure 1). Concurrently, arterial pH increased from 7.14 to 7.41, and Pao2 increased from 80 to 144 mm Hg on 100% Fio2.
Figure 2. An intravenous nitroglycerin solution bottle is connected via intravenous tubing and a 3-way stopcock to a vibrating mesh nebulizer to facilitate delivery of inhaled nitroglycerin.
Given this success, we attempted to create another solution of a higher nitroglycerin concentration by placing 6 tablets in 3 mL of 0.9% saline, but the tablets did not appear to fully dissolve. Additionally, we had no way to regulate the rate of aerosolization, that is, whatever was placed into the aerosolization chamber was delivered at a constant rate. Because our mixture needed redosing every 10–15 minutes and each mixture required 3 tablets, we potentially needed over 430 tablets for one 24-hour period. There was also significant labor associated with constantly dissolving and replenishing the nitroglycerin tablet solution. Fortunately, we were able to procure a bottle of intravenous nitroglycerin solution (concentration 100 µg/mL) approximately 1 hour after trialing the nebulized nitroglycerin. Intravenous tubing and a 3-way stopcock were used to continuously transfer the solution into the nebulizer chamber (Figure 2), with the rate of transfer adjusted using a roller clamp. Because the aerosolization chamber was always full and the aerosolization rate was constant, we were not able to increase the delivered dose of nebulized nitroglycerin. Approximately 1 hour after starting the continuously nebulized intravenous nitroglycerin solution, Paco2 remained stable at 63 mm Hg and arterial pH was 7.40 (Figure 1).
During the initial 4 hours of nebulized nitroglycerin, the epinephrine and vasopressin infusions that had been started 10 hours previously were successfully weaned off, with a resulting mean arterial pressure of 65 mm Hg. The urine output increased to over 1 mL/kg and lactate decreased from 5.5 to 1.7 mmol/L. Fio2 was decreased from 100% to 80% while the Spo2 remained approximately 90%. Despite these initial improvements, the patient’s multiorgan failure and C-ARDS continued to worsen and he eventually died 5 days later from hypoxemic respiratory failure.
DISCUSSION
Pulmonary vasodilators are important therapeutic interventions in ARDS, a condition partially characterized by increased right ventricular afterload and disruption of normal V/Q matching. Inhaled administration of pulmonary vasodilators are favored over intravenous administration in ARDS because they selectively act on the pulmonary circulation to improve gas exchange while limiting systemic side effects.4 By preferentially improving pulmonary blood flow in well-ventilated regions, inhaled vasodilators preserve or improve V/Q matching and reduce pulmonary vascular resistance, leading to improved cardiac output.5 iNO is more effective at improving oxygenation than other inhaled vasodilators such as prostacyclin and milrinone.6 Unfortunately, inhaled pulmonary vasodilators have failed to decrease mortality, as was true for our described patient.7 Despite this lack of mortality benefit, inhaled pulmonary vasodilators remain useful tools when caring for patients with ARDS, refractory hypoxemia, and depressed right ventricular function.
Inhaled nitroglycerin is quickly metabolized to nitric oxide, making it an effective pulmonary vasodilator that decreases both mean pulmonary artery pressure and pulmonary vascular resistance while improving V/Q matching.2,3,8 Reports of its use are mainly limited to cardiac surgery. Because nitroglycerin is readily available and does not require special equipment, it may be preferred in resource-limited environments. While inhaled pulmonary vasodilators demonstrate improved right heart function compared to intravenous forms, there are no trials comparing iNO to inhaled nitroglycerin.9,10 Wang et al11 compared inhaled nitroglycerin to inhaled milrinone and found similar decreases in pulmonary vascular resistance, although the effects of nitroglycerin were more transient.
Before the COVID-19 pandemic, the Food and Drug Administration (FDA) estimated that 56% of US community hospitals had drug shortages that changed or delayed patient care.12 This has worsened with the COVID-19 pandemic. Since April 2020, the FDA has declared shortages of critical drugs such as dexmedetomidine, propofol, midazolam, cisatracurium, fentanyl, hydromorphone, furosemide, and continuous renal replacement therapy fluid.13 Shortages of ventilators have prompted physicians, respiratory therapists, and ventilator production companies to collaborate on ways to safely ventilate multiple patients with a single device.14 Our case demonstrates yet another example of ingenuity bred by resource constraints. We used existing supplies to make an improvised form of inhaled nitroglycerin as a surrogate for nitric oxide in a New York hospital during the height of the COVID-19 pandemic when conventional pulmonary vasodilators were unavailable. The result of our efforts proved safe, efficacious, and inspiring to many health care workers in our intensive care unit.
DISCLOSURES
Name: Benjamin T. Daxon, MD.
Contribution: This author coordinated all efforts and wrote the abstract and case description.
Name: Erin Lark, NP.
Contribution: This author helped retrieve patient information and family contact information for consent.
Name: Luke J. Matzek, MD.
Contribution: This author helped research pertinent literature and wrote part of the discussion.
Name: Amanda R. Fields, MD.
Contribution: This author helped research pertinent literature and wrote part of the discussion.
Name: Kyle J. Haselton, MD.
Contribution: This author helped research pertinent literature and wrote part of the discussion.
This manuscript was handled by: BobbieJean Sweitzer, MD, FACP.
GLOSSARY
ARDS acute respiratory distress syndrome
C-ARDS COVID-19–associated acute respiratory distress syndrome
COVID-19 coronavirus disease 2019
ECMO extracorporeal membrane oxygenation
FDA Food and Drug Administration
Fio2 fraction of inspired oxygen
iNO inhaled nitric oxide
Spo2 pulse oximetry saturation
V/Q ventilation/perfusion
Funding: None.
The authors declare no conflicts of interest. | ACETAMINOPHEN, EPINEPHRINE, NITROGLYCERIN, NOREPINEPHRINE BITARTRATE, VASOPRESSIN | DrugsGivenReaction | CC BY-NC-ND | 33560642 | 18,997,573 | 2021-02-05 |
Give an alphabetized list of all active substances of drugs taken by the patient who experienced 'Off label use'. | Nebulized Nitroglycerin for Coronavirus Disease 2019-Associated Acute Respiratory Distress Syndrome: A Case Report.
We present a case where nitroglycerin tablets dissolved in saline and intravenous nitroglycerin solution were nebulized as surrogates for inhaled nitric oxide (iNO) after our iNO supply was depleted during the coronavirus disease 2019 (COVID-19) surge in New York. We gave this treatment to a COVID-19 patient with severe acute respiratory distress syndrome (ARDS) and hypercarbia. In response, the patient had immediate and clinically meaningful improvement in multiple organ systems despite no other interventions or ventilator changes.
Coronavirus disease 2019 (COVID-19) can result in profound lung pathology with potentially large fractions of dead space ventilation. Given this and the growing evidence for microvascular occlusions of the pulmonary vessels, inhaled pulmonary vasodilators are suggested as a potential therapy.1 The surge of COVID-19 patients in New York in 2020 exhausted of our hospital’s supply of nitric oxide (ie, the preferred pulmonary vasodilator), and epoprostenol (ie, a synthetic analog of prostacyclin that is also a pulmonary vasodilator) was not available. Previous studies in humans have demonstrated that nebulized intravenous nitroglycerin solution is an effective pulmonary vasodilator.2,3 It is readily absorbed into the pulmonary vasculature and quickly converted into nitric oxide, resulting in improved ventilation/perfusion (V/Q) matching and reduced right heart afterload with minimal systemic side effects.
Given the scarcity of pulmonary vasodilators and the potential for benefit in a patient with acute pulmonary failure, we trialed a form of inhaled pulmonary vasodilator therapy that has not been reported previously. We dissolved nitroglycerin tablets in saline and nebulized the resulting solution as a surrogate for traditional pulmonary vasodilators. We administered this therapy to a patient with COVID-19 and multiorgan failure, that included COVID-19–associated acute respiratory distress syndrome (C-ARDS) with profound hypercarbia. Without any changes to the ventilator, there was an immediate and clinically meaningful improvement in the patient’s hypercarbia as well as in several other organ functions.
This case report reflects the potential role for pulmonary vasodilators in C-ARDS, the feasibility of inhaled nitroglycerin as a pulmonary vasodilator, and the need for ingenuity and creativity in the face of resource scarcity during a pandemic.
Written Health Insurance Portability and Accountability Act authorization and consent for this case report was obtained from the patient’s family. All personal health information identifiers have been removed.
CASE DESCRIPTION
A 58-year-old man with COVID-19 had been hospitalized for 22 days and intubated and mechanically ventilated for 18 days. For a majority of that time, he had severe C-ARDS and multiorgan failure. For more than 48 hours, the patient’s Paco2 was >91 mm Hg, with the highest value being 154 mm Hg. He also required 100% inspired oxygen to maintain a pulse oximetry saturation (Spo2) of 90%. Despite heavy sedation, he demonstrated significant ventilator dyssynchrony and was pharmacologically paralyzed for approximately two-thirds of these 48 hours. He received scheduled acetaminophen (1000 mg every 6 hours intravenously) and cold packs to decrease his core temperature (bladder temperature consistently kept <38°C) and lessen CO2 production. His ventilator settings were adjusted numerous times, eventually increasing to a ventilatory rate of 35 times/min with a tidal volume of 450 mL (resulting in an expired minute ventilation of approximately 16 L/min), but his Paco2 remained significantly elevated at 104 mm Hg with an arterial pH of 7.14 (Figure 1). As his CO2 became more difficult to manage, he needed increasing doses of norepinephrine to maintain a mean arterial pressure of 65 mm Hg, eventually requiring the addition of epinephrine and vasopressin infusions. His heart rate was 100–110 beats/min. Coinciding with increasing vasopressor needs, the patient’s urine output declined to <0.5 mL/kg/h for over 6 hours. Given his pathology, we thought a pulmonary vasodilator would benefit him, but the hospital’s supply of inhaled nitric oxide (iNO) was exhausted due to the surge of COVID-19 patients and it was unknown when additional supplies would arrive. Inhaled epoprostenol was also not available. The patient was not an extracorporeal membrane oxygenation (ECMO) candidate given his prolonged mechanical ventilation with high pressures and fraction of inspired oxygen (Fio2) and regional resource constraints on ECMO during the pandemic.
Figure 1. Serial arterial blood gases over the course of 14 h. Column 4 shows a hypercarbic and acidotic blood gas with lactate increased from 1.4 to 5.5 mmol/L approximately 4.5 h earlier. Column 3 shows a blood gas taken immediately after trialing nebulized nitroglycerin tablets diluted in 0.9% normal saline with a decreased Paco2 and improved Pao2. Column 2 shows a stable Paco2 reduction after transitioning to a nebulized intravenous nitroglycerin solution. And column 1 shows a persistently reduced Paco2 with lactate decreased from 5.5 to 1.7 mmol/L after starting nebulized nitroglycerin approximately 5 h earlier.
We decided to trial inhaled nitroglycerin. There was initial difficulty procuring intravenous nitroglycerin, so we dissolved three 0.3 mg nitroglycerine tablets (the form intended for sublingual use) with 3 mL of 0.9% normal saline. This mixture was placed into a vibrating mesh nebulizer and incorporated into the airway circuit (Figure 2). After approximately 10–15 minutes, the solution was exhausted, and an arterial blood gas showed that the Paco2 had decreased from 104 to 60 mm Hg—a 44 mm Hg decrease—despite no changes to the ventilator (Figure 1). Concurrently, arterial pH increased from 7.14 to 7.41, and Pao2 increased from 80 to 144 mm Hg on 100% Fio2.
Figure 2. An intravenous nitroglycerin solution bottle is connected via intravenous tubing and a 3-way stopcock to a vibrating mesh nebulizer to facilitate delivery of inhaled nitroglycerin.
Given this success, we attempted to create another solution of a higher nitroglycerin concentration by placing 6 tablets in 3 mL of 0.9% saline, but the tablets did not appear to fully dissolve. Additionally, we had no way to regulate the rate of aerosolization, that is, whatever was placed into the aerosolization chamber was delivered at a constant rate. Because our mixture needed redosing every 10–15 minutes and each mixture required 3 tablets, we potentially needed over 430 tablets for one 24-hour period. There was also significant labor associated with constantly dissolving and replenishing the nitroglycerin tablet solution. Fortunately, we were able to procure a bottle of intravenous nitroglycerin solution (concentration 100 µg/mL) approximately 1 hour after trialing the nebulized nitroglycerin. Intravenous tubing and a 3-way stopcock were used to continuously transfer the solution into the nebulizer chamber (Figure 2), with the rate of transfer adjusted using a roller clamp. Because the aerosolization chamber was always full and the aerosolization rate was constant, we were not able to increase the delivered dose of nebulized nitroglycerin. Approximately 1 hour after starting the continuously nebulized intravenous nitroglycerin solution, Paco2 remained stable at 63 mm Hg and arterial pH was 7.40 (Figure 1).
During the initial 4 hours of nebulized nitroglycerin, the epinephrine and vasopressin infusions that had been started 10 hours previously were successfully weaned off, with a resulting mean arterial pressure of 65 mm Hg. The urine output increased to over 1 mL/kg and lactate decreased from 5.5 to 1.7 mmol/L. Fio2 was decreased from 100% to 80% while the Spo2 remained approximately 90%. Despite these initial improvements, the patient’s multiorgan failure and C-ARDS continued to worsen and he eventually died 5 days later from hypoxemic respiratory failure.
DISCUSSION
Pulmonary vasodilators are important therapeutic interventions in ARDS, a condition partially characterized by increased right ventricular afterload and disruption of normal V/Q matching. Inhaled administration of pulmonary vasodilators are favored over intravenous administration in ARDS because they selectively act on the pulmonary circulation to improve gas exchange while limiting systemic side effects.4 By preferentially improving pulmonary blood flow in well-ventilated regions, inhaled vasodilators preserve or improve V/Q matching and reduce pulmonary vascular resistance, leading to improved cardiac output.5 iNO is more effective at improving oxygenation than other inhaled vasodilators such as prostacyclin and milrinone.6 Unfortunately, inhaled pulmonary vasodilators have failed to decrease mortality, as was true for our described patient.7 Despite this lack of mortality benefit, inhaled pulmonary vasodilators remain useful tools when caring for patients with ARDS, refractory hypoxemia, and depressed right ventricular function.
Inhaled nitroglycerin is quickly metabolized to nitric oxide, making it an effective pulmonary vasodilator that decreases both mean pulmonary artery pressure and pulmonary vascular resistance while improving V/Q matching.2,3,8 Reports of its use are mainly limited to cardiac surgery. Because nitroglycerin is readily available and does not require special equipment, it may be preferred in resource-limited environments. While inhaled pulmonary vasodilators demonstrate improved right heart function compared to intravenous forms, there are no trials comparing iNO to inhaled nitroglycerin.9,10 Wang et al11 compared inhaled nitroglycerin to inhaled milrinone and found similar decreases in pulmonary vascular resistance, although the effects of nitroglycerin were more transient.
Before the COVID-19 pandemic, the Food and Drug Administration (FDA) estimated that 56% of US community hospitals had drug shortages that changed or delayed patient care.12 This has worsened with the COVID-19 pandemic. Since April 2020, the FDA has declared shortages of critical drugs such as dexmedetomidine, propofol, midazolam, cisatracurium, fentanyl, hydromorphone, furosemide, and continuous renal replacement therapy fluid.13 Shortages of ventilators have prompted physicians, respiratory therapists, and ventilator production companies to collaborate on ways to safely ventilate multiple patients with a single device.14 Our case demonstrates yet another example of ingenuity bred by resource constraints. We used existing supplies to make an improvised form of inhaled nitroglycerin as a surrogate for nitric oxide in a New York hospital during the height of the COVID-19 pandemic when conventional pulmonary vasodilators were unavailable. The result of our efforts proved safe, efficacious, and inspiring to many health care workers in our intensive care unit.
DISCLOSURES
Name: Benjamin T. Daxon, MD.
Contribution: This author coordinated all efforts and wrote the abstract and case description.
Name: Erin Lark, NP.
Contribution: This author helped retrieve patient information and family contact information for consent.
Name: Luke J. Matzek, MD.
Contribution: This author helped research pertinent literature and wrote part of the discussion.
Name: Amanda R. Fields, MD.
Contribution: This author helped research pertinent literature and wrote part of the discussion.
Name: Kyle J. Haselton, MD.
Contribution: This author helped research pertinent literature and wrote part of the discussion.
This manuscript was handled by: BobbieJean Sweitzer, MD, FACP.
GLOSSARY
ARDS acute respiratory distress syndrome
C-ARDS COVID-19–associated acute respiratory distress syndrome
COVID-19 coronavirus disease 2019
ECMO extracorporeal membrane oxygenation
FDA Food and Drug Administration
Fio2 fraction of inspired oxygen
iNO inhaled nitric oxide
Spo2 pulse oximetry saturation
V/Q ventilation/perfusion
Funding: None.
The authors declare no conflicts of interest. | ACETAMINOPHEN, EPINEPHRINE, NITROGLYCERIN, NOREPINEPHRINE BITARTRATE, VASOPRESSIN | DrugsGivenReaction | CC BY-NC-ND | 33560642 | 18,997,573 | 2021-02-05 |
Give an alphabetized list of all active substances of drugs taken by the patient who experienced 'Respiratory failure'. | Nebulized Nitroglycerin for Coronavirus Disease 2019-Associated Acute Respiratory Distress Syndrome: A Case Report.
We present a case where nitroglycerin tablets dissolved in saline and intravenous nitroglycerin solution were nebulized as surrogates for inhaled nitric oxide (iNO) after our iNO supply was depleted during the coronavirus disease 2019 (COVID-19) surge in New York. We gave this treatment to a COVID-19 patient with severe acute respiratory distress syndrome (ARDS) and hypercarbia. In response, the patient had immediate and clinically meaningful improvement in multiple organ systems despite no other interventions or ventilator changes.
Coronavirus disease 2019 (COVID-19) can result in profound lung pathology with potentially large fractions of dead space ventilation. Given this and the growing evidence for microvascular occlusions of the pulmonary vessels, inhaled pulmonary vasodilators are suggested as a potential therapy.1 The surge of COVID-19 patients in New York in 2020 exhausted of our hospital’s supply of nitric oxide (ie, the preferred pulmonary vasodilator), and epoprostenol (ie, a synthetic analog of prostacyclin that is also a pulmonary vasodilator) was not available. Previous studies in humans have demonstrated that nebulized intravenous nitroglycerin solution is an effective pulmonary vasodilator.2,3 It is readily absorbed into the pulmonary vasculature and quickly converted into nitric oxide, resulting in improved ventilation/perfusion (V/Q) matching and reduced right heart afterload with minimal systemic side effects.
Given the scarcity of pulmonary vasodilators and the potential for benefit in a patient with acute pulmonary failure, we trialed a form of inhaled pulmonary vasodilator therapy that has not been reported previously. We dissolved nitroglycerin tablets in saline and nebulized the resulting solution as a surrogate for traditional pulmonary vasodilators. We administered this therapy to a patient with COVID-19 and multiorgan failure, that included COVID-19–associated acute respiratory distress syndrome (C-ARDS) with profound hypercarbia. Without any changes to the ventilator, there was an immediate and clinically meaningful improvement in the patient’s hypercarbia as well as in several other organ functions.
This case report reflects the potential role for pulmonary vasodilators in C-ARDS, the feasibility of inhaled nitroglycerin as a pulmonary vasodilator, and the need for ingenuity and creativity in the face of resource scarcity during a pandemic.
Written Health Insurance Portability and Accountability Act authorization and consent for this case report was obtained from the patient’s family. All personal health information identifiers have been removed.
CASE DESCRIPTION
A 58-year-old man with COVID-19 had been hospitalized for 22 days and intubated and mechanically ventilated for 18 days. For a majority of that time, he had severe C-ARDS and multiorgan failure. For more than 48 hours, the patient’s Paco2 was >91 mm Hg, with the highest value being 154 mm Hg. He also required 100% inspired oxygen to maintain a pulse oximetry saturation (Spo2) of 90%. Despite heavy sedation, he demonstrated significant ventilator dyssynchrony and was pharmacologically paralyzed for approximately two-thirds of these 48 hours. He received scheduled acetaminophen (1000 mg every 6 hours intravenously) and cold packs to decrease his core temperature (bladder temperature consistently kept <38°C) and lessen CO2 production. His ventilator settings were adjusted numerous times, eventually increasing to a ventilatory rate of 35 times/min with a tidal volume of 450 mL (resulting in an expired minute ventilation of approximately 16 L/min), but his Paco2 remained significantly elevated at 104 mm Hg with an arterial pH of 7.14 (Figure 1). As his CO2 became more difficult to manage, he needed increasing doses of norepinephrine to maintain a mean arterial pressure of 65 mm Hg, eventually requiring the addition of epinephrine and vasopressin infusions. His heart rate was 100–110 beats/min. Coinciding with increasing vasopressor needs, the patient’s urine output declined to <0.5 mL/kg/h for over 6 hours. Given his pathology, we thought a pulmonary vasodilator would benefit him, but the hospital’s supply of inhaled nitric oxide (iNO) was exhausted due to the surge of COVID-19 patients and it was unknown when additional supplies would arrive. Inhaled epoprostenol was also not available. The patient was not an extracorporeal membrane oxygenation (ECMO) candidate given his prolonged mechanical ventilation with high pressures and fraction of inspired oxygen (Fio2) and regional resource constraints on ECMO during the pandemic.
Figure 1. Serial arterial blood gases over the course of 14 h. Column 4 shows a hypercarbic and acidotic blood gas with lactate increased from 1.4 to 5.5 mmol/L approximately 4.5 h earlier. Column 3 shows a blood gas taken immediately after trialing nebulized nitroglycerin tablets diluted in 0.9% normal saline with a decreased Paco2 and improved Pao2. Column 2 shows a stable Paco2 reduction after transitioning to a nebulized intravenous nitroglycerin solution. And column 1 shows a persistently reduced Paco2 with lactate decreased from 5.5 to 1.7 mmol/L after starting nebulized nitroglycerin approximately 5 h earlier.
We decided to trial inhaled nitroglycerin. There was initial difficulty procuring intravenous nitroglycerin, so we dissolved three 0.3 mg nitroglycerine tablets (the form intended for sublingual use) with 3 mL of 0.9% normal saline. This mixture was placed into a vibrating mesh nebulizer and incorporated into the airway circuit (Figure 2). After approximately 10–15 minutes, the solution was exhausted, and an arterial blood gas showed that the Paco2 had decreased from 104 to 60 mm Hg—a 44 mm Hg decrease—despite no changes to the ventilator (Figure 1). Concurrently, arterial pH increased from 7.14 to 7.41, and Pao2 increased from 80 to 144 mm Hg on 100% Fio2.
Figure 2. An intravenous nitroglycerin solution bottle is connected via intravenous tubing and a 3-way stopcock to a vibrating mesh nebulizer to facilitate delivery of inhaled nitroglycerin.
Given this success, we attempted to create another solution of a higher nitroglycerin concentration by placing 6 tablets in 3 mL of 0.9% saline, but the tablets did not appear to fully dissolve. Additionally, we had no way to regulate the rate of aerosolization, that is, whatever was placed into the aerosolization chamber was delivered at a constant rate. Because our mixture needed redosing every 10–15 minutes and each mixture required 3 tablets, we potentially needed over 430 tablets for one 24-hour period. There was also significant labor associated with constantly dissolving and replenishing the nitroglycerin tablet solution. Fortunately, we were able to procure a bottle of intravenous nitroglycerin solution (concentration 100 µg/mL) approximately 1 hour after trialing the nebulized nitroglycerin. Intravenous tubing and a 3-way stopcock were used to continuously transfer the solution into the nebulizer chamber (Figure 2), with the rate of transfer adjusted using a roller clamp. Because the aerosolization chamber was always full and the aerosolization rate was constant, we were not able to increase the delivered dose of nebulized nitroglycerin. Approximately 1 hour after starting the continuously nebulized intravenous nitroglycerin solution, Paco2 remained stable at 63 mm Hg and arterial pH was 7.40 (Figure 1).
During the initial 4 hours of nebulized nitroglycerin, the epinephrine and vasopressin infusions that had been started 10 hours previously were successfully weaned off, with a resulting mean arterial pressure of 65 mm Hg. The urine output increased to over 1 mL/kg and lactate decreased from 5.5 to 1.7 mmol/L. Fio2 was decreased from 100% to 80% while the Spo2 remained approximately 90%. Despite these initial improvements, the patient’s multiorgan failure and C-ARDS continued to worsen and he eventually died 5 days later from hypoxemic respiratory failure.
DISCUSSION
Pulmonary vasodilators are important therapeutic interventions in ARDS, a condition partially characterized by increased right ventricular afterload and disruption of normal V/Q matching. Inhaled administration of pulmonary vasodilators are favored over intravenous administration in ARDS because they selectively act on the pulmonary circulation to improve gas exchange while limiting systemic side effects.4 By preferentially improving pulmonary blood flow in well-ventilated regions, inhaled vasodilators preserve or improve V/Q matching and reduce pulmonary vascular resistance, leading to improved cardiac output.5 iNO is more effective at improving oxygenation than other inhaled vasodilators such as prostacyclin and milrinone.6 Unfortunately, inhaled pulmonary vasodilators have failed to decrease mortality, as was true for our described patient.7 Despite this lack of mortality benefit, inhaled pulmonary vasodilators remain useful tools when caring for patients with ARDS, refractory hypoxemia, and depressed right ventricular function.
Inhaled nitroglycerin is quickly metabolized to nitric oxide, making it an effective pulmonary vasodilator that decreases both mean pulmonary artery pressure and pulmonary vascular resistance while improving V/Q matching.2,3,8 Reports of its use are mainly limited to cardiac surgery. Because nitroglycerin is readily available and does not require special equipment, it may be preferred in resource-limited environments. While inhaled pulmonary vasodilators demonstrate improved right heart function compared to intravenous forms, there are no trials comparing iNO to inhaled nitroglycerin.9,10 Wang et al11 compared inhaled nitroglycerin to inhaled milrinone and found similar decreases in pulmonary vascular resistance, although the effects of nitroglycerin were more transient.
Before the COVID-19 pandemic, the Food and Drug Administration (FDA) estimated that 56% of US community hospitals had drug shortages that changed or delayed patient care.12 This has worsened with the COVID-19 pandemic. Since April 2020, the FDA has declared shortages of critical drugs such as dexmedetomidine, propofol, midazolam, cisatracurium, fentanyl, hydromorphone, furosemide, and continuous renal replacement therapy fluid.13 Shortages of ventilators have prompted physicians, respiratory therapists, and ventilator production companies to collaborate on ways to safely ventilate multiple patients with a single device.14 Our case demonstrates yet another example of ingenuity bred by resource constraints. We used existing supplies to make an improvised form of inhaled nitroglycerin as a surrogate for nitric oxide in a New York hospital during the height of the COVID-19 pandemic when conventional pulmonary vasodilators were unavailable. The result of our efforts proved safe, efficacious, and inspiring to many health care workers in our intensive care unit.
DISCLOSURES
Name: Benjamin T. Daxon, MD.
Contribution: This author coordinated all efforts and wrote the abstract and case description.
Name: Erin Lark, NP.
Contribution: This author helped retrieve patient information and family contact information for consent.
Name: Luke J. Matzek, MD.
Contribution: This author helped research pertinent literature and wrote part of the discussion.
Name: Amanda R. Fields, MD.
Contribution: This author helped research pertinent literature and wrote part of the discussion.
Name: Kyle J. Haselton, MD.
Contribution: This author helped research pertinent literature and wrote part of the discussion.
This manuscript was handled by: BobbieJean Sweitzer, MD, FACP.
GLOSSARY
ARDS acute respiratory distress syndrome
C-ARDS COVID-19–associated acute respiratory distress syndrome
COVID-19 coronavirus disease 2019
ECMO extracorporeal membrane oxygenation
FDA Food and Drug Administration
Fio2 fraction of inspired oxygen
iNO inhaled nitric oxide
Spo2 pulse oximetry saturation
V/Q ventilation/perfusion
Funding: None.
The authors declare no conflicts of interest. | ACETAMINOPHEN, EPINEPHRINE, NITROGLYCERIN, NOREPINEPHRINE BITARTRATE, VASOPRESSIN | DrugsGivenReaction | CC BY-NC-ND | 33560642 | 18,997,573 | 2021-02-05 |
What was the administration route of drug 'ACETAMINOPHEN'? | Nebulized Nitroglycerin for Coronavirus Disease 2019-Associated Acute Respiratory Distress Syndrome: A Case Report.
We present a case where nitroglycerin tablets dissolved in saline and intravenous nitroglycerin solution were nebulized as surrogates for inhaled nitric oxide (iNO) after our iNO supply was depleted during the coronavirus disease 2019 (COVID-19) surge in New York. We gave this treatment to a COVID-19 patient with severe acute respiratory distress syndrome (ARDS) and hypercarbia. In response, the patient had immediate and clinically meaningful improvement in multiple organ systems despite no other interventions or ventilator changes.
Coronavirus disease 2019 (COVID-19) can result in profound lung pathology with potentially large fractions of dead space ventilation. Given this and the growing evidence for microvascular occlusions of the pulmonary vessels, inhaled pulmonary vasodilators are suggested as a potential therapy.1 The surge of COVID-19 patients in New York in 2020 exhausted of our hospital’s supply of nitric oxide (ie, the preferred pulmonary vasodilator), and epoprostenol (ie, a synthetic analog of prostacyclin that is also a pulmonary vasodilator) was not available. Previous studies in humans have demonstrated that nebulized intravenous nitroglycerin solution is an effective pulmonary vasodilator.2,3 It is readily absorbed into the pulmonary vasculature and quickly converted into nitric oxide, resulting in improved ventilation/perfusion (V/Q) matching and reduced right heart afterload with minimal systemic side effects.
Given the scarcity of pulmonary vasodilators and the potential for benefit in a patient with acute pulmonary failure, we trialed a form of inhaled pulmonary vasodilator therapy that has not been reported previously. We dissolved nitroglycerin tablets in saline and nebulized the resulting solution as a surrogate for traditional pulmonary vasodilators. We administered this therapy to a patient with COVID-19 and multiorgan failure, that included COVID-19–associated acute respiratory distress syndrome (C-ARDS) with profound hypercarbia. Without any changes to the ventilator, there was an immediate and clinically meaningful improvement in the patient’s hypercarbia as well as in several other organ functions.
This case report reflects the potential role for pulmonary vasodilators in C-ARDS, the feasibility of inhaled nitroglycerin as a pulmonary vasodilator, and the need for ingenuity and creativity in the face of resource scarcity during a pandemic.
Written Health Insurance Portability and Accountability Act authorization and consent for this case report was obtained from the patient’s family. All personal health information identifiers have been removed.
CASE DESCRIPTION
A 58-year-old man with COVID-19 had been hospitalized for 22 days and intubated and mechanically ventilated for 18 days. For a majority of that time, he had severe C-ARDS and multiorgan failure. For more than 48 hours, the patient’s Paco2 was >91 mm Hg, with the highest value being 154 mm Hg. He also required 100% inspired oxygen to maintain a pulse oximetry saturation (Spo2) of 90%. Despite heavy sedation, he demonstrated significant ventilator dyssynchrony and was pharmacologically paralyzed for approximately two-thirds of these 48 hours. He received scheduled acetaminophen (1000 mg every 6 hours intravenously) and cold packs to decrease his core temperature (bladder temperature consistently kept <38°C) and lessen CO2 production. His ventilator settings were adjusted numerous times, eventually increasing to a ventilatory rate of 35 times/min with a tidal volume of 450 mL (resulting in an expired minute ventilation of approximately 16 L/min), but his Paco2 remained significantly elevated at 104 mm Hg with an arterial pH of 7.14 (Figure 1). As his CO2 became more difficult to manage, he needed increasing doses of norepinephrine to maintain a mean arterial pressure of 65 mm Hg, eventually requiring the addition of epinephrine and vasopressin infusions. His heart rate was 100–110 beats/min. Coinciding with increasing vasopressor needs, the patient’s urine output declined to <0.5 mL/kg/h for over 6 hours. Given his pathology, we thought a pulmonary vasodilator would benefit him, but the hospital’s supply of inhaled nitric oxide (iNO) was exhausted due to the surge of COVID-19 patients and it was unknown when additional supplies would arrive. Inhaled epoprostenol was also not available. The patient was not an extracorporeal membrane oxygenation (ECMO) candidate given his prolonged mechanical ventilation with high pressures and fraction of inspired oxygen (Fio2) and regional resource constraints on ECMO during the pandemic.
Figure 1. Serial arterial blood gases over the course of 14 h. Column 4 shows a hypercarbic and acidotic blood gas with lactate increased from 1.4 to 5.5 mmol/L approximately 4.5 h earlier. Column 3 shows a blood gas taken immediately after trialing nebulized nitroglycerin tablets diluted in 0.9% normal saline with a decreased Paco2 and improved Pao2. Column 2 shows a stable Paco2 reduction after transitioning to a nebulized intravenous nitroglycerin solution. And column 1 shows a persistently reduced Paco2 with lactate decreased from 5.5 to 1.7 mmol/L after starting nebulized nitroglycerin approximately 5 h earlier.
We decided to trial inhaled nitroglycerin. There was initial difficulty procuring intravenous nitroglycerin, so we dissolved three 0.3 mg nitroglycerine tablets (the form intended for sublingual use) with 3 mL of 0.9% normal saline. This mixture was placed into a vibrating mesh nebulizer and incorporated into the airway circuit (Figure 2). After approximately 10–15 minutes, the solution was exhausted, and an arterial blood gas showed that the Paco2 had decreased from 104 to 60 mm Hg—a 44 mm Hg decrease—despite no changes to the ventilator (Figure 1). Concurrently, arterial pH increased from 7.14 to 7.41, and Pao2 increased from 80 to 144 mm Hg on 100% Fio2.
Figure 2. An intravenous nitroglycerin solution bottle is connected via intravenous tubing and a 3-way stopcock to a vibrating mesh nebulizer to facilitate delivery of inhaled nitroglycerin.
Given this success, we attempted to create another solution of a higher nitroglycerin concentration by placing 6 tablets in 3 mL of 0.9% saline, but the tablets did not appear to fully dissolve. Additionally, we had no way to regulate the rate of aerosolization, that is, whatever was placed into the aerosolization chamber was delivered at a constant rate. Because our mixture needed redosing every 10–15 minutes and each mixture required 3 tablets, we potentially needed over 430 tablets for one 24-hour period. There was also significant labor associated with constantly dissolving and replenishing the nitroglycerin tablet solution. Fortunately, we were able to procure a bottle of intravenous nitroglycerin solution (concentration 100 µg/mL) approximately 1 hour after trialing the nebulized nitroglycerin. Intravenous tubing and a 3-way stopcock were used to continuously transfer the solution into the nebulizer chamber (Figure 2), with the rate of transfer adjusted using a roller clamp. Because the aerosolization chamber was always full and the aerosolization rate was constant, we were not able to increase the delivered dose of nebulized nitroglycerin. Approximately 1 hour after starting the continuously nebulized intravenous nitroglycerin solution, Paco2 remained stable at 63 mm Hg and arterial pH was 7.40 (Figure 1).
During the initial 4 hours of nebulized nitroglycerin, the epinephrine and vasopressin infusions that had been started 10 hours previously were successfully weaned off, with a resulting mean arterial pressure of 65 mm Hg. The urine output increased to over 1 mL/kg and lactate decreased from 5.5 to 1.7 mmol/L. Fio2 was decreased from 100% to 80% while the Spo2 remained approximately 90%. Despite these initial improvements, the patient’s multiorgan failure and C-ARDS continued to worsen and he eventually died 5 days later from hypoxemic respiratory failure.
DISCUSSION
Pulmonary vasodilators are important therapeutic interventions in ARDS, a condition partially characterized by increased right ventricular afterload and disruption of normal V/Q matching. Inhaled administration of pulmonary vasodilators are favored over intravenous administration in ARDS because they selectively act on the pulmonary circulation to improve gas exchange while limiting systemic side effects.4 By preferentially improving pulmonary blood flow in well-ventilated regions, inhaled vasodilators preserve or improve V/Q matching and reduce pulmonary vascular resistance, leading to improved cardiac output.5 iNO is more effective at improving oxygenation than other inhaled vasodilators such as prostacyclin and milrinone.6 Unfortunately, inhaled pulmonary vasodilators have failed to decrease mortality, as was true for our described patient.7 Despite this lack of mortality benefit, inhaled pulmonary vasodilators remain useful tools when caring for patients with ARDS, refractory hypoxemia, and depressed right ventricular function.
Inhaled nitroglycerin is quickly metabolized to nitric oxide, making it an effective pulmonary vasodilator that decreases both mean pulmonary artery pressure and pulmonary vascular resistance while improving V/Q matching.2,3,8 Reports of its use are mainly limited to cardiac surgery. Because nitroglycerin is readily available and does not require special equipment, it may be preferred in resource-limited environments. While inhaled pulmonary vasodilators demonstrate improved right heart function compared to intravenous forms, there are no trials comparing iNO to inhaled nitroglycerin.9,10 Wang et al11 compared inhaled nitroglycerin to inhaled milrinone and found similar decreases in pulmonary vascular resistance, although the effects of nitroglycerin were more transient.
Before the COVID-19 pandemic, the Food and Drug Administration (FDA) estimated that 56% of US community hospitals had drug shortages that changed or delayed patient care.12 This has worsened with the COVID-19 pandemic. Since April 2020, the FDA has declared shortages of critical drugs such as dexmedetomidine, propofol, midazolam, cisatracurium, fentanyl, hydromorphone, furosemide, and continuous renal replacement therapy fluid.13 Shortages of ventilators have prompted physicians, respiratory therapists, and ventilator production companies to collaborate on ways to safely ventilate multiple patients with a single device.14 Our case demonstrates yet another example of ingenuity bred by resource constraints. We used existing supplies to make an improvised form of inhaled nitroglycerin as a surrogate for nitric oxide in a New York hospital during the height of the COVID-19 pandemic when conventional pulmonary vasodilators were unavailable. The result of our efforts proved safe, efficacious, and inspiring to many health care workers in our intensive care unit.
DISCLOSURES
Name: Benjamin T. Daxon, MD.
Contribution: This author coordinated all efforts and wrote the abstract and case description.
Name: Erin Lark, NP.
Contribution: This author helped retrieve patient information and family contact information for consent.
Name: Luke J. Matzek, MD.
Contribution: This author helped research pertinent literature and wrote part of the discussion.
Name: Amanda R. Fields, MD.
Contribution: This author helped research pertinent literature and wrote part of the discussion.
Name: Kyle J. Haselton, MD.
Contribution: This author helped research pertinent literature and wrote part of the discussion.
This manuscript was handled by: BobbieJean Sweitzer, MD, FACP.
GLOSSARY
ARDS acute respiratory distress syndrome
C-ARDS COVID-19–associated acute respiratory distress syndrome
COVID-19 coronavirus disease 2019
ECMO extracorporeal membrane oxygenation
FDA Food and Drug Administration
Fio2 fraction of inspired oxygen
iNO inhaled nitric oxide
Spo2 pulse oximetry saturation
V/Q ventilation/perfusion
Funding: None.
The authors declare no conflicts of interest. | Intravenous (not otherwise specified) | DrugAdministrationRoute | CC BY-NC-ND | 33560642 | 18,997,573 | 2021-02-05 |
What was the administration route of drug 'NITROGLYCERIN'? | Nebulized Nitroglycerin for Coronavirus Disease 2019-Associated Acute Respiratory Distress Syndrome: A Case Report.
We present a case where nitroglycerin tablets dissolved in saline and intravenous nitroglycerin solution were nebulized as surrogates for inhaled nitric oxide (iNO) after our iNO supply was depleted during the coronavirus disease 2019 (COVID-19) surge in New York. We gave this treatment to a COVID-19 patient with severe acute respiratory distress syndrome (ARDS) and hypercarbia. In response, the patient had immediate and clinically meaningful improvement in multiple organ systems despite no other interventions or ventilator changes.
Coronavirus disease 2019 (COVID-19) can result in profound lung pathology with potentially large fractions of dead space ventilation. Given this and the growing evidence for microvascular occlusions of the pulmonary vessels, inhaled pulmonary vasodilators are suggested as a potential therapy.1 The surge of COVID-19 patients in New York in 2020 exhausted of our hospital’s supply of nitric oxide (ie, the preferred pulmonary vasodilator), and epoprostenol (ie, a synthetic analog of prostacyclin that is also a pulmonary vasodilator) was not available. Previous studies in humans have demonstrated that nebulized intravenous nitroglycerin solution is an effective pulmonary vasodilator.2,3 It is readily absorbed into the pulmonary vasculature and quickly converted into nitric oxide, resulting in improved ventilation/perfusion (V/Q) matching and reduced right heart afterload with minimal systemic side effects.
Given the scarcity of pulmonary vasodilators and the potential for benefit in a patient with acute pulmonary failure, we trialed a form of inhaled pulmonary vasodilator therapy that has not been reported previously. We dissolved nitroglycerin tablets in saline and nebulized the resulting solution as a surrogate for traditional pulmonary vasodilators. We administered this therapy to a patient with COVID-19 and multiorgan failure, that included COVID-19–associated acute respiratory distress syndrome (C-ARDS) with profound hypercarbia. Without any changes to the ventilator, there was an immediate and clinically meaningful improvement in the patient’s hypercarbia as well as in several other organ functions.
This case report reflects the potential role for pulmonary vasodilators in C-ARDS, the feasibility of inhaled nitroglycerin as a pulmonary vasodilator, and the need for ingenuity and creativity in the face of resource scarcity during a pandemic.
Written Health Insurance Portability and Accountability Act authorization and consent for this case report was obtained from the patient’s family. All personal health information identifiers have been removed.
CASE DESCRIPTION
A 58-year-old man with COVID-19 had been hospitalized for 22 days and intubated and mechanically ventilated for 18 days. For a majority of that time, he had severe C-ARDS and multiorgan failure. For more than 48 hours, the patient’s Paco2 was >91 mm Hg, with the highest value being 154 mm Hg. He also required 100% inspired oxygen to maintain a pulse oximetry saturation (Spo2) of 90%. Despite heavy sedation, he demonstrated significant ventilator dyssynchrony and was pharmacologically paralyzed for approximately two-thirds of these 48 hours. He received scheduled acetaminophen (1000 mg every 6 hours intravenously) and cold packs to decrease his core temperature (bladder temperature consistently kept <38°C) and lessen CO2 production. His ventilator settings were adjusted numerous times, eventually increasing to a ventilatory rate of 35 times/min with a tidal volume of 450 mL (resulting in an expired minute ventilation of approximately 16 L/min), but his Paco2 remained significantly elevated at 104 mm Hg with an arterial pH of 7.14 (Figure 1). As his CO2 became more difficult to manage, he needed increasing doses of norepinephrine to maintain a mean arterial pressure of 65 mm Hg, eventually requiring the addition of epinephrine and vasopressin infusions. His heart rate was 100–110 beats/min. Coinciding with increasing vasopressor needs, the patient’s urine output declined to <0.5 mL/kg/h for over 6 hours. Given his pathology, we thought a pulmonary vasodilator would benefit him, but the hospital’s supply of inhaled nitric oxide (iNO) was exhausted due to the surge of COVID-19 patients and it was unknown when additional supplies would arrive. Inhaled epoprostenol was also not available. The patient was not an extracorporeal membrane oxygenation (ECMO) candidate given his prolonged mechanical ventilation with high pressures and fraction of inspired oxygen (Fio2) and regional resource constraints on ECMO during the pandemic.
Figure 1. Serial arterial blood gases over the course of 14 h. Column 4 shows a hypercarbic and acidotic blood gas with lactate increased from 1.4 to 5.5 mmol/L approximately 4.5 h earlier. Column 3 shows a blood gas taken immediately after trialing nebulized nitroglycerin tablets diluted in 0.9% normal saline with a decreased Paco2 and improved Pao2. Column 2 shows a stable Paco2 reduction after transitioning to a nebulized intravenous nitroglycerin solution. And column 1 shows a persistently reduced Paco2 with lactate decreased from 5.5 to 1.7 mmol/L after starting nebulized nitroglycerin approximately 5 h earlier.
We decided to trial inhaled nitroglycerin. There was initial difficulty procuring intravenous nitroglycerin, so we dissolved three 0.3 mg nitroglycerine tablets (the form intended for sublingual use) with 3 mL of 0.9% normal saline. This mixture was placed into a vibrating mesh nebulizer and incorporated into the airway circuit (Figure 2). After approximately 10–15 minutes, the solution was exhausted, and an arterial blood gas showed that the Paco2 had decreased from 104 to 60 mm Hg—a 44 mm Hg decrease—despite no changes to the ventilator (Figure 1). Concurrently, arterial pH increased from 7.14 to 7.41, and Pao2 increased from 80 to 144 mm Hg on 100% Fio2.
Figure 2. An intravenous nitroglycerin solution bottle is connected via intravenous tubing and a 3-way stopcock to a vibrating mesh nebulizer to facilitate delivery of inhaled nitroglycerin.
Given this success, we attempted to create another solution of a higher nitroglycerin concentration by placing 6 tablets in 3 mL of 0.9% saline, but the tablets did not appear to fully dissolve. Additionally, we had no way to regulate the rate of aerosolization, that is, whatever was placed into the aerosolization chamber was delivered at a constant rate. Because our mixture needed redosing every 10–15 minutes and each mixture required 3 tablets, we potentially needed over 430 tablets for one 24-hour period. There was also significant labor associated with constantly dissolving and replenishing the nitroglycerin tablet solution. Fortunately, we were able to procure a bottle of intravenous nitroglycerin solution (concentration 100 µg/mL) approximately 1 hour after trialing the nebulized nitroglycerin. Intravenous tubing and a 3-way stopcock were used to continuously transfer the solution into the nebulizer chamber (Figure 2), with the rate of transfer adjusted using a roller clamp. Because the aerosolization chamber was always full and the aerosolization rate was constant, we were not able to increase the delivered dose of nebulized nitroglycerin. Approximately 1 hour after starting the continuously nebulized intravenous nitroglycerin solution, Paco2 remained stable at 63 mm Hg and arterial pH was 7.40 (Figure 1).
During the initial 4 hours of nebulized nitroglycerin, the epinephrine and vasopressin infusions that had been started 10 hours previously were successfully weaned off, with a resulting mean arterial pressure of 65 mm Hg. The urine output increased to over 1 mL/kg and lactate decreased from 5.5 to 1.7 mmol/L. Fio2 was decreased from 100% to 80% while the Spo2 remained approximately 90%. Despite these initial improvements, the patient’s multiorgan failure and C-ARDS continued to worsen and he eventually died 5 days later from hypoxemic respiratory failure.
DISCUSSION
Pulmonary vasodilators are important therapeutic interventions in ARDS, a condition partially characterized by increased right ventricular afterload and disruption of normal V/Q matching. Inhaled administration of pulmonary vasodilators are favored over intravenous administration in ARDS because they selectively act on the pulmonary circulation to improve gas exchange while limiting systemic side effects.4 By preferentially improving pulmonary blood flow in well-ventilated regions, inhaled vasodilators preserve or improve V/Q matching and reduce pulmonary vascular resistance, leading to improved cardiac output.5 iNO is more effective at improving oxygenation than other inhaled vasodilators such as prostacyclin and milrinone.6 Unfortunately, inhaled pulmonary vasodilators have failed to decrease mortality, as was true for our described patient.7 Despite this lack of mortality benefit, inhaled pulmonary vasodilators remain useful tools when caring for patients with ARDS, refractory hypoxemia, and depressed right ventricular function.
Inhaled nitroglycerin is quickly metabolized to nitric oxide, making it an effective pulmonary vasodilator that decreases both mean pulmonary artery pressure and pulmonary vascular resistance while improving V/Q matching.2,3,8 Reports of its use are mainly limited to cardiac surgery. Because nitroglycerin is readily available and does not require special equipment, it may be preferred in resource-limited environments. While inhaled pulmonary vasodilators demonstrate improved right heart function compared to intravenous forms, there are no trials comparing iNO to inhaled nitroglycerin.9,10 Wang et al11 compared inhaled nitroglycerin to inhaled milrinone and found similar decreases in pulmonary vascular resistance, although the effects of nitroglycerin were more transient.
Before the COVID-19 pandemic, the Food and Drug Administration (FDA) estimated that 56% of US community hospitals had drug shortages that changed or delayed patient care.12 This has worsened with the COVID-19 pandemic. Since April 2020, the FDA has declared shortages of critical drugs such as dexmedetomidine, propofol, midazolam, cisatracurium, fentanyl, hydromorphone, furosemide, and continuous renal replacement therapy fluid.13 Shortages of ventilators have prompted physicians, respiratory therapists, and ventilator production companies to collaborate on ways to safely ventilate multiple patients with a single device.14 Our case demonstrates yet another example of ingenuity bred by resource constraints. We used existing supplies to make an improvised form of inhaled nitroglycerin as a surrogate for nitric oxide in a New York hospital during the height of the COVID-19 pandemic when conventional pulmonary vasodilators were unavailable. The result of our efforts proved safe, efficacious, and inspiring to many health care workers in our intensive care unit.
DISCLOSURES
Name: Benjamin T. Daxon, MD.
Contribution: This author coordinated all efforts and wrote the abstract and case description.
Name: Erin Lark, NP.
Contribution: This author helped retrieve patient information and family contact information for consent.
Name: Luke J. Matzek, MD.
Contribution: This author helped research pertinent literature and wrote part of the discussion.
Name: Amanda R. Fields, MD.
Contribution: This author helped research pertinent literature and wrote part of the discussion.
Name: Kyle J. Haselton, MD.
Contribution: This author helped research pertinent literature and wrote part of the discussion.
This manuscript was handled by: BobbieJean Sweitzer, MD, FACP.
GLOSSARY
ARDS acute respiratory distress syndrome
C-ARDS COVID-19–associated acute respiratory distress syndrome
COVID-19 coronavirus disease 2019
ECMO extracorporeal membrane oxygenation
FDA Food and Drug Administration
Fio2 fraction of inspired oxygen
iNO inhaled nitric oxide
Spo2 pulse oximetry saturation
V/Q ventilation/perfusion
Funding: None.
The authors declare no conflicts of interest. | Respiratory (inhalation) | DrugAdministrationRoute | CC BY-NC-ND | 33560642 | 18,997,573 | 2021-02-05 |
What was the outcome of reaction 'Drug ineffective for unapproved indication'? | Nebulized Nitroglycerin for Coronavirus Disease 2019-Associated Acute Respiratory Distress Syndrome: A Case Report.
We present a case where nitroglycerin tablets dissolved in saline and intravenous nitroglycerin solution were nebulized as surrogates for inhaled nitric oxide (iNO) after our iNO supply was depleted during the coronavirus disease 2019 (COVID-19) surge in New York. We gave this treatment to a COVID-19 patient with severe acute respiratory distress syndrome (ARDS) and hypercarbia. In response, the patient had immediate and clinically meaningful improvement in multiple organ systems despite no other interventions or ventilator changes.
Coronavirus disease 2019 (COVID-19) can result in profound lung pathology with potentially large fractions of dead space ventilation. Given this and the growing evidence for microvascular occlusions of the pulmonary vessels, inhaled pulmonary vasodilators are suggested as a potential therapy.1 The surge of COVID-19 patients in New York in 2020 exhausted of our hospital’s supply of nitric oxide (ie, the preferred pulmonary vasodilator), and epoprostenol (ie, a synthetic analog of prostacyclin that is also a pulmonary vasodilator) was not available. Previous studies in humans have demonstrated that nebulized intravenous nitroglycerin solution is an effective pulmonary vasodilator.2,3 It is readily absorbed into the pulmonary vasculature and quickly converted into nitric oxide, resulting in improved ventilation/perfusion (V/Q) matching and reduced right heart afterload with minimal systemic side effects.
Given the scarcity of pulmonary vasodilators and the potential for benefit in a patient with acute pulmonary failure, we trialed a form of inhaled pulmonary vasodilator therapy that has not been reported previously. We dissolved nitroglycerin tablets in saline and nebulized the resulting solution as a surrogate for traditional pulmonary vasodilators. We administered this therapy to a patient with COVID-19 and multiorgan failure, that included COVID-19–associated acute respiratory distress syndrome (C-ARDS) with profound hypercarbia. Without any changes to the ventilator, there was an immediate and clinically meaningful improvement in the patient’s hypercarbia as well as in several other organ functions.
This case report reflects the potential role for pulmonary vasodilators in C-ARDS, the feasibility of inhaled nitroglycerin as a pulmonary vasodilator, and the need for ingenuity and creativity in the face of resource scarcity during a pandemic.
Written Health Insurance Portability and Accountability Act authorization and consent for this case report was obtained from the patient’s family. All personal health information identifiers have been removed.
CASE DESCRIPTION
A 58-year-old man with COVID-19 had been hospitalized for 22 days and intubated and mechanically ventilated for 18 days. For a majority of that time, he had severe C-ARDS and multiorgan failure. For more than 48 hours, the patient’s Paco2 was >91 mm Hg, with the highest value being 154 mm Hg. He also required 100% inspired oxygen to maintain a pulse oximetry saturation (Spo2) of 90%. Despite heavy sedation, he demonstrated significant ventilator dyssynchrony and was pharmacologically paralyzed for approximately two-thirds of these 48 hours. He received scheduled acetaminophen (1000 mg every 6 hours intravenously) and cold packs to decrease his core temperature (bladder temperature consistently kept <38°C) and lessen CO2 production. His ventilator settings were adjusted numerous times, eventually increasing to a ventilatory rate of 35 times/min with a tidal volume of 450 mL (resulting in an expired minute ventilation of approximately 16 L/min), but his Paco2 remained significantly elevated at 104 mm Hg with an arterial pH of 7.14 (Figure 1). As his CO2 became more difficult to manage, he needed increasing doses of norepinephrine to maintain a mean arterial pressure of 65 mm Hg, eventually requiring the addition of epinephrine and vasopressin infusions. His heart rate was 100–110 beats/min. Coinciding with increasing vasopressor needs, the patient’s urine output declined to <0.5 mL/kg/h for over 6 hours. Given his pathology, we thought a pulmonary vasodilator would benefit him, but the hospital’s supply of inhaled nitric oxide (iNO) was exhausted due to the surge of COVID-19 patients and it was unknown when additional supplies would arrive. Inhaled epoprostenol was also not available. The patient was not an extracorporeal membrane oxygenation (ECMO) candidate given his prolonged mechanical ventilation with high pressures and fraction of inspired oxygen (Fio2) and regional resource constraints on ECMO during the pandemic.
Figure 1. Serial arterial blood gases over the course of 14 h. Column 4 shows a hypercarbic and acidotic blood gas with lactate increased from 1.4 to 5.5 mmol/L approximately 4.5 h earlier. Column 3 shows a blood gas taken immediately after trialing nebulized nitroglycerin tablets diluted in 0.9% normal saline with a decreased Paco2 and improved Pao2. Column 2 shows a stable Paco2 reduction after transitioning to a nebulized intravenous nitroglycerin solution. And column 1 shows a persistently reduced Paco2 with lactate decreased from 5.5 to 1.7 mmol/L after starting nebulized nitroglycerin approximately 5 h earlier.
We decided to trial inhaled nitroglycerin. There was initial difficulty procuring intravenous nitroglycerin, so we dissolved three 0.3 mg nitroglycerine tablets (the form intended for sublingual use) with 3 mL of 0.9% normal saline. This mixture was placed into a vibrating mesh nebulizer and incorporated into the airway circuit (Figure 2). After approximately 10–15 minutes, the solution was exhausted, and an arterial blood gas showed that the Paco2 had decreased from 104 to 60 mm Hg—a 44 mm Hg decrease—despite no changes to the ventilator (Figure 1). Concurrently, arterial pH increased from 7.14 to 7.41, and Pao2 increased from 80 to 144 mm Hg on 100% Fio2.
Figure 2. An intravenous nitroglycerin solution bottle is connected via intravenous tubing and a 3-way stopcock to a vibrating mesh nebulizer to facilitate delivery of inhaled nitroglycerin.
Given this success, we attempted to create another solution of a higher nitroglycerin concentration by placing 6 tablets in 3 mL of 0.9% saline, but the tablets did not appear to fully dissolve. Additionally, we had no way to regulate the rate of aerosolization, that is, whatever was placed into the aerosolization chamber was delivered at a constant rate. Because our mixture needed redosing every 10–15 minutes and each mixture required 3 tablets, we potentially needed over 430 tablets for one 24-hour period. There was also significant labor associated with constantly dissolving and replenishing the nitroglycerin tablet solution. Fortunately, we were able to procure a bottle of intravenous nitroglycerin solution (concentration 100 µg/mL) approximately 1 hour after trialing the nebulized nitroglycerin. Intravenous tubing and a 3-way stopcock were used to continuously transfer the solution into the nebulizer chamber (Figure 2), with the rate of transfer adjusted using a roller clamp. Because the aerosolization chamber was always full and the aerosolization rate was constant, we were not able to increase the delivered dose of nebulized nitroglycerin. Approximately 1 hour after starting the continuously nebulized intravenous nitroglycerin solution, Paco2 remained stable at 63 mm Hg and arterial pH was 7.40 (Figure 1).
During the initial 4 hours of nebulized nitroglycerin, the epinephrine and vasopressin infusions that had been started 10 hours previously were successfully weaned off, with a resulting mean arterial pressure of 65 mm Hg. The urine output increased to over 1 mL/kg and lactate decreased from 5.5 to 1.7 mmol/L. Fio2 was decreased from 100% to 80% while the Spo2 remained approximately 90%. Despite these initial improvements, the patient’s multiorgan failure and C-ARDS continued to worsen and he eventually died 5 days later from hypoxemic respiratory failure.
DISCUSSION
Pulmonary vasodilators are important therapeutic interventions in ARDS, a condition partially characterized by increased right ventricular afterload and disruption of normal V/Q matching. Inhaled administration of pulmonary vasodilators are favored over intravenous administration in ARDS because they selectively act on the pulmonary circulation to improve gas exchange while limiting systemic side effects.4 By preferentially improving pulmonary blood flow in well-ventilated regions, inhaled vasodilators preserve or improve V/Q matching and reduce pulmonary vascular resistance, leading to improved cardiac output.5 iNO is more effective at improving oxygenation than other inhaled vasodilators such as prostacyclin and milrinone.6 Unfortunately, inhaled pulmonary vasodilators have failed to decrease mortality, as was true for our described patient.7 Despite this lack of mortality benefit, inhaled pulmonary vasodilators remain useful tools when caring for patients with ARDS, refractory hypoxemia, and depressed right ventricular function.
Inhaled nitroglycerin is quickly metabolized to nitric oxide, making it an effective pulmonary vasodilator that decreases both mean pulmonary artery pressure and pulmonary vascular resistance while improving V/Q matching.2,3,8 Reports of its use are mainly limited to cardiac surgery. Because nitroglycerin is readily available and does not require special equipment, it may be preferred in resource-limited environments. While inhaled pulmonary vasodilators demonstrate improved right heart function compared to intravenous forms, there are no trials comparing iNO to inhaled nitroglycerin.9,10 Wang et al11 compared inhaled nitroglycerin to inhaled milrinone and found similar decreases in pulmonary vascular resistance, although the effects of nitroglycerin were more transient.
Before the COVID-19 pandemic, the Food and Drug Administration (FDA) estimated that 56% of US community hospitals had drug shortages that changed or delayed patient care.12 This has worsened with the COVID-19 pandemic. Since April 2020, the FDA has declared shortages of critical drugs such as dexmedetomidine, propofol, midazolam, cisatracurium, fentanyl, hydromorphone, furosemide, and continuous renal replacement therapy fluid.13 Shortages of ventilators have prompted physicians, respiratory therapists, and ventilator production companies to collaborate on ways to safely ventilate multiple patients with a single device.14 Our case demonstrates yet another example of ingenuity bred by resource constraints. We used existing supplies to make an improvised form of inhaled nitroglycerin as a surrogate for nitric oxide in a New York hospital during the height of the COVID-19 pandemic when conventional pulmonary vasodilators were unavailable. The result of our efforts proved safe, efficacious, and inspiring to many health care workers in our intensive care unit.
DISCLOSURES
Name: Benjamin T. Daxon, MD.
Contribution: This author coordinated all efforts and wrote the abstract and case description.
Name: Erin Lark, NP.
Contribution: This author helped retrieve patient information and family contact information for consent.
Name: Luke J. Matzek, MD.
Contribution: This author helped research pertinent literature and wrote part of the discussion.
Name: Amanda R. Fields, MD.
Contribution: This author helped research pertinent literature and wrote part of the discussion.
Name: Kyle J. Haselton, MD.
Contribution: This author helped research pertinent literature and wrote part of the discussion.
This manuscript was handled by: BobbieJean Sweitzer, MD, FACP.
GLOSSARY
ARDS acute respiratory distress syndrome
C-ARDS COVID-19–associated acute respiratory distress syndrome
COVID-19 coronavirus disease 2019
ECMO extracorporeal membrane oxygenation
FDA Food and Drug Administration
Fio2 fraction of inspired oxygen
iNO inhaled nitric oxide
Spo2 pulse oximetry saturation
V/Q ventilation/perfusion
Funding: None.
The authors declare no conflicts of interest. | Fatal | ReactionOutcome | CC BY-NC-ND | 33560642 | 18,997,573 | 2021-02-05 |
What was the outcome of reaction 'Multiple organ dysfunction syndrome'? | Nebulized Nitroglycerin for Coronavirus Disease 2019-Associated Acute Respiratory Distress Syndrome: A Case Report.
We present a case where nitroglycerin tablets dissolved in saline and intravenous nitroglycerin solution were nebulized as surrogates for inhaled nitric oxide (iNO) after our iNO supply was depleted during the coronavirus disease 2019 (COVID-19) surge in New York. We gave this treatment to a COVID-19 patient with severe acute respiratory distress syndrome (ARDS) and hypercarbia. In response, the patient had immediate and clinically meaningful improvement in multiple organ systems despite no other interventions or ventilator changes.
Coronavirus disease 2019 (COVID-19) can result in profound lung pathology with potentially large fractions of dead space ventilation. Given this and the growing evidence for microvascular occlusions of the pulmonary vessels, inhaled pulmonary vasodilators are suggested as a potential therapy.1 The surge of COVID-19 patients in New York in 2020 exhausted of our hospital’s supply of nitric oxide (ie, the preferred pulmonary vasodilator), and epoprostenol (ie, a synthetic analog of prostacyclin that is also a pulmonary vasodilator) was not available. Previous studies in humans have demonstrated that nebulized intravenous nitroglycerin solution is an effective pulmonary vasodilator.2,3 It is readily absorbed into the pulmonary vasculature and quickly converted into nitric oxide, resulting in improved ventilation/perfusion (V/Q) matching and reduced right heart afterload with minimal systemic side effects.
Given the scarcity of pulmonary vasodilators and the potential for benefit in a patient with acute pulmonary failure, we trialed a form of inhaled pulmonary vasodilator therapy that has not been reported previously. We dissolved nitroglycerin tablets in saline and nebulized the resulting solution as a surrogate for traditional pulmonary vasodilators. We administered this therapy to a patient with COVID-19 and multiorgan failure, that included COVID-19–associated acute respiratory distress syndrome (C-ARDS) with profound hypercarbia. Without any changes to the ventilator, there was an immediate and clinically meaningful improvement in the patient’s hypercarbia as well as in several other organ functions.
This case report reflects the potential role for pulmonary vasodilators in C-ARDS, the feasibility of inhaled nitroglycerin as a pulmonary vasodilator, and the need for ingenuity and creativity in the face of resource scarcity during a pandemic.
Written Health Insurance Portability and Accountability Act authorization and consent for this case report was obtained from the patient’s family. All personal health information identifiers have been removed.
CASE DESCRIPTION
A 58-year-old man with COVID-19 had been hospitalized for 22 days and intubated and mechanically ventilated for 18 days. For a majority of that time, he had severe C-ARDS and multiorgan failure. For more than 48 hours, the patient’s Paco2 was >91 mm Hg, with the highest value being 154 mm Hg. He also required 100% inspired oxygen to maintain a pulse oximetry saturation (Spo2) of 90%. Despite heavy sedation, he demonstrated significant ventilator dyssynchrony and was pharmacologically paralyzed for approximately two-thirds of these 48 hours. He received scheduled acetaminophen (1000 mg every 6 hours intravenously) and cold packs to decrease his core temperature (bladder temperature consistently kept <38°C) and lessen CO2 production. His ventilator settings were adjusted numerous times, eventually increasing to a ventilatory rate of 35 times/min with a tidal volume of 450 mL (resulting in an expired minute ventilation of approximately 16 L/min), but his Paco2 remained significantly elevated at 104 mm Hg with an arterial pH of 7.14 (Figure 1). As his CO2 became more difficult to manage, he needed increasing doses of norepinephrine to maintain a mean arterial pressure of 65 mm Hg, eventually requiring the addition of epinephrine and vasopressin infusions. His heart rate was 100–110 beats/min. Coinciding with increasing vasopressor needs, the patient’s urine output declined to <0.5 mL/kg/h for over 6 hours. Given his pathology, we thought a pulmonary vasodilator would benefit him, but the hospital’s supply of inhaled nitric oxide (iNO) was exhausted due to the surge of COVID-19 patients and it was unknown when additional supplies would arrive. Inhaled epoprostenol was also not available. The patient was not an extracorporeal membrane oxygenation (ECMO) candidate given his prolonged mechanical ventilation with high pressures and fraction of inspired oxygen (Fio2) and regional resource constraints on ECMO during the pandemic.
Figure 1. Serial arterial blood gases over the course of 14 h. Column 4 shows a hypercarbic and acidotic blood gas with lactate increased from 1.4 to 5.5 mmol/L approximately 4.5 h earlier. Column 3 shows a blood gas taken immediately after trialing nebulized nitroglycerin tablets diluted in 0.9% normal saline with a decreased Paco2 and improved Pao2. Column 2 shows a stable Paco2 reduction after transitioning to a nebulized intravenous nitroglycerin solution. And column 1 shows a persistently reduced Paco2 with lactate decreased from 5.5 to 1.7 mmol/L after starting nebulized nitroglycerin approximately 5 h earlier.
We decided to trial inhaled nitroglycerin. There was initial difficulty procuring intravenous nitroglycerin, so we dissolved three 0.3 mg nitroglycerine tablets (the form intended for sublingual use) with 3 mL of 0.9% normal saline. This mixture was placed into a vibrating mesh nebulizer and incorporated into the airway circuit (Figure 2). After approximately 10–15 minutes, the solution was exhausted, and an arterial blood gas showed that the Paco2 had decreased from 104 to 60 mm Hg—a 44 mm Hg decrease—despite no changes to the ventilator (Figure 1). Concurrently, arterial pH increased from 7.14 to 7.41, and Pao2 increased from 80 to 144 mm Hg on 100% Fio2.
Figure 2. An intravenous nitroglycerin solution bottle is connected via intravenous tubing and a 3-way stopcock to a vibrating mesh nebulizer to facilitate delivery of inhaled nitroglycerin.
Given this success, we attempted to create another solution of a higher nitroglycerin concentration by placing 6 tablets in 3 mL of 0.9% saline, but the tablets did not appear to fully dissolve. Additionally, we had no way to regulate the rate of aerosolization, that is, whatever was placed into the aerosolization chamber was delivered at a constant rate. Because our mixture needed redosing every 10–15 minutes and each mixture required 3 tablets, we potentially needed over 430 tablets for one 24-hour period. There was also significant labor associated with constantly dissolving and replenishing the nitroglycerin tablet solution. Fortunately, we were able to procure a bottle of intravenous nitroglycerin solution (concentration 100 µg/mL) approximately 1 hour after trialing the nebulized nitroglycerin. Intravenous tubing and a 3-way stopcock were used to continuously transfer the solution into the nebulizer chamber (Figure 2), with the rate of transfer adjusted using a roller clamp. Because the aerosolization chamber was always full and the aerosolization rate was constant, we were not able to increase the delivered dose of nebulized nitroglycerin. Approximately 1 hour after starting the continuously nebulized intravenous nitroglycerin solution, Paco2 remained stable at 63 mm Hg and arterial pH was 7.40 (Figure 1).
During the initial 4 hours of nebulized nitroglycerin, the epinephrine and vasopressin infusions that had been started 10 hours previously were successfully weaned off, with a resulting mean arterial pressure of 65 mm Hg. The urine output increased to over 1 mL/kg and lactate decreased from 5.5 to 1.7 mmol/L. Fio2 was decreased from 100% to 80% while the Spo2 remained approximately 90%. Despite these initial improvements, the patient’s multiorgan failure and C-ARDS continued to worsen and he eventually died 5 days later from hypoxemic respiratory failure.
DISCUSSION
Pulmonary vasodilators are important therapeutic interventions in ARDS, a condition partially characterized by increased right ventricular afterload and disruption of normal V/Q matching. Inhaled administration of pulmonary vasodilators are favored over intravenous administration in ARDS because they selectively act on the pulmonary circulation to improve gas exchange while limiting systemic side effects.4 By preferentially improving pulmonary blood flow in well-ventilated regions, inhaled vasodilators preserve or improve V/Q matching and reduce pulmonary vascular resistance, leading to improved cardiac output.5 iNO is more effective at improving oxygenation than other inhaled vasodilators such as prostacyclin and milrinone.6 Unfortunately, inhaled pulmonary vasodilators have failed to decrease mortality, as was true for our described patient.7 Despite this lack of mortality benefit, inhaled pulmonary vasodilators remain useful tools when caring for patients with ARDS, refractory hypoxemia, and depressed right ventricular function.
Inhaled nitroglycerin is quickly metabolized to nitric oxide, making it an effective pulmonary vasodilator that decreases both mean pulmonary artery pressure and pulmonary vascular resistance while improving V/Q matching.2,3,8 Reports of its use are mainly limited to cardiac surgery. Because nitroglycerin is readily available and does not require special equipment, it may be preferred in resource-limited environments. While inhaled pulmonary vasodilators demonstrate improved right heart function compared to intravenous forms, there are no trials comparing iNO to inhaled nitroglycerin.9,10 Wang et al11 compared inhaled nitroglycerin to inhaled milrinone and found similar decreases in pulmonary vascular resistance, although the effects of nitroglycerin were more transient.
Before the COVID-19 pandemic, the Food and Drug Administration (FDA) estimated that 56% of US community hospitals had drug shortages that changed or delayed patient care.12 This has worsened with the COVID-19 pandemic. Since April 2020, the FDA has declared shortages of critical drugs such as dexmedetomidine, propofol, midazolam, cisatracurium, fentanyl, hydromorphone, furosemide, and continuous renal replacement therapy fluid.13 Shortages of ventilators have prompted physicians, respiratory therapists, and ventilator production companies to collaborate on ways to safely ventilate multiple patients with a single device.14 Our case demonstrates yet another example of ingenuity bred by resource constraints. We used existing supplies to make an improvised form of inhaled nitroglycerin as a surrogate for nitric oxide in a New York hospital during the height of the COVID-19 pandemic when conventional pulmonary vasodilators were unavailable. The result of our efforts proved safe, efficacious, and inspiring to many health care workers in our intensive care unit.
DISCLOSURES
Name: Benjamin T. Daxon, MD.
Contribution: This author coordinated all efforts and wrote the abstract and case description.
Name: Erin Lark, NP.
Contribution: This author helped retrieve patient information and family contact information for consent.
Name: Luke J. Matzek, MD.
Contribution: This author helped research pertinent literature and wrote part of the discussion.
Name: Amanda R. Fields, MD.
Contribution: This author helped research pertinent literature and wrote part of the discussion.
Name: Kyle J. Haselton, MD.
Contribution: This author helped research pertinent literature and wrote part of the discussion.
This manuscript was handled by: BobbieJean Sweitzer, MD, FACP.
GLOSSARY
ARDS acute respiratory distress syndrome
C-ARDS COVID-19–associated acute respiratory distress syndrome
COVID-19 coronavirus disease 2019
ECMO extracorporeal membrane oxygenation
FDA Food and Drug Administration
Fio2 fraction of inspired oxygen
iNO inhaled nitric oxide
Spo2 pulse oximetry saturation
V/Q ventilation/perfusion
Funding: None.
The authors declare no conflicts of interest. | Fatal | ReactionOutcome | CC BY-NC-ND | 33560642 | 18,997,573 | 2021-02-05 |
What was the outcome of reaction 'Respiratory failure'? | Nebulized Nitroglycerin for Coronavirus Disease 2019-Associated Acute Respiratory Distress Syndrome: A Case Report.
We present a case where nitroglycerin tablets dissolved in saline and intravenous nitroglycerin solution were nebulized as surrogates for inhaled nitric oxide (iNO) after our iNO supply was depleted during the coronavirus disease 2019 (COVID-19) surge in New York. We gave this treatment to a COVID-19 patient with severe acute respiratory distress syndrome (ARDS) and hypercarbia. In response, the patient had immediate and clinically meaningful improvement in multiple organ systems despite no other interventions or ventilator changes.
Coronavirus disease 2019 (COVID-19) can result in profound lung pathology with potentially large fractions of dead space ventilation. Given this and the growing evidence for microvascular occlusions of the pulmonary vessels, inhaled pulmonary vasodilators are suggested as a potential therapy.1 The surge of COVID-19 patients in New York in 2020 exhausted of our hospital’s supply of nitric oxide (ie, the preferred pulmonary vasodilator), and epoprostenol (ie, a synthetic analog of prostacyclin that is also a pulmonary vasodilator) was not available. Previous studies in humans have demonstrated that nebulized intravenous nitroglycerin solution is an effective pulmonary vasodilator.2,3 It is readily absorbed into the pulmonary vasculature and quickly converted into nitric oxide, resulting in improved ventilation/perfusion (V/Q) matching and reduced right heart afterload with minimal systemic side effects.
Given the scarcity of pulmonary vasodilators and the potential for benefit in a patient with acute pulmonary failure, we trialed a form of inhaled pulmonary vasodilator therapy that has not been reported previously. We dissolved nitroglycerin tablets in saline and nebulized the resulting solution as a surrogate for traditional pulmonary vasodilators. We administered this therapy to a patient with COVID-19 and multiorgan failure, that included COVID-19–associated acute respiratory distress syndrome (C-ARDS) with profound hypercarbia. Without any changes to the ventilator, there was an immediate and clinically meaningful improvement in the patient’s hypercarbia as well as in several other organ functions.
This case report reflects the potential role for pulmonary vasodilators in C-ARDS, the feasibility of inhaled nitroglycerin as a pulmonary vasodilator, and the need for ingenuity and creativity in the face of resource scarcity during a pandemic.
Written Health Insurance Portability and Accountability Act authorization and consent for this case report was obtained from the patient’s family. All personal health information identifiers have been removed.
CASE DESCRIPTION
A 58-year-old man with COVID-19 had been hospitalized for 22 days and intubated and mechanically ventilated for 18 days. For a majority of that time, he had severe C-ARDS and multiorgan failure. For more than 48 hours, the patient’s Paco2 was >91 mm Hg, with the highest value being 154 mm Hg. He also required 100% inspired oxygen to maintain a pulse oximetry saturation (Spo2) of 90%. Despite heavy sedation, he demonstrated significant ventilator dyssynchrony and was pharmacologically paralyzed for approximately two-thirds of these 48 hours. He received scheduled acetaminophen (1000 mg every 6 hours intravenously) and cold packs to decrease his core temperature (bladder temperature consistently kept <38°C) and lessen CO2 production. His ventilator settings were adjusted numerous times, eventually increasing to a ventilatory rate of 35 times/min with a tidal volume of 450 mL (resulting in an expired minute ventilation of approximately 16 L/min), but his Paco2 remained significantly elevated at 104 mm Hg with an arterial pH of 7.14 (Figure 1). As his CO2 became more difficult to manage, he needed increasing doses of norepinephrine to maintain a mean arterial pressure of 65 mm Hg, eventually requiring the addition of epinephrine and vasopressin infusions. His heart rate was 100–110 beats/min. Coinciding with increasing vasopressor needs, the patient’s urine output declined to <0.5 mL/kg/h for over 6 hours. Given his pathology, we thought a pulmonary vasodilator would benefit him, but the hospital’s supply of inhaled nitric oxide (iNO) was exhausted due to the surge of COVID-19 patients and it was unknown when additional supplies would arrive. Inhaled epoprostenol was also not available. The patient was not an extracorporeal membrane oxygenation (ECMO) candidate given his prolonged mechanical ventilation with high pressures and fraction of inspired oxygen (Fio2) and regional resource constraints on ECMO during the pandemic.
Figure 1. Serial arterial blood gases over the course of 14 h. Column 4 shows a hypercarbic and acidotic blood gas with lactate increased from 1.4 to 5.5 mmol/L approximately 4.5 h earlier. Column 3 shows a blood gas taken immediately after trialing nebulized nitroglycerin tablets diluted in 0.9% normal saline with a decreased Paco2 and improved Pao2. Column 2 shows a stable Paco2 reduction after transitioning to a nebulized intravenous nitroglycerin solution. And column 1 shows a persistently reduced Paco2 with lactate decreased from 5.5 to 1.7 mmol/L after starting nebulized nitroglycerin approximately 5 h earlier.
We decided to trial inhaled nitroglycerin. There was initial difficulty procuring intravenous nitroglycerin, so we dissolved three 0.3 mg nitroglycerine tablets (the form intended for sublingual use) with 3 mL of 0.9% normal saline. This mixture was placed into a vibrating mesh nebulizer and incorporated into the airway circuit (Figure 2). After approximately 10–15 minutes, the solution was exhausted, and an arterial blood gas showed that the Paco2 had decreased from 104 to 60 mm Hg—a 44 mm Hg decrease—despite no changes to the ventilator (Figure 1). Concurrently, arterial pH increased from 7.14 to 7.41, and Pao2 increased from 80 to 144 mm Hg on 100% Fio2.
Figure 2. An intravenous nitroglycerin solution bottle is connected via intravenous tubing and a 3-way stopcock to a vibrating mesh nebulizer to facilitate delivery of inhaled nitroglycerin.
Given this success, we attempted to create another solution of a higher nitroglycerin concentration by placing 6 tablets in 3 mL of 0.9% saline, but the tablets did not appear to fully dissolve. Additionally, we had no way to regulate the rate of aerosolization, that is, whatever was placed into the aerosolization chamber was delivered at a constant rate. Because our mixture needed redosing every 10–15 minutes and each mixture required 3 tablets, we potentially needed over 430 tablets for one 24-hour period. There was also significant labor associated with constantly dissolving and replenishing the nitroglycerin tablet solution. Fortunately, we were able to procure a bottle of intravenous nitroglycerin solution (concentration 100 µg/mL) approximately 1 hour after trialing the nebulized nitroglycerin. Intravenous tubing and a 3-way stopcock were used to continuously transfer the solution into the nebulizer chamber (Figure 2), with the rate of transfer adjusted using a roller clamp. Because the aerosolization chamber was always full and the aerosolization rate was constant, we were not able to increase the delivered dose of nebulized nitroglycerin. Approximately 1 hour after starting the continuously nebulized intravenous nitroglycerin solution, Paco2 remained stable at 63 mm Hg and arterial pH was 7.40 (Figure 1).
During the initial 4 hours of nebulized nitroglycerin, the epinephrine and vasopressin infusions that had been started 10 hours previously were successfully weaned off, with a resulting mean arterial pressure of 65 mm Hg. The urine output increased to over 1 mL/kg and lactate decreased from 5.5 to 1.7 mmol/L. Fio2 was decreased from 100% to 80% while the Spo2 remained approximately 90%. Despite these initial improvements, the patient’s multiorgan failure and C-ARDS continued to worsen and he eventually died 5 days later from hypoxemic respiratory failure.
DISCUSSION
Pulmonary vasodilators are important therapeutic interventions in ARDS, a condition partially characterized by increased right ventricular afterload and disruption of normal V/Q matching. Inhaled administration of pulmonary vasodilators are favored over intravenous administration in ARDS because they selectively act on the pulmonary circulation to improve gas exchange while limiting systemic side effects.4 By preferentially improving pulmonary blood flow in well-ventilated regions, inhaled vasodilators preserve or improve V/Q matching and reduce pulmonary vascular resistance, leading to improved cardiac output.5 iNO is more effective at improving oxygenation than other inhaled vasodilators such as prostacyclin and milrinone.6 Unfortunately, inhaled pulmonary vasodilators have failed to decrease mortality, as was true for our described patient.7 Despite this lack of mortality benefit, inhaled pulmonary vasodilators remain useful tools when caring for patients with ARDS, refractory hypoxemia, and depressed right ventricular function.
Inhaled nitroglycerin is quickly metabolized to nitric oxide, making it an effective pulmonary vasodilator that decreases both mean pulmonary artery pressure and pulmonary vascular resistance while improving V/Q matching.2,3,8 Reports of its use are mainly limited to cardiac surgery. Because nitroglycerin is readily available and does not require special equipment, it may be preferred in resource-limited environments. While inhaled pulmonary vasodilators demonstrate improved right heart function compared to intravenous forms, there are no trials comparing iNO to inhaled nitroglycerin.9,10 Wang et al11 compared inhaled nitroglycerin to inhaled milrinone and found similar decreases in pulmonary vascular resistance, although the effects of nitroglycerin were more transient.
Before the COVID-19 pandemic, the Food and Drug Administration (FDA) estimated that 56% of US community hospitals had drug shortages that changed or delayed patient care.12 This has worsened with the COVID-19 pandemic. Since April 2020, the FDA has declared shortages of critical drugs such as dexmedetomidine, propofol, midazolam, cisatracurium, fentanyl, hydromorphone, furosemide, and continuous renal replacement therapy fluid.13 Shortages of ventilators have prompted physicians, respiratory therapists, and ventilator production companies to collaborate on ways to safely ventilate multiple patients with a single device.14 Our case demonstrates yet another example of ingenuity bred by resource constraints. We used existing supplies to make an improvised form of inhaled nitroglycerin as a surrogate for nitric oxide in a New York hospital during the height of the COVID-19 pandemic when conventional pulmonary vasodilators were unavailable. The result of our efforts proved safe, efficacious, and inspiring to many health care workers in our intensive care unit.
DISCLOSURES
Name: Benjamin T. Daxon, MD.
Contribution: This author coordinated all efforts and wrote the abstract and case description.
Name: Erin Lark, NP.
Contribution: This author helped retrieve patient information and family contact information for consent.
Name: Luke J. Matzek, MD.
Contribution: This author helped research pertinent literature and wrote part of the discussion.
Name: Amanda R. Fields, MD.
Contribution: This author helped research pertinent literature and wrote part of the discussion.
Name: Kyle J. Haselton, MD.
Contribution: This author helped research pertinent literature and wrote part of the discussion.
This manuscript was handled by: BobbieJean Sweitzer, MD, FACP.
GLOSSARY
ARDS acute respiratory distress syndrome
C-ARDS COVID-19–associated acute respiratory distress syndrome
COVID-19 coronavirus disease 2019
ECMO extracorporeal membrane oxygenation
FDA Food and Drug Administration
Fio2 fraction of inspired oxygen
iNO inhaled nitric oxide
Spo2 pulse oximetry saturation
V/Q ventilation/perfusion
Funding: None.
The authors declare no conflicts of interest. | Fatal | ReactionOutcome | CC BY-NC-ND | 33560642 | 18,997,573 | 2021-02-05 |
Give an alphabetized list of all active substances of drugs taken by the patient who experienced 'Hypokalaemia'. | Unmasking Long QT Syndrome in the Emergency Department: A Case Report.
BACKGROUND
Long QT syndrome (LQTS) is an uncommon disorder that can lead to potentially life-threatening dysrhythmias. LQTS can be genetic, acquired, or both.
METHODS
A 44-year-old female with well-controlled hypertension and asthma presented with chest tightness. An initial electrocardiogram yielded a normal corrected QT interval of 423 milliseconds (ms) (normal <480 ms in females). Albuterol was administered and induced agitation, tremulousness, and tachycardia. Follow-up electrocardiograms demonstrated extreme prolongation of the corrected QT interval to 633 ms and morphology change of the T wave. Lab values were later notable for hypokalemia and hypomagnesemia, attributable to a recently started thiazide diuretic. The patient was ultimately diagnosed with congenital LQTS after initial unmasking by albuterol in the emergency department.
CONCLUSIONS
LQTS can be unmasked or exacerbated by electrolyte abnormalities and QT prolonging medications.
INTRODUCTION
Long QT syndrome (LQTS) is a rare condition in which cardiac myocytes are predisposed to repolarization phase abnormalities, which can lead to life-threatening torsades de pointes.1 It is one of the leading causes of unexplained sudden cardiac death.1 Long QT syndrome can be congenital, acquired, or both.
The prevalence of congenital LQTS is estimated at 1 in 2000 births.2 This does not account for patients with electrocardiographically silent LQTS and those who are genotype positive but phenotype negative.2 Thus, the true prevalence of the LQTS gene is likely higher. Patients may have electrocardiographically silent LQTS, only to be unmasked by certain QT prolonging medications, electrolyte abnormalities, or sympathetic stimulation.3 Type 1 LQTS, one of the most common forms of congenital LQTS, is particularly susceptible to sympathetic stimulation.3
Several classes of medications have been demonstrated to lengthen the repolarization phase of cardiac myocytes, thus lengthening the QT interval. Medications classically known to prolong the QT interval include certain antiarrhythmics, calcium antagonists, anti-psychotics, antihistamines, macrolide and fluoroquinolone antibiotics, certain antifungals, and antiretroviral medications (a complete list can be found at crediblemeds.org.).4–6 In addition, electrolyte abnormalities can similarly affect the repolarization phase. Alterations in serum potassium levels are the most likely to alter the QT interval, however magnesium, calcium and sodium are contributory as well.4 Sympathetic stimulation has also been implicated, most notably in sudden exposure to cold water, accounting for a large proportion of sudden cardiac death occurring during swimming.3,7 In fact, during provocative electrophysiology testing, epinephrine boluses are sometimes used to directly affect the QT interval due to its sympathomimetic effect.7 Bradycardia, structural heart diseases, female gender, impaired hepatic and renal function, and advanced age are also known risk factors.8,9
Due to the above-mentioned risk of sudden death, it is crucially important to recognize LQTS and subsequently follow an appropriate treatment plan. All patients with any significant prolongation of the QT interval, whether transient or persistent, should undergo genetic testing to determine whether they have an underlying channelopathy.10 If an underlying genetic alteration is identified, family members should be counseled on the need for further testing and evaluation.10 Treatment for patients with acquired QT prolongation includes withholding medications with known QT prolonging effects and avoiding serum electrolyte perturbations. Treatments for patients with congenital prolonged QT include the above strategies, observation, beta blocker therapy, avoidance of high intensity sports, or implantable cardiac defibrillator (ICD) placement.11
CASE REPORT
A 44-year-old female with a history of well-controlled asthma and hypertension presented to the emergency department (ED) with “chest tightness”, which the patient described as inability to take a full breath with occasional pressure-like sensation across the precordium. The patient denied exertional component, leg swelling, history of coagulopathy, thrombotic risk factors, family history for coronary artery disease, cough, fever, vomiting, or abdominal pain. One week prior to ED presentation, the patient had a routine checkup with her family physician and was started on chlorthalidone for her hypertension. She was prescribed the following home medications: montelukast, fluticasone, chlorthalidone, loratidine, ascorbic acid, ferrous sulfate, and albuterol.
The patient’s initial presenting vital signs were the following: pulse 82 beats per minute; blood pressure of 123/73 millimeters of mercury; respirations 18 per minute; oxygen saturation 100%; temperature 98.2 degrees Fahrenheit. On physical exam, breath sounds were mildly diminished in all lung fields. A subtle end expiratory wheeze was appreciated. There was no accessory muscle use or increased respiratory effort. There was no evidence of stridor or upper airway swelling. Cardiac auscultation demonstrated a regular rate and rhythm with no murmur appreciated. The abdomen was soft, nontender and nondistended. Pulses were equally present and strong in all four extremities. No lower extremity swelling was appreciated. A chest radiograph was within normal limits. An initial electrocardiogram (ECG) (Image A) demonstrated no acute ischemia or dysrhythmia (Bazett QTc 423 milliseconds [ms]).
A troponin was similarly negative after days of symptoms, lowering concern for acute coronary syndrome. A trial of albuterol was instituted as some of her symptoms were considered to be attributable to her otherwise well-controlled asthma. Shortly after receiving the nebulized albuterol treatment, the patient became tachycardic and very tremulous. A repeat ECG was obtained (Image B) and notable for a significantly prolonged QT interval (Bazett QTc 633 ms) with distinct morphology change of the T wave. Laboratory studies were reviewed and notable for hypokalemia of 3.2 milliequivalents per liter (mEq/L) (reference range 3.4–5.1 mEq/L) and hypomagnesemia of 1.6 milligrams per deciliter (milligrams per deciliter [mg]/dL) (reference range 1.7–2.2 mg/dL). The albuterol treatment was terminated. The patient was immediately treated with 2 grams intravenous (IV) magnesium sulfate, 20 mEq IV potassium chloride, and 40mEq oral potassium chloride. After one hour, the QT interval had shortened (QTc 428 ms) (Image C) but retained the T wave morphology change. The patient was observed in the ED for several more hours, and discharged home with a next day follow-up to have her electrolyte levels reassessed. The patient’s chlorthalidone and albuterol were discontinued.
CPC-EM Capsule
What do we already know about this clinical entity?
Long QT Syndrome can predispose patients to Torsades de Pointes. Certain medications are known to further prolong the QT interval.
What makes this presentation of disease reportable?
The patient’s underlying Long QT syndrome was effectively unmasked in the emergency department (ED) in the context of albuterol treatment and electrolyte changes from diuretic use.
What is the major learning point?
Be vigilant of the QT prolonging effects of certain medications and electrolyte derangements to further prolong the QT interval. Genetic Long QT Syndrome may only be “unmasked” briefly.
How might this improve emergency medicine practice?
Genetic Long QT Syndrome can be identified in the ED and potentially life-saving referrals can be made.
The patient was referred to an electrophysiologist and ultimately diagnosed with Type 1 LQTS. The patient’s family was referred for genetic counseling. Despite the patient’s asthma being a contraindication, after a risk-and-benefit conversation she was initiated on low-dose beta blocker therapy which was well tolerated. She declined placement of an ICD. The importance of close monitoring of her electrolytes was stressed, particularly during situations in which electrolyte loss is possible (diarrhea, vomiting, exercise).
DISCUSSION
This case was unique in that it contained elements of both genetic and acquired LQTS. Given her normal ECG at presentation, this represents a case of electrocardiographically silent LQTS. Only after provocation with albuterol did she have demonstrable prolonged QT on ECG. In addition, the electrolyte abnormalities caused by the chlorthalidone lowered the threshold for abnormalities in the repolarization phase. The computer-calculated QTc should always be checked with a manual QTc. This can be done by using Bazett’s equation. This should be repeated with multiple different beats in different leads, preferably lead II and V5. After correction the patient’s QT was calculated to be 633 ms. See Image 1 for our calculation.
Patients with congenital LQTS most commonly have mutations to the Kv11.1 and Kv7.1 potassium channel proteins, responsible for the rapid (IKR) and slow (IKS) delayed potassium rectifier currents, respectively.8 These altered IKR and IKS currents can lead to excessive local extracellular potassium levels and ultimately repolarization abnormalities.12 Should these gradients worsen, the patient is at risk for entering torsades de pointes.
The figure is a schematic demonstrating the action potential of a cardiac myocyte.13 As described above, IKR and IKS are the most commonly affected currents in congenital LQTS. These will directly affect phase three, causing a delay in repolarization. On the ECG, this corresponds to the altered T wave morphology and subsequently the prolonged QT interval.
In addition, generalized sympathetic stimulation can prolong the QT interval. In fact, in electrophysiology laboratory testing, patients are given epinephrine boluses to elicit sympathetic stimulation to unmask LQTS.3 The albuterol “challenge” that was administered in the ED certainly could have had a similar sympathomimetic effect. Indeed, a study by Thottathil et al showed beta-2 agonist use by patients with LQTS is a risk factor for cardiac events.14 Asthmatic patients with LQTS who need beta-2 agonists should have electrolyte levels monitored and repleted as necessary. When not contraindicated, the provider should also consider using a beta blocker as there is decreased risk of cardiac events when beta blockers are used.14
CONCLUSION
In conclusion, this is a cautionary tale in which a patient with an underlying cardiac channelopathy was administered a QT prolonging agent in the context of multiple electrolyte abnormalities induced by a recently started thiazide diuretic. Caution should be exercised in administering patients a medication with known QT prolonging effects. It is not infrequent that several medications with the potential for QT prolongation may be used simultaneously in the ED setting (eg, an agitated elderly patient with chronic obstructive pulmonary disease found to have pneumonia). In patients receiving these medications, consider first obtaining an ECG and/or placing the patient on a cardiac monitor.
Section Editor: Manish Amin, DO
Full text available through open access at http://escholarship.org/uc/uciem_cpcem
Patient consent has been obtained and filed for the publication of this case report.
Conflicts of Interest: By the CPC-EM article submission agreement, all authors are required to disclose all affiliations, funding sources and financial or management relationships that could be perceived as potential sources of bias. The authors disclosed none. “The views expressed in this case report are those of the authors and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, or the United States Government. We are military service members. This work was prepared as part of our official duties. Title 17 U.S.C. 105 provides that “Copyright protection under this title is not available for any work of the United States Government.” Title 17 U.S.C. 101 defines a United States Government work as a work prepared by a military service member or employee of the United States Government as part of that person’s official duties.”
Figure Cardiac Myocyte Action Potential. Slow delayed rectifier potassium current (IKS) and rapid delayed potassium rectifier current (IKR) are responsible for efflux of potassium ion during the repolarization phase of the cardiac myocyte (Phase 3). Abnormal serum potassium levels can further affect repolarization in the context of dysfunctional potassium channels.
K+, potassium; Na+, sodium; Cl−, chloride; Ca2+, calcium; IK1, inward rectifier potassium current; INa, inward sodium channel; Ito1,2, transient outward potassium current; ICa-L, L-type calcium current; IKS, slow delayed rectifier potassium current; IKR, rapid delayed potassium rectifier current; ms, milliseconds.
*Adapted and modified from Wikimedia Commons with permission.
Image Serial electrocardiograms (ECG) demonstrating QT prolongation after albuterol use. ECG A demonstrates the patient’s baseline with no acute dysrhythmia or ischemia and QTc of 423 milliseconds (ms). ECG B demonstrates a QTc interval of 633 ms and T wave morphology change. ECG C demonstrates QTc return to 428ms, with retention of the T wave morphology. | ALBUTEROL, ASCORBIC ACID, CHLORTHALIDONE, FERROUS SULFATE, FLUTICASONE, LORATADINE, MONTELUKAST SODIUM | DrugsGivenReaction | CC BY | 33560961 | 18,924,576 | 2021-02 |
Give an alphabetized list of all active substances of drugs taken by the patient who experienced 'Hypomagnesaemia'. | Unmasking Long QT Syndrome in the Emergency Department: A Case Report.
BACKGROUND
Long QT syndrome (LQTS) is an uncommon disorder that can lead to potentially life-threatening dysrhythmias. LQTS can be genetic, acquired, or both.
METHODS
A 44-year-old female with well-controlled hypertension and asthma presented with chest tightness. An initial electrocardiogram yielded a normal corrected QT interval of 423 milliseconds (ms) (normal <480 ms in females). Albuterol was administered and induced agitation, tremulousness, and tachycardia. Follow-up electrocardiograms demonstrated extreme prolongation of the corrected QT interval to 633 ms and morphology change of the T wave. Lab values were later notable for hypokalemia and hypomagnesemia, attributable to a recently started thiazide diuretic. The patient was ultimately diagnosed with congenital LQTS after initial unmasking by albuterol in the emergency department.
CONCLUSIONS
LQTS can be unmasked or exacerbated by electrolyte abnormalities and QT prolonging medications.
INTRODUCTION
Long QT syndrome (LQTS) is a rare condition in which cardiac myocytes are predisposed to repolarization phase abnormalities, which can lead to life-threatening torsades de pointes.1 It is one of the leading causes of unexplained sudden cardiac death.1 Long QT syndrome can be congenital, acquired, or both.
The prevalence of congenital LQTS is estimated at 1 in 2000 births.2 This does not account for patients with electrocardiographically silent LQTS and those who are genotype positive but phenotype negative.2 Thus, the true prevalence of the LQTS gene is likely higher. Patients may have electrocardiographically silent LQTS, only to be unmasked by certain QT prolonging medications, electrolyte abnormalities, or sympathetic stimulation.3 Type 1 LQTS, one of the most common forms of congenital LQTS, is particularly susceptible to sympathetic stimulation.3
Several classes of medications have been demonstrated to lengthen the repolarization phase of cardiac myocytes, thus lengthening the QT interval. Medications classically known to prolong the QT interval include certain antiarrhythmics, calcium antagonists, anti-psychotics, antihistamines, macrolide and fluoroquinolone antibiotics, certain antifungals, and antiretroviral medications (a complete list can be found at crediblemeds.org.).4–6 In addition, electrolyte abnormalities can similarly affect the repolarization phase. Alterations in serum potassium levels are the most likely to alter the QT interval, however magnesium, calcium and sodium are contributory as well.4 Sympathetic stimulation has also been implicated, most notably in sudden exposure to cold water, accounting for a large proportion of sudden cardiac death occurring during swimming.3,7 In fact, during provocative electrophysiology testing, epinephrine boluses are sometimes used to directly affect the QT interval due to its sympathomimetic effect.7 Bradycardia, structural heart diseases, female gender, impaired hepatic and renal function, and advanced age are also known risk factors.8,9
Due to the above-mentioned risk of sudden death, it is crucially important to recognize LQTS and subsequently follow an appropriate treatment plan. All patients with any significant prolongation of the QT interval, whether transient or persistent, should undergo genetic testing to determine whether they have an underlying channelopathy.10 If an underlying genetic alteration is identified, family members should be counseled on the need for further testing and evaluation.10 Treatment for patients with acquired QT prolongation includes withholding medications with known QT prolonging effects and avoiding serum electrolyte perturbations. Treatments for patients with congenital prolonged QT include the above strategies, observation, beta blocker therapy, avoidance of high intensity sports, or implantable cardiac defibrillator (ICD) placement.11
CASE REPORT
A 44-year-old female with a history of well-controlled asthma and hypertension presented to the emergency department (ED) with “chest tightness”, which the patient described as inability to take a full breath with occasional pressure-like sensation across the precordium. The patient denied exertional component, leg swelling, history of coagulopathy, thrombotic risk factors, family history for coronary artery disease, cough, fever, vomiting, or abdominal pain. One week prior to ED presentation, the patient had a routine checkup with her family physician and was started on chlorthalidone for her hypertension. She was prescribed the following home medications: montelukast, fluticasone, chlorthalidone, loratidine, ascorbic acid, ferrous sulfate, and albuterol.
The patient’s initial presenting vital signs were the following: pulse 82 beats per minute; blood pressure of 123/73 millimeters of mercury; respirations 18 per minute; oxygen saturation 100%; temperature 98.2 degrees Fahrenheit. On physical exam, breath sounds were mildly diminished in all lung fields. A subtle end expiratory wheeze was appreciated. There was no accessory muscle use or increased respiratory effort. There was no evidence of stridor or upper airway swelling. Cardiac auscultation demonstrated a regular rate and rhythm with no murmur appreciated. The abdomen was soft, nontender and nondistended. Pulses were equally present and strong in all four extremities. No lower extremity swelling was appreciated. A chest radiograph was within normal limits. An initial electrocardiogram (ECG) (Image A) demonstrated no acute ischemia or dysrhythmia (Bazett QTc 423 milliseconds [ms]).
A troponin was similarly negative after days of symptoms, lowering concern for acute coronary syndrome. A trial of albuterol was instituted as some of her symptoms were considered to be attributable to her otherwise well-controlled asthma. Shortly after receiving the nebulized albuterol treatment, the patient became tachycardic and very tremulous. A repeat ECG was obtained (Image B) and notable for a significantly prolonged QT interval (Bazett QTc 633 ms) with distinct morphology change of the T wave. Laboratory studies were reviewed and notable for hypokalemia of 3.2 milliequivalents per liter (mEq/L) (reference range 3.4–5.1 mEq/L) and hypomagnesemia of 1.6 milligrams per deciliter (milligrams per deciliter [mg]/dL) (reference range 1.7–2.2 mg/dL). The albuterol treatment was terminated. The patient was immediately treated with 2 grams intravenous (IV) magnesium sulfate, 20 mEq IV potassium chloride, and 40mEq oral potassium chloride. After one hour, the QT interval had shortened (QTc 428 ms) (Image C) but retained the T wave morphology change. The patient was observed in the ED for several more hours, and discharged home with a next day follow-up to have her electrolyte levels reassessed. The patient’s chlorthalidone and albuterol were discontinued.
CPC-EM Capsule
What do we already know about this clinical entity?
Long QT Syndrome can predispose patients to Torsades de Pointes. Certain medications are known to further prolong the QT interval.
What makes this presentation of disease reportable?
The patient’s underlying Long QT syndrome was effectively unmasked in the emergency department (ED) in the context of albuterol treatment and electrolyte changes from diuretic use.
What is the major learning point?
Be vigilant of the QT prolonging effects of certain medications and electrolyte derangements to further prolong the QT interval. Genetic Long QT Syndrome may only be “unmasked” briefly.
How might this improve emergency medicine practice?
Genetic Long QT Syndrome can be identified in the ED and potentially life-saving referrals can be made.
The patient was referred to an electrophysiologist and ultimately diagnosed with Type 1 LQTS. The patient’s family was referred for genetic counseling. Despite the patient’s asthma being a contraindication, after a risk-and-benefit conversation she was initiated on low-dose beta blocker therapy which was well tolerated. She declined placement of an ICD. The importance of close monitoring of her electrolytes was stressed, particularly during situations in which electrolyte loss is possible (diarrhea, vomiting, exercise).
DISCUSSION
This case was unique in that it contained elements of both genetic and acquired LQTS. Given her normal ECG at presentation, this represents a case of electrocardiographically silent LQTS. Only after provocation with albuterol did she have demonstrable prolonged QT on ECG. In addition, the electrolyte abnormalities caused by the chlorthalidone lowered the threshold for abnormalities in the repolarization phase. The computer-calculated QTc should always be checked with a manual QTc. This can be done by using Bazett’s equation. This should be repeated with multiple different beats in different leads, preferably lead II and V5. After correction the patient’s QT was calculated to be 633 ms. See Image 1 for our calculation.
Patients with congenital LQTS most commonly have mutations to the Kv11.1 and Kv7.1 potassium channel proteins, responsible for the rapid (IKR) and slow (IKS) delayed potassium rectifier currents, respectively.8 These altered IKR and IKS currents can lead to excessive local extracellular potassium levels and ultimately repolarization abnormalities.12 Should these gradients worsen, the patient is at risk for entering torsades de pointes.
The figure is a schematic demonstrating the action potential of a cardiac myocyte.13 As described above, IKR and IKS are the most commonly affected currents in congenital LQTS. These will directly affect phase three, causing a delay in repolarization. On the ECG, this corresponds to the altered T wave morphology and subsequently the prolonged QT interval.
In addition, generalized sympathetic stimulation can prolong the QT interval. In fact, in electrophysiology laboratory testing, patients are given epinephrine boluses to elicit sympathetic stimulation to unmask LQTS.3 The albuterol “challenge” that was administered in the ED certainly could have had a similar sympathomimetic effect. Indeed, a study by Thottathil et al showed beta-2 agonist use by patients with LQTS is a risk factor for cardiac events.14 Asthmatic patients with LQTS who need beta-2 agonists should have electrolyte levels monitored and repleted as necessary. When not contraindicated, the provider should also consider using a beta blocker as there is decreased risk of cardiac events when beta blockers are used.14
CONCLUSION
In conclusion, this is a cautionary tale in which a patient with an underlying cardiac channelopathy was administered a QT prolonging agent in the context of multiple electrolyte abnormalities induced by a recently started thiazide diuretic. Caution should be exercised in administering patients a medication with known QT prolonging effects. It is not infrequent that several medications with the potential for QT prolongation may be used simultaneously in the ED setting (eg, an agitated elderly patient with chronic obstructive pulmonary disease found to have pneumonia). In patients receiving these medications, consider first obtaining an ECG and/or placing the patient on a cardiac monitor.
Section Editor: Manish Amin, DO
Full text available through open access at http://escholarship.org/uc/uciem_cpcem
Patient consent has been obtained and filed for the publication of this case report.
Conflicts of Interest: By the CPC-EM article submission agreement, all authors are required to disclose all affiliations, funding sources and financial or management relationships that could be perceived as potential sources of bias. The authors disclosed none. “The views expressed in this case report are those of the authors and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, or the United States Government. We are military service members. This work was prepared as part of our official duties. Title 17 U.S.C. 105 provides that “Copyright protection under this title is not available for any work of the United States Government.” Title 17 U.S.C. 101 defines a United States Government work as a work prepared by a military service member or employee of the United States Government as part of that person’s official duties.”
Figure Cardiac Myocyte Action Potential. Slow delayed rectifier potassium current (IKS) and rapid delayed potassium rectifier current (IKR) are responsible for efflux of potassium ion during the repolarization phase of the cardiac myocyte (Phase 3). Abnormal serum potassium levels can further affect repolarization in the context of dysfunctional potassium channels.
K+, potassium; Na+, sodium; Cl−, chloride; Ca2+, calcium; IK1, inward rectifier potassium current; INa, inward sodium channel; Ito1,2, transient outward potassium current; ICa-L, L-type calcium current; IKS, slow delayed rectifier potassium current; IKR, rapid delayed potassium rectifier current; ms, milliseconds.
*Adapted and modified from Wikimedia Commons with permission.
Image Serial electrocardiograms (ECG) demonstrating QT prolongation after albuterol use. ECG A demonstrates the patient’s baseline with no acute dysrhythmia or ischemia and QTc of 423 milliseconds (ms). ECG B demonstrates a QTc interval of 633 ms and T wave morphology change. ECG C demonstrates QTc return to 428ms, with retention of the T wave morphology. | ALBUTEROL, ASCORBIC ACID, CHLORTHALIDONE, FERROUS SULFATE, FLUTICASONE, LORATADINE, MONTELUKAST SODIUM | DrugsGivenReaction | CC BY | 33560961 | 18,924,576 | 2021-02 |
Give an alphabetized list of all active substances of drugs taken by the patient who experienced 'Long QT syndrome'. | Unmasking Long QT Syndrome in the Emergency Department: A Case Report.
BACKGROUND
Long QT syndrome (LQTS) is an uncommon disorder that can lead to potentially life-threatening dysrhythmias. LQTS can be genetic, acquired, or both.
METHODS
A 44-year-old female with well-controlled hypertension and asthma presented with chest tightness. An initial electrocardiogram yielded a normal corrected QT interval of 423 milliseconds (ms) (normal <480 ms in females). Albuterol was administered and induced agitation, tremulousness, and tachycardia. Follow-up electrocardiograms demonstrated extreme prolongation of the corrected QT interval to 633 ms and morphology change of the T wave. Lab values were later notable for hypokalemia and hypomagnesemia, attributable to a recently started thiazide diuretic. The patient was ultimately diagnosed with congenital LQTS after initial unmasking by albuterol in the emergency department.
CONCLUSIONS
LQTS can be unmasked or exacerbated by electrolyte abnormalities and QT prolonging medications.
INTRODUCTION
Long QT syndrome (LQTS) is a rare condition in which cardiac myocytes are predisposed to repolarization phase abnormalities, which can lead to life-threatening torsades de pointes.1 It is one of the leading causes of unexplained sudden cardiac death.1 Long QT syndrome can be congenital, acquired, or both.
The prevalence of congenital LQTS is estimated at 1 in 2000 births.2 This does not account for patients with electrocardiographically silent LQTS and those who are genotype positive but phenotype negative.2 Thus, the true prevalence of the LQTS gene is likely higher. Patients may have electrocardiographically silent LQTS, only to be unmasked by certain QT prolonging medications, electrolyte abnormalities, or sympathetic stimulation.3 Type 1 LQTS, one of the most common forms of congenital LQTS, is particularly susceptible to sympathetic stimulation.3
Several classes of medications have been demonstrated to lengthen the repolarization phase of cardiac myocytes, thus lengthening the QT interval. Medications classically known to prolong the QT interval include certain antiarrhythmics, calcium antagonists, anti-psychotics, antihistamines, macrolide and fluoroquinolone antibiotics, certain antifungals, and antiretroviral medications (a complete list can be found at crediblemeds.org.).4–6 In addition, electrolyte abnormalities can similarly affect the repolarization phase. Alterations in serum potassium levels are the most likely to alter the QT interval, however magnesium, calcium and sodium are contributory as well.4 Sympathetic stimulation has also been implicated, most notably in sudden exposure to cold water, accounting for a large proportion of sudden cardiac death occurring during swimming.3,7 In fact, during provocative electrophysiology testing, epinephrine boluses are sometimes used to directly affect the QT interval due to its sympathomimetic effect.7 Bradycardia, structural heart diseases, female gender, impaired hepatic and renal function, and advanced age are also known risk factors.8,9
Due to the above-mentioned risk of sudden death, it is crucially important to recognize LQTS and subsequently follow an appropriate treatment plan. All patients with any significant prolongation of the QT interval, whether transient or persistent, should undergo genetic testing to determine whether they have an underlying channelopathy.10 If an underlying genetic alteration is identified, family members should be counseled on the need for further testing and evaluation.10 Treatment for patients with acquired QT prolongation includes withholding medications with known QT prolonging effects and avoiding serum electrolyte perturbations. Treatments for patients with congenital prolonged QT include the above strategies, observation, beta blocker therapy, avoidance of high intensity sports, or implantable cardiac defibrillator (ICD) placement.11
CASE REPORT
A 44-year-old female with a history of well-controlled asthma and hypertension presented to the emergency department (ED) with “chest tightness”, which the patient described as inability to take a full breath with occasional pressure-like sensation across the precordium. The patient denied exertional component, leg swelling, history of coagulopathy, thrombotic risk factors, family history for coronary artery disease, cough, fever, vomiting, or abdominal pain. One week prior to ED presentation, the patient had a routine checkup with her family physician and was started on chlorthalidone for her hypertension. She was prescribed the following home medications: montelukast, fluticasone, chlorthalidone, loratidine, ascorbic acid, ferrous sulfate, and albuterol.
The patient’s initial presenting vital signs were the following: pulse 82 beats per minute; blood pressure of 123/73 millimeters of mercury; respirations 18 per minute; oxygen saturation 100%; temperature 98.2 degrees Fahrenheit. On physical exam, breath sounds were mildly diminished in all lung fields. A subtle end expiratory wheeze was appreciated. There was no accessory muscle use or increased respiratory effort. There was no evidence of stridor or upper airway swelling. Cardiac auscultation demonstrated a regular rate and rhythm with no murmur appreciated. The abdomen was soft, nontender and nondistended. Pulses were equally present and strong in all four extremities. No lower extremity swelling was appreciated. A chest radiograph was within normal limits. An initial electrocardiogram (ECG) (Image A) demonstrated no acute ischemia or dysrhythmia (Bazett QTc 423 milliseconds [ms]).
A troponin was similarly negative after days of symptoms, lowering concern for acute coronary syndrome. A trial of albuterol was instituted as some of her symptoms were considered to be attributable to her otherwise well-controlled asthma. Shortly after receiving the nebulized albuterol treatment, the patient became tachycardic and very tremulous. A repeat ECG was obtained (Image B) and notable for a significantly prolonged QT interval (Bazett QTc 633 ms) with distinct morphology change of the T wave. Laboratory studies were reviewed and notable for hypokalemia of 3.2 milliequivalents per liter (mEq/L) (reference range 3.4–5.1 mEq/L) and hypomagnesemia of 1.6 milligrams per deciliter (milligrams per deciliter [mg]/dL) (reference range 1.7–2.2 mg/dL). The albuterol treatment was terminated. The patient was immediately treated with 2 grams intravenous (IV) magnesium sulfate, 20 mEq IV potassium chloride, and 40mEq oral potassium chloride. After one hour, the QT interval had shortened (QTc 428 ms) (Image C) but retained the T wave morphology change. The patient was observed in the ED for several more hours, and discharged home with a next day follow-up to have her electrolyte levels reassessed. The patient’s chlorthalidone and albuterol were discontinued.
CPC-EM Capsule
What do we already know about this clinical entity?
Long QT Syndrome can predispose patients to Torsades de Pointes. Certain medications are known to further prolong the QT interval.
What makes this presentation of disease reportable?
The patient’s underlying Long QT syndrome was effectively unmasked in the emergency department (ED) in the context of albuterol treatment and electrolyte changes from diuretic use.
What is the major learning point?
Be vigilant of the QT prolonging effects of certain medications and electrolyte derangements to further prolong the QT interval. Genetic Long QT Syndrome may only be “unmasked” briefly.
How might this improve emergency medicine practice?
Genetic Long QT Syndrome can be identified in the ED and potentially life-saving referrals can be made.
The patient was referred to an electrophysiologist and ultimately diagnosed with Type 1 LQTS. The patient’s family was referred for genetic counseling. Despite the patient’s asthma being a contraindication, after a risk-and-benefit conversation she was initiated on low-dose beta blocker therapy which was well tolerated. She declined placement of an ICD. The importance of close monitoring of her electrolytes was stressed, particularly during situations in which electrolyte loss is possible (diarrhea, vomiting, exercise).
DISCUSSION
This case was unique in that it contained elements of both genetic and acquired LQTS. Given her normal ECG at presentation, this represents a case of electrocardiographically silent LQTS. Only after provocation with albuterol did she have demonstrable prolonged QT on ECG. In addition, the electrolyte abnormalities caused by the chlorthalidone lowered the threshold for abnormalities in the repolarization phase. The computer-calculated QTc should always be checked with a manual QTc. This can be done by using Bazett’s equation. This should be repeated with multiple different beats in different leads, preferably lead II and V5. After correction the patient’s QT was calculated to be 633 ms. See Image 1 for our calculation.
Patients with congenital LQTS most commonly have mutations to the Kv11.1 and Kv7.1 potassium channel proteins, responsible for the rapid (IKR) and slow (IKS) delayed potassium rectifier currents, respectively.8 These altered IKR and IKS currents can lead to excessive local extracellular potassium levels and ultimately repolarization abnormalities.12 Should these gradients worsen, the patient is at risk for entering torsades de pointes.
The figure is a schematic demonstrating the action potential of a cardiac myocyte.13 As described above, IKR and IKS are the most commonly affected currents in congenital LQTS. These will directly affect phase three, causing a delay in repolarization. On the ECG, this corresponds to the altered T wave morphology and subsequently the prolonged QT interval.
In addition, generalized sympathetic stimulation can prolong the QT interval. In fact, in electrophysiology laboratory testing, patients are given epinephrine boluses to elicit sympathetic stimulation to unmask LQTS.3 The albuterol “challenge” that was administered in the ED certainly could have had a similar sympathomimetic effect. Indeed, a study by Thottathil et al showed beta-2 agonist use by patients with LQTS is a risk factor for cardiac events.14 Asthmatic patients with LQTS who need beta-2 agonists should have electrolyte levels monitored and repleted as necessary. When not contraindicated, the provider should also consider using a beta blocker as there is decreased risk of cardiac events when beta blockers are used.14
CONCLUSION
In conclusion, this is a cautionary tale in which a patient with an underlying cardiac channelopathy was administered a QT prolonging agent in the context of multiple electrolyte abnormalities induced by a recently started thiazide diuretic. Caution should be exercised in administering patients a medication with known QT prolonging effects. It is not infrequent that several medications with the potential for QT prolongation may be used simultaneously in the ED setting (eg, an agitated elderly patient with chronic obstructive pulmonary disease found to have pneumonia). In patients receiving these medications, consider first obtaining an ECG and/or placing the patient on a cardiac monitor.
Section Editor: Manish Amin, DO
Full text available through open access at http://escholarship.org/uc/uciem_cpcem
Patient consent has been obtained and filed for the publication of this case report.
Conflicts of Interest: By the CPC-EM article submission agreement, all authors are required to disclose all affiliations, funding sources and financial or management relationships that could be perceived as potential sources of bias. The authors disclosed none. “The views expressed in this case report are those of the authors and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, or the United States Government. We are military service members. This work was prepared as part of our official duties. Title 17 U.S.C. 105 provides that “Copyright protection under this title is not available for any work of the United States Government.” Title 17 U.S.C. 101 defines a United States Government work as a work prepared by a military service member or employee of the United States Government as part of that person’s official duties.”
Figure Cardiac Myocyte Action Potential. Slow delayed rectifier potassium current (IKS) and rapid delayed potassium rectifier current (IKR) are responsible for efflux of potassium ion during the repolarization phase of the cardiac myocyte (Phase 3). Abnormal serum potassium levels can further affect repolarization in the context of dysfunctional potassium channels.
K+, potassium; Na+, sodium; Cl−, chloride; Ca2+, calcium; IK1, inward rectifier potassium current; INa, inward sodium channel; Ito1,2, transient outward potassium current; ICa-L, L-type calcium current; IKS, slow delayed rectifier potassium current; IKR, rapid delayed potassium rectifier current; ms, milliseconds.
*Adapted and modified from Wikimedia Commons with permission.
Image Serial electrocardiograms (ECG) demonstrating QT prolongation after albuterol use. ECG A demonstrates the patient’s baseline with no acute dysrhythmia or ischemia and QTc of 423 milliseconds (ms). ECG B demonstrates a QTc interval of 633 ms and T wave morphology change. ECG C demonstrates QTc return to 428ms, with retention of the T wave morphology. | ALBUTEROL, ASCORBIC ACID, CHLORTHALIDONE, FERROUS SULFATE, FLUTICASONE, LORATADINE, MONTELUKAST SODIUM | DrugsGivenReaction | CC BY | 33560961 | 18,999,127 | 2021-02 |
Give an alphabetized list of all active substances of drugs taken by the patient who experienced 'Potentiating drug interaction'. | Unmasking Long QT Syndrome in the Emergency Department: A Case Report.
BACKGROUND
Long QT syndrome (LQTS) is an uncommon disorder that can lead to potentially life-threatening dysrhythmias. LQTS can be genetic, acquired, or both.
METHODS
A 44-year-old female with well-controlled hypertension and asthma presented with chest tightness. An initial electrocardiogram yielded a normal corrected QT interval of 423 milliseconds (ms) (normal <480 ms in females). Albuterol was administered and induced agitation, tremulousness, and tachycardia. Follow-up electrocardiograms demonstrated extreme prolongation of the corrected QT interval to 633 ms and morphology change of the T wave. Lab values were later notable for hypokalemia and hypomagnesemia, attributable to a recently started thiazide diuretic. The patient was ultimately diagnosed with congenital LQTS after initial unmasking by albuterol in the emergency department.
CONCLUSIONS
LQTS can be unmasked or exacerbated by electrolyte abnormalities and QT prolonging medications.
INTRODUCTION
Long QT syndrome (LQTS) is a rare condition in which cardiac myocytes are predisposed to repolarization phase abnormalities, which can lead to life-threatening torsades de pointes.1 It is one of the leading causes of unexplained sudden cardiac death.1 Long QT syndrome can be congenital, acquired, or both.
The prevalence of congenital LQTS is estimated at 1 in 2000 births.2 This does not account for patients with electrocardiographically silent LQTS and those who are genotype positive but phenotype negative.2 Thus, the true prevalence of the LQTS gene is likely higher. Patients may have electrocardiographically silent LQTS, only to be unmasked by certain QT prolonging medications, electrolyte abnormalities, or sympathetic stimulation.3 Type 1 LQTS, one of the most common forms of congenital LQTS, is particularly susceptible to sympathetic stimulation.3
Several classes of medications have been demonstrated to lengthen the repolarization phase of cardiac myocytes, thus lengthening the QT interval. Medications classically known to prolong the QT interval include certain antiarrhythmics, calcium antagonists, anti-psychotics, antihistamines, macrolide and fluoroquinolone antibiotics, certain antifungals, and antiretroviral medications (a complete list can be found at crediblemeds.org.).4–6 In addition, electrolyte abnormalities can similarly affect the repolarization phase. Alterations in serum potassium levels are the most likely to alter the QT interval, however magnesium, calcium and sodium are contributory as well.4 Sympathetic stimulation has also been implicated, most notably in sudden exposure to cold water, accounting for a large proportion of sudden cardiac death occurring during swimming.3,7 In fact, during provocative electrophysiology testing, epinephrine boluses are sometimes used to directly affect the QT interval due to its sympathomimetic effect.7 Bradycardia, structural heart diseases, female gender, impaired hepatic and renal function, and advanced age are also known risk factors.8,9
Due to the above-mentioned risk of sudden death, it is crucially important to recognize LQTS and subsequently follow an appropriate treatment plan. All patients with any significant prolongation of the QT interval, whether transient or persistent, should undergo genetic testing to determine whether they have an underlying channelopathy.10 If an underlying genetic alteration is identified, family members should be counseled on the need for further testing and evaluation.10 Treatment for patients with acquired QT prolongation includes withholding medications with known QT prolonging effects and avoiding serum electrolyte perturbations. Treatments for patients with congenital prolonged QT include the above strategies, observation, beta blocker therapy, avoidance of high intensity sports, or implantable cardiac defibrillator (ICD) placement.11
CASE REPORT
A 44-year-old female with a history of well-controlled asthma and hypertension presented to the emergency department (ED) with “chest tightness”, which the patient described as inability to take a full breath with occasional pressure-like sensation across the precordium. The patient denied exertional component, leg swelling, history of coagulopathy, thrombotic risk factors, family history for coronary artery disease, cough, fever, vomiting, or abdominal pain. One week prior to ED presentation, the patient had a routine checkup with her family physician and was started on chlorthalidone for her hypertension. She was prescribed the following home medications: montelukast, fluticasone, chlorthalidone, loratidine, ascorbic acid, ferrous sulfate, and albuterol.
The patient’s initial presenting vital signs were the following: pulse 82 beats per minute; blood pressure of 123/73 millimeters of mercury; respirations 18 per minute; oxygen saturation 100%; temperature 98.2 degrees Fahrenheit. On physical exam, breath sounds were mildly diminished in all lung fields. A subtle end expiratory wheeze was appreciated. There was no accessory muscle use or increased respiratory effort. There was no evidence of stridor or upper airway swelling. Cardiac auscultation demonstrated a regular rate and rhythm with no murmur appreciated. The abdomen was soft, nontender and nondistended. Pulses were equally present and strong in all four extremities. No lower extremity swelling was appreciated. A chest radiograph was within normal limits. An initial electrocardiogram (ECG) (Image A) demonstrated no acute ischemia or dysrhythmia (Bazett QTc 423 milliseconds [ms]).
A troponin was similarly negative after days of symptoms, lowering concern for acute coronary syndrome. A trial of albuterol was instituted as some of her symptoms were considered to be attributable to her otherwise well-controlled asthma. Shortly after receiving the nebulized albuterol treatment, the patient became tachycardic and very tremulous. A repeat ECG was obtained (Image B) and notable for a significantly prolonged QT interval (Bazett QTc 633 ms) with distinct morphology change of the T wave. Laboratory studies were reviewed and notable for hypokalemia of 3.2 milliequivalents per liter (mEq/L) (reference range 3.4–5.1 mEq/L) and hypomagnesemia of 1.6 milligrams per deciliter (milligrams per deciliter [mg]/dL) (reference range 1.7–2.2 mg/dL). The albuterol treatment was terminated. The patient was immediately treated with 2 grams intravenous (IV) magnesium sulfate, 20 mEq IV potassium chloride, and 40mEq oral potassium chloride. After one hour, the QT interval had shortened (QTc 428 ms) (Image C) but retained the T wave morphology change. The patient was observed in the ED for several more hours, and discharged home with a next day follow-up to have her electrolyte levels reassessed. The patient’s chlorthalidone and albuterol were discontinued.
CPC-EM Capsule
What do we already know about this clinical entity?
Long QT Syndrome can predispose patients to Torsades de Pointes. Certain medications are known to further prolong the QT interval.
What makes this presentation of disease reportable?
The patient’s underlying Long QT syndrome was effectively unmasked in the emergency department (ED) in the context of albuterol treatment and electrolyte changes from diuretic use.
What is the major learning point?
Be vigilant of the QT prolonging effects of certain medications and electrolyte derangements to further prolong the QT interval. Genetic Long QT Syndrome may only be “unmasked” briefly.
How might this improve emergency medicine practice?
Genetic Long QT Syndrome can be identified in the ED and potentially life-saving referrals can be made.
The patient was referred to an electrophysiologist and ultimately diagnosed with Type 1 LQTS. The patient’s family was referred for genetic counseling. Despite the patient’s asthma being a contraindication, after a risk-and-benefit conversation she was initiated on low-dose beta blocker therapy which was well tolerated. She declined placement of an ICD. The importance of close monitoring of her electrolytes was stressed, particularly during situations in which electrolyte loss is possible (diarrhea, vomiting, exercise).
DISCUSSION
This case was unique in that it contained elements of both genetic and acquired LQTS. Given her normal ECG at presentation, this represents a case of electrocardiographically silent LQTS. Only after provocation with albuterol did she have demonstrable prolonged QT on ECG. In addition, the electrolyte abnormalities caused by the chlorthalidone lowered the threshold for abnormalities in the repolarization phase. The computer-calculated QTc should always be checked with a manual QTc. This can be done by using Bazett’s equation. This should be repeated with multiple different beats in different leads, preferably lead II and V5. After correction the patient’s QT was calculated to be 633 ms. See Image 1 for our calculation.
Patients with congenital LQTS most commonly have mutations to the Kv11.1 and Kv7.1 potassium channel proteins, responsible for the rapid (IKR) and slow (IKS) delayed potassium rectifier currents, respectively.8 These altered IKR and IKS currents can lead to excessive local extracellular potassium levels and ultimately repolarization abnormalities.12 Should these gradients worsen, the patient is at risk for entering torsades de pointes.
The figure is a schematic demonstrating the action potential of a cardiac myocyte.13 As described above, IKR and IKS are the most commonly affected currents in congenital LQTS. These will directly affect phase three, causing a delay in repolarization. On the ECG, this corresponds to the altered T wave morphology and subsequently the prolonged QT interval.
In addition, generalized sympathetic stimulation can prolong the QT interval. In fact, in electrophysiology laboratory testing, patients are given epinephrine boluses to elicit sympathetic stimulation to unmask LQTS.3 The albuterol “challenge” that was administered in the ED certainly could have had a similar sympathomimetic effect. Indeed, a study by Thottathil et al showed beta-2 agonist use by patients with LQTS is a risk factor for cardiac events.14 Asthmatic patients with LQTS who need beta-2 agonists should have electrolyte levels monitored and repleted as necessary. When not contraindicated, the provider should also consider using a beta blocker as there is decreased risk of cardiac events when beta blockers are used.14
CONCLUSION
In conclusion, this is a cautionary tale in which a patient with an underlying cardiac channelopathy was administered a QT prolonging agent in the context of multiple electrolyte abnormalities induced by a recently started thiazide diuretic. Caution should be exercised in administering patients a medication with known QT prolonging effects. It is not infrequent that several medications with the potential for QT prolongation may be used simultaneously in the ED setting (eg, an agitated elderly patient with chronic obstructive pulmonary disease found to have pneumonia). In patients receiving these medications, consider first obtaining an ECG and/or placing the patient on a cardiac monitor.
Section Editor: Manish Amin, DO
Full text available through open access at http://escholarship.org/uc/uciem_cpcem
Patient consent has been obtained and filed for the publication of this case report.
Conflicts of Interest: By the CPC-EM article submission agreement, all authors are required to disclose all affiliations, funding sources and financial or management relationships that could be perceived as potential sources of bias. The authors disclosed none. “The views expressed in this case report are those of the authors and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, or the United States Government. We are military service members. This work was prepared as part of our official duties. Title 17 U.S.C. 105 provides that “Copyright protection under this title is not available for any work of the United States Government.” Title 17 U.S.C. 101 defines a United States Government work as a work prepared by a military service member or employee of the United States Government as part of that person’s official duties.”
Figure Cardiac Myocyte Action Potential. Slow delayed rectifier potassium current (IKS) and rapid delayed potassium rectifier current (IKR) are responsible for efflux of potassium ion during the repolarization phase of the cardiac myocyte (Phase 3). Abnormal serum potassium levels can further affect repolarization in the context of dysfunctional potassium channels.
K+, potassium; Na+, sodium; Cl−, chloride; Ca2+, calcium; IK1, inward rectifier potassium current; INa, inward sodium channel; Ito1,2, transient outward potassium current; ICa-L, L-type calcium current; IKS, slow delayed rectifier potassium current; IKR, rapid delayed potassium rectifier current; ms, milliseconds.
*Adapted and modified from Wikimedia Commons with permission.
Image Serial electrocardiograms (ECG) demonstrating QT prolongation after albuterol use. ECG A demonstrates the patient’s baseline with no acute dysrhythmia or ischemia and QTc of 423 milliseconds (ms). ECG B demonstrates a QTc interval of 633 ms and T wave morphology change. ECG C demonstrates QTc return to 428ms, with retention of the T wave morphology. | ALBUTEROL, ASCORBIC ACID, CHLORTHALIDONE, FERROUS SULFATE, FLUTICASONE, LORATADINE, MONTELUKAST SODIUM | DrugsGivenReaction | CC BY | 33560961 | 18,924,576 | 2021-02 |
Give an alphabetized list of all active substances of drugs taken by the patient who experienced 'Tachycardia'. | Unmasking Long QT Syndrome in the Emergency Department: A Case Report.
BACKGROUND
Long QT syndrome (LQTS) is an uncommon disorder that can lead to potentially life-threatening dysrhythmias. LQTS can be genetic, acquired, or both.
METHODS
A 44-year-old female with well-controlled hypertension and asthma presented with chest tightness. An initial electrocardiogram yielded a normal corrected QT interval of 423 milliseconds (ms) (normal <480 ms in females). Albuterol was administered and induced agitation, tremulousness, and tachycardia. Follow-up electrocardiograms demonstrated extreme prolongation of the corrected QT interval to 633 ms and morphology change of the T wave. Lab values were later notable for hypokalemia and hypomagnesemia, attributable to a recently started thiazide diuretic. The patient was ultimately diagnosed with congenital LQTS after initial unmasking by albuterol in the emergency department.
CONCLUSIONS
LQTS can be unmasked or exacerbated by electrolyte abnormalities and QT prolonging medications.
INTRODUCTION
Long QT syndrome (LQTS) is a rare condition in which cardiac myocytes are predisposed to repolarization phase abnormalities, which can lead to life-threatening torsades de pointes.1 It is one of the leading causes of unexplained sudden cardiac death.1 Long QT syndrome can be congenital, acquired, or both.
The prevalence of congenital LQTS is estimated at 1 in 2000 births.2 This does not account for patients with electrocardiographically silent LQTS and those who are genotype positive but phenotype negative.2 Thus, the true prevalence of the LQTS gene is likely higher. Patients may have electrocardiographically silent LQTS, only to be unmasked by certain QT prolonging medications, electrolyte abnormalities, or sympathetic stimulation.3 Type 1 LQTS, one of the most common forms of congenital LQTS, is particularly susceptible to sympathetic stimulation.3
Several classes of medications have been demonstrated to lengthen the repolarization phase of cardiac myocytes, thus lengthening the QT interval. Medications classically known to prolong the QT interval include certain antiarrhythmics, calcium antagonists, anti-psychotics, antihistamines, macrolide and fluoroquinolone antibiotics, certain antifungals, and antiretroviral medications (a complete list can be found at crediblemeds.org.).4–6 In addition, electrolyte abnormalities can similarly affect the repolarization phase. Alterations in serum potassium levels are the most likely to alter the QT interval, however magnesium, calcium and sodium are contributory as well.4 Sympathetic stimulation has also been implicated, most notably in sudden exposure to cold water, accounting for a large proportion of sudden cardiac death occurring during swimming.3,7 In fact, during provocative electrophysiology testing, epinephrine boluses are sometimes used to directly affect the QT interval due to its sympathomimetic effect.7 Bradycardia, structural heart diseases, female gender, impaired hepatic and renal function, and advanced age are also known risk factors.8,9
Due to the above-mentioned risk of sudden death, it is crucially important to recognize LQTS and subsequently follow an appropriate treatment plan. All patients with any significant prolongation of the QT interval, whether transient or persistent, should undergo genetic testing to determine whether they have an underlying channelopathy.10 If an underlying genetic alteration is identified, family members should be counseled on the need for further testing and evaluation.10 Treatment for patients with acquired QT prolongation includes withholding medications with known QT prolonging effects and avoiding serum electrolyte perturbations. Treatments for patients with congenital prolonged QT include the above strategies, observation, beta blocker therapy, avoidance of high intensity sports, or implantable cardiac defibrillator (ICD) placement.11
CASE REPORT
A 44-year-old female with a history of well-controlled asthma and hypertension presented to the emergency department (ED) with “chest tightness”, which the patient described as inability to take a full breath with occasional pressure-like sensation across the precordium. The patient denied exertional component, leg swelling, history of coagulopathy, thrombotic risk factors, family history for coronary artery disease, cough, fever, vomiting, or abdominal pain. One week prior to ED presentation, the patient had a routine checkup with her family physician and was started on chlorthalidone for her hypertension. She was prescribed the following home medications: montelukast, fluticasone, chlorthalidone, loratidine, ascorbic acid, ferrous sulfate, and albuterol.
The patient’s initial presenting vital signs were the following: pulse 82 beats per minute; blood pressure of 123/73 millimeters of mercury; respirations 18 per minute; oxygen saturation 100%; temperature 98.2 degrees Fahrenheit. On physical exam, breath sounds were mildly diminished in all lung fields. A subtle end expiratory wheeze was appreciated. There was no accessory muscle use or increased respiratory effort. There was no evidence of stridor or upper airway swelling. Cardiac auscultation demonstrated a regular rate and rhythm with no murmur appreciated. The abdomen was soft, nontender and nondistended. Pulses were equally present and strong in all four extremities. No lower extremity swelling was appreciated. A chest radiograph was within normal limits. An initial electrocardiogram (ECG) (Image A) demonstrated no acute ischemia or dysrhythmia (Bazett QTc 423 milliseconds [ms]).
A troponin was similarly negative after days of symptoms, lowering concern for acute coronary syndrome. A trial of albuterol was instituted as some of her symptoms were considered to be attributable to her otherwise well-controlled asthma. Shortly after receiving the nebulized albuterol treatment, the patient became tachycardic and very tremulous. A repeat ECG was obtained (Image B) and notable for a significantly prolonged QT interval (Bazett QTc 633 ms) with distinct morphology change of the T wave. Laboratory studies were reviewed and notable for hypokalemia of 3.2 milliequivalents per liter (mEq/L) (reference range 3.4–5.1 mEq/L) and hypomagnesemia of 1.6 milligrams per deciliter (milligrams per deciliter [mg]/dL) (reference range 1.7–2.2 mg/dL). The albuterol treatment was terminated. The patient was immediately treated with 2 grams intravenous (IV) magnesium sulfate, 20 mEq IV potassium chloride, and 40mEq oral potassium chloride. After one hour, the QT interval had shortened (QTc 428 ms) (Image C) but retained the T wave morphology change. The patient was observed in the ED for several more hours, and discharged home with a next day follow-up to have her electrolyte levels reassessed. The patient’s chlorthalidone and albuterol were discontinued.
CPC-EM Capsule
What do we already know about this clinical entity?
Long QT Syndrome can predispose patients to Torsades de Pointes. Certain medications are known to further prolong the QT interval.
What makes this presentation of disease reportable?
The patient’s underlying Long QT syndrome was effectively unmasked in the emergency department (ED) in the context of albuterol treatment and electrolyte changes from diuretic use.
What is the major learning point?
Be vigilant of the QT prolonging effects of certain medications and electrolyte derangements to further prolong the QT interval. Genetic Long QT Syndrome may only be “unmasked” briefly.
How might this improve emergency medicine practice?
Genetic Long QT Syndrome can be identified in the ED and potentially life-saving referrals can be made.
The patient was referred to an electrophysiologist and ultimately diagnosed with Type 1 LQTS. The patient’s family was referred for genetic counseling. Despite the patient’s asthma being a contraindication, after a risk-and-benefit conversation she was initiated on low-dose beta blocker therapy which was well tolerated. She declined placement of an ICD. The importance of close monitoring of her electrolytes was stressed, particularly during situations in which electrolyte loss is possible (diarrhea, vomiting, exercise).
DISCUSSION
This case was unique in that it contained elements of both genetic and acquired LQTS. Given her normal ECG at presentation, this represents a case of electrocardiographically silent LQTS. Only after provocation with albuterol did she have demonstrable prolonged QT on ECG. In addition, the electrolyte abnormalities caused by the chlorthalidone lowered the threshold for abnormalities in the repolarization phase. The computer-calculated QTc should always be checked with a manual QTc. This can be done by using Bazett’s equation. This should be repeated with multiple different beats in different leads, preferably lead II and V5. After correction the patient’s QT was calculated to be 633 ms. See Image 1 for our calculation.
Patients with congenital LQTS most commonly have mutations to the Kv11.1 and Kv7.1 potassium channel proteins, responsible for the rapid (IKR) and slow (IKS) delayed potassium rectifier currents, respectively.8 These altered IKR and IKS currents can lead to excessive local extracellular potassium levels and ultimately repolarization abnormalities.12 Should these gradients worsen, the patient is at risk for entering torsades de pointes.
The figure is a schematic demonstrating the action potential of a cardiac myocyte.13 As described above, IKR and IKS are the most commonly affected currents in congenital LQTS. These will directly affect phase three, causing a delay in repolarization. On the ECG, this corresponds to the altered T wave morphology and subsequently the prolonged QT interval.
In addition, generalized sympathetic stimulation can prolong the QT interval. In fact, in electrophysiology laboratory testing, patients are given epinephrine boluses to elicit sympathetic stimulation to unmask LQTS.3 The albuterol “challenge” that was administered in the ED certainly could have had a similar sympathomimetic effect. Indeed, a study by Thottathil et al showed beta-2 agonist use by patients with LQTS is a risk factor for cardiac events.14 Asthmatic patients with LQTS who need beta-2 agonists should have electrolyte levels monitored and repleted as necessary. When not contraindicated, the provider should also consider using a beta blocker as there is decreased risk of cardiac events when beta blockers are used.14
CONCLUSION
In conclusion, this is a cautionary tale in which a patient with an underlying cardiac channelopathy was administered a QT prolonging agent in the context of multiple electrolyte abnormalities induced by a recently started thiazide diuretic. Caution should be exercised in administering patients a medication with known QT prolonging effects. It is not infrequent that several medications with the potential for QT prolongation may be used simultaneously in the ED setting (eg, an agitated elderly patient with chronic obstructive pulmonary disease found to have pneumonia). In patients receiving these medications, consider first obtaining an ECG and/or placing the patient on a cardiac monitor.
Section Editor: Manish Amin, DO
Full text available through open access at http://escholarship.org/uc/uciem_cpcem
Patient consent has been obtained and filed for the publication of this case report.
Conflicts of Interest: By the CPC-EM article submission agreement, all authors are required to disclose all affiliations, funding sources and financial or management relationships that could be perceived as potential sources of bias. The authors disclosed none. “The views expressed in this case report are those of the authors and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, or the United States Government. We are military service members. This work was prepared as part of our official duties. Title 17 U.S.C. 105 provides that “Copyright protection under this title is not available for any work of the United States Government.” Title 17 U.S.C. 101 defines a United States Government work as a work prepared by a military service member or employee of the United States Government as part of that person’s official duties.”
Figure Cardiac Myocyte Action Potential. Slow delayed rectifier potassium current (IKS) and rapid delayed potassium rectifier current (IKR) are responsible for efflux of potassium ion during the repolarization phase of the cardiac myocyte (Phase 3). Abnormal serum potassium levels can further affect repolarization in the context of dysfunctional potassium channels.
K+, potassium; Na+, sodium; Cl−, chloride; Ca2+, calcium; IK1, inward rectifier potassium current; INa, inward sodium channel; Ito1,2, transient outward potassium current; ICa-L, L-type calcium current; IKS, slow delayed rectifier potassium current; IKR, rapid delayed potassium rectifier current; ms, milliseconds.
*Adapted and modified from Wikimedia Commons with permission.
Image Serial electrocardiograms (ECG) demonstrating QT prolongation after albuterol use. ECG A demonstrates the patient’s baseline with no acute dysrhythmia or ischemia and QTc of 423 milliseconds (ms). ECG B demonstrates a QTc interval of 633 ms and T wave morphology change. ECG C demonstrates QTc return to 428ms, with retention of the T wave morphology. | ALBUTEROL SULFATE, ASCORBIC ACID, CHLORTHALIDONE, FERROUS SULFATE, LORATADINE, MONTELUKAST SODIUM | DrugsGivenReaction | CC BY | 33560961 | 18,970,926 | 2021-02 |
What was the administration route of drug 'ALBUTEROL'? | Unmasking Long QT Syndrome in the Emergency Department: A Case Report.
BACKGROUND
Long QT syndrome (LQTS) is an uncommon disorder that can lead to potentially life-threatening dysrhythmias. LQTS can be genetic, acquired, or both.
METHODS
A 44-year-old female with well-controlled hypertension and asthma presented with chest tightness. An initial electrocardiogram yielded a normal corrected QT interval of 423 milliseconds (ms) (normal <480 ms in females). Albuterol was administered and induced agitation, tremulousness, and tachycardia. Follow-up electrocardiograms demonstrated extreme prolongation of the corrected QT interval to 633 ms and morphology change of the T wave. Lab values were later notable for hypokalemia and hypomagnesemia, attributable to a recently started thiazide diuretic. The patient was ultimately diagnosed with congenital LQTS after initial unmasking by albuterol in the emergency department.
CONCLUSIONS
LQTS can be unmasked or exacerbated by electrolyte abnormalities and QT prolonging medications.
INTRODUCTION
Long QT syndrome (LQTS) is a rare condition in which cardiac myocytes are predisposed to repolarization phase abnormalities, which can lead to life-threatening torsades de pointes.1 It is one of the leading causes of unexplained sudden cardiac death.1 Long QT syndrome can be congenital, acquired, or both.
The prevalence of congenital LQTS is estimated at 1 in 2000 births.2 This does not account for patients with electrocardiographically silent LQTS and those who are genotype positive but phenotype negative.2 Thus, the true prevalence of the LQTS gene is likely higher. Patients may have electrocardiographically silent LQTS, only to be unmasked by certain QT prolonging medications, electrolyte abnormalities, or sympathetic stimulation.3 Type 1 LQTS, one of the most common forms of congenital LQTS, is particularly susceptible to sympathetic stimulation.3
Several classes of medications have been demonstrated to lengthen the repolarization phase of cardiac myocytes, thus lengthening the QT interval. Medications classically known to prolong the QT interval include certain antiarrhythmics, calcium antagonists, anti-psychotics, antihistamines, macrolide and fluoroquinolone antibiotics, certain antifungals, and antiretroviral medications (a complete list can be found at crediblemeds.org.).4–6 In addition, electrolyte abnormalities can similarly affect the repolarization phase. Alterations in serum potassium levels are the most likely to alter the QT interval, however magnesium, calcium and sodium are contributory as well.4 Sympathetic stimulation has also been implicated, most notably in sudden exposure to cold water, accounting for a large proportion of sudden cardiac death occurring during swimming.3,7 In fact, during provocative electrophysiology testing, epinephrine boluses are sometimes used to directly affect the QT interval due to its sympathomimetic effect.7 Bradycardia, structural heart diseases, female gender, impaired hepatic and renal function, and advanced age are also known risk factors.8,9
Due to the above-mentioned risk of sudden death, it is crucially important to recognize LQTS and subsequently follow an appropriate treatment plan. All patients with any significant prolongation of the QT interval, whether transient or persistent, should undergo genetic testing to determine whether they have an underlying channelopathy.10 If an underlying genetic alteration is identified, family members should be counseled on the need for further testing and evaluation.10 Treatment for patients with acquired QT prolongation includes withholding medications with known QT prolonging effects and avoiding serum electrolyte perturbations. Treatments for patients with congenital prolonged QT include the above strategies, observation, beta blocker therapy, avoidance of high intensity sports, or implantable cardiac defibrillator (ICD) placement.11
CASE REPORT
A 44-year-old female with a history of well-controlled asthma and hypertension presented to the emergency department (ED) with “chest tightness”, which the patient described as inability to take a full breath with occasional pressure-like sensation across the precordium. The patient denied exertional component, leg swelling, history of coagulopathy, thrombotic risk factors, family history for coronary artery disease, cough, fever, vomiting, or abdominal pain. One week prior to ED presentation, the patient had a routine checkup with her family physician and was started on chlorthalidone for her hypertension. She was prescribed the following home medications: montelukast, fluticasone, chlorthalidone, loratidine, ascorbic acid, ferrous sulfate, and albuterol.
The patient’s initial presenting vital signs were the following: pulse 82 beats per minute; blood pressure of 123/73 millimeters of mercury; respirations 18 per minute; oxygen saturation 100%; temperature 98.2 degrees Fahrenheit. On physical exam, breath sounds were mildly diminished in all lung fields. A subtle end expiratory wheeze was appreciated. There was no accessory muscle use or increased respiratory effort. There was no evidence of stridor or upper airway swelling. Cardiac auscultation demonstrated a regular rate and rhythm with no murmur appreciated. The abdomen was soft, nontender and nondistended. Pulses were equally present and strong in all four extremities. No lower extremity swelling was appreciated. A chest radiograph was within normal limits. An initial electrocardiogram (ECG) (Image A) demonstrated no acute ischemia or dysrhythmia (Bazett QTc 423 milliseconds [ms]).
A troponin was similarly negative after days of symptoms, lowering concern for acute coronary syndrome. A trial of albuterol was instituted as some of her symptoms were considered to be attributable to her otherwise well-controlled asthma. Shortly after receiving the nebulized albuterol treatment, the patient became tachycardic and very tremulous. A repeat ECG was obtained (Image B) and notable for a significantly prolonged QT interval (Bazett QTc 633 ms) with distinct morphology change of the T wave. Laboratory studies were reviewed and notable for hypokalemia of 3.2 milliequivalents per liter (mEq/L) (reference range 3.4–5.1 mEq/L) and hypomagnesemia of 1.6 milligrams per deciliter (milligrams per deciliter [mg]/dL) (reference range 1.7–2.2 mg/dL). The albuterol treatment was terminated. The patient was immediately treated with 2 grams intravenous (IV) magnesium sulfate, 20 mEq IV potassium chloride, and 40mEq oral potassium chloride. After one hour, the QT interval had shortened (QTc 428 ms) (Image C) but retained the T wave morphology change. The patient was observed in the ED for several more hours, and discharged home with a next day follow-up to have her electrolyte levels reassessed. The patient’s chlorthalidone and albuterol were discontinued.
CPC-EM Capsule
What do we already know about this clinical entity?
Long QT Syndrome can predispose patients to Torsades de Pointes. Certain medications are known to further prolong the QT interval.
What makes this presentation of disease reportable?
The patient’s underlying Long QT syndrome was effectively unmasked in the emergency department (ED) in the context of albuterol treatment and electrolyte changes from diuretic use.
What is the major learning point?
Be vigilant of the QT prolonging effects of certain medications and electrolyte derangements to further prolong the QT interval. Genetic Long QT Syndrome may only be “unmasked” briefly.
How might this improve emergency medicine practice?
Genetic Long QT Syndrome can be identified in the ED and potentially life-saving referrals can be made.
The patient was referred to an electrophysiologist and ultimately diagnosed with Type 1 LQTS. The patient’s family was referred for genetic counseling. Despite the patient’s asthma being a contraindication, after a risk-and-benefit conversation she was initiated on low-dose beta blocker therapy which was well tolerated. She declined placement of an ICD. The importance of close monitoring of her electrolytes was stressed, particularly during situations in which electrolyte loss is possible (diarrhea, vomiting, exercise).
DISCUSSION
This case was unique in that it contained elements of both genetic and acquired LQTS. Given her normal ECG at presentation, this represents a case of electrocardiographically silent LQTS. Only after provocation with albuterol did she have demonstrable prolonged QT on ECG. In addition, the electrolyte abnormalities caused by the chlorthalidone lowered the threshold for abnormalities in the repolarization phase. The computer-calculated QTc should always be checked with a manual QTc. This can be done by using Bazett’s equation. This should be repeated with multiple different beats in different leads, preferably lead II and V5. After correction the patient’s QT was calculated to be 633 ms. See Image 1 for our calculation.
Patients with congenital LQTS most commonly have mutations to the Kv11.1 and Kv7.1 potassium channel proteins, responsible for the rapid (IKR) and slow (IKS) delayed potassium rectifier currents, respectively.8 These altered IKR and IKS currents can lead to excessive local extracellular potassium levels and ultimately repolarization abnormalities.12 Should these gradients worsen, the patient is at risk for entering torsades de pointes.
The figure is a schematic demonstrating the action potential of a cardiac myocyte.13 As described above, IKR and IKS are the most commonly affected currents in congenital LQTS. These will directly affect phase three, causing a delay in repolarization. On the ECG, this corresponds to the altered T wave morphology and subsequently the prolonged QT interval.
In addition, generalized sympathetic stimulation can prolong the QT interval. In fact, in electrophysiology laboratory testing, patients are given epinephrine boluses to elicit sympathetic stimulation to unmask LQTS.3 The albuterol “challenge” that was administered in the ED certainly could have had a similar sympathomimetic effect. Indeed, a study by Thottathil et al showed beta-2 agonist use by patients with LQTS is a risk factor for cardiac events.14 Asthmatic patients with LQTS who need beta-2 agonists should have electrolyte levels monitored and repleted as necessary. When not contraindicated, the provider should also consider using a beta blocker as there is decreased risk of cardiac events when beta blockers are used.14
CONCLUSION
In conclusion, this is a cautionary tale in which a patient with an underlying cardiac channelopathy was administered a QT prolonging agent in the context of multiple electrolyte abnormalities induced by a recently started thiazide diuretic. Caution should be exercised in administering patients a medication with known QT prolonging effects. It is not infrequent that several medications with the potential for QT prolongation may be used simultaneously in the ED setting (eg, an agitated elderly patient with chronic obstructive pulmonary disease found to have pneumonia). In patients receiving these medications, consider first obtaining an ECG and/or placing the patient on a cardiac monitor.
Section Editor: Manish Amin, DO
Full text available through open access at http://escholarship.org/uc/uciem_cpcem
Patient consent has been obtained and filed for the publication of this case report.
Conflicts of Interest: By the CPC-EM article submission agreement, all authors are required to disclose all affiliations, funding sources and financial or management relationships that could be perceived as potential sources of bias. The authors disclosed none. “The views expressed in this case report are those of the authors and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, or the United States Government. We are military service members. This work was prepared as part of our official duties. Title 17 U.S.C. 105 provides that “Copyright protection under this title is not available for any work of the United States Government.” Title 17 U.S.C. 101 defines a United States Government work as a work prepared by a military service member or employee of the United States Government as part of that person’s official duties.”
Figure Cardiac Myocyte Action Potential. Slow delayed rectifier potassium current (IKS) and rapid delayed potassium rectifier current (IKR) are responsible for efflux of potassium ion during the repolarization phase of the cardiac myocyte (Phase 3). Abnormal serum potassium levels can further affect repolarization in the context of dysfunctional potassium channels.
K+, potassium; Na+, sodium; Cl−, chloride; Ca2+, calcium; IK1, inward rectifier potassium current; INa, inward sodium channel; Ito1,2, transient outward potassium current; ICa-L, L-type calcium current; IKS, slow delayed rectifier potassium current; IKR, rapid delayed potassium rectifier current; ms, milliseconds.
*Adapted and modified from Wikimedia Commons with permission.
Image Serial electrocardiograms (ECG) demonstrating QT prolongation after albuterol use. ECG A demonstrates the patient’s baseline with no acute dysrhythmia or ischemia and QTc of 423 milliseconds (ms). ECG B demonstrates a QTc interval of 633 ms and T wave morphology change. ECG C demonstrates QTc return to 428ms, with retention of the T wave morphology. | Respiratory (inhalation) | DrugAdministrationRoute | CC BY | 33560961 | 18,924,576 | 2021-02 |
What was the outcome of reaction 'Agitation'? | Unmasking Long QT Syndrome in the Emergency Department: A Case Report.
BACKGROUND
Long QT syndrome (LQTS) is an uncommon disorder that can lead to potentially life-threatening dysrhythmias. LQTS can be genetic, acquired, or both.
METHODS
A 44-year-old female with well-controlled hypertension and asthma presented with chest tightness. An initial electrocardiogram yielded a normal corrected QT interval of 423 milliseconds (ms) (normal <480 ms in females). Albuterol was administered and induced agitation, tremulousness, and tachycardia. Follow-up electrocardiograms demonstrated extreme prolongation of the corrected QT interval to 633 ms and morphology change of the T wave. Lab values were later notable for hypokalemia and hypomagnesemia, attributable to a recently started thiazide diuretic. The patient was ultimately diagnosed with congenital LQTS after initial unmasking by albuterol in the emergency department.
CONCLUSIONS
LQTS can be unmasked or exacerbated by electrolyte abnormalities and QT prolonging medications.
INTRODUCTION
Long QT syndrome (LQTS) is a rare condition in which cardiac myocytes are predisposed to repolarization phase abnormalities, which can lead to life-threatening torsades de pointes.1 It is one of the leading causes of unexplained sudden cardiac death.1 Long QT syndrome can be congenital, acquired, or both.
The prevalence of congenital LQTS is estimated at 1 in 2000 births.2 This does not account for patients with electrocardiographically silent LQTS and those who are genotype positive but phenotype negative.2 Thus, the true prevalence of the LQTS gene is likely higher. Patients may have electrocardiographically silent LQTS, only to be unmasked by certain QT prolonging medications, electrolyte abnormalities, or sympathetic stimulation.3 Type 1 LQTS, one of the most common forms of congenital LQTS, is particularly susceptible to sympathetic stimulation.3
Several classes of medications have been demonstrated to lengthen the repolarization phase of cardiac myocytes, thus lengthening the QT interval. Medications classically known to prolong the QT interval include certain antiarrhythmics, calcium antagonists, anti-psychotics, antihistamines, macrolide and fluoroquinolone antibiotics, certain antifungals, and antiretroviral medications (a complete list can be found at crediblemeds.org.).4–6 In addition, electrolyte abnormalities can similarly affect the repolarization phase. Alterations in serum potassium levels are the most likely to alter the QT interval, however magnesium, calcium and sodium are contributory as well.4 Sympathetic stimulation has also been implicated, most notably in sudden exposure to cold water, accounting for a large proportion of sudden cardiac death occurring during swimming.3,7 In fact, during provocative electrophysiology testing, epinephrine boluses are sometimes used to directly affect the QT interval due to its sympathomimetic effect.7 Bradycardia, structural heart diseases, female gender, impaired hepatic and renal function, and advanced age are also known risk factors.8,9
Due to the above-mentioned risk of sudden death, it is crucially important to recognize LQTS and subsequently follow an appropriate treatment plan. All patients with any significant prolongation of the QT interval, whether transient or persistent, should undergo genetic testing to determine whether they have an underlying channelopathy.10 If an underlying genetic alteration is identified, family members should be counseled on the need for further testing and evaluation.10 Treatment for patients with acquired QT prolongation includes withholding medications with known QT prolonging effects and avoiding serum electrolyte perturbations. Treatments for patients with congenital prolonged QT include the above strategies, observation, beta blocker therapy, avoidance of high intensity sports, or implantable cardiac defibrillator (ICD) placement.11
CASE REPORT
A 44-year-old female with a history of well-controlled asthma and hypertension presented to the emergency department (ED) with “chest tightness”, which the patient described as inability to take a full breath with occasional pressure-like sensation across the precordium. The patient denied exertional component, leg swelling, history of coagulopathy, thrombotic risk factors, family history for coronary artery disease, cough, fever, vomiting, or abdominal pain. One week prior to ED presentation, the patient had a routine checkup with her family physician and was started on chlorthalidone for her hypertension. She was prescribed the following home medications: montelukast, fluticasone, chlorthalidone, loratidine, ascorbic acid, ferrous sulfate, and albuterol.
The patient’s initial presenting vital signs were the following: pulse 82 beats per minute; blood pressure of 123/73 millimeters of mercury; respirations 18 per minute; oxygen saturation 100%; temperature 98.2 degrees Fahrenheit. On physical exam, breath sounds were mildly diminished in all lung fields. A subtle end expiratory wheeze was appreciated. There was no accessory muscle use or increased respiratory effort. There was no evidence of stridor or upper airway swelling. Cardiac auscultation demonstrated a regular rate and rhythm with no murmur appreciated. The abdomen was soft, nontender and nondistended. Pulses were equally present and strong in all four extremities. No lower extremity swelling was appreciated. A chest radiograph was within normal limits. An initial electrocardiogram (ECG) (Image A) demonstrated no acute ischemia or dysrhythmia (Bazett QTc 423 milliseconds [ms]).
A troponin was similarly negative after days of symptoms, lowering concern for acute coronary syndrome. A trial of albuterol was instituted as some of her symptoms were considered to be attributable to her otherwise well-controlled asthma. Shortly after receiving the nebulized albuterol treatment, the patient became tachycardic and very tremulous. A repeat ECG was obtained (Image B) and notable for a significantly prolonged QT interval (Bazett QTc 633 ms) with distinct morphology change of the T wave. Laboratory studies were reviewed and notable for hypokalemia of 3.2 milliequivalents per liter (mEq/L) (reference range 3.4–5.1 mEq/L) and hypomagnesemia of 1.6 milligrams per deciliter (milligrams per deciliter [mg]/dL) (reference range 1.7–2.2 mg/dL). The albuterol treatment was terminated. The patient was immediately treated with 2 grams intravenous (IV) magnesium sulfate, 20 mEq IV potassium chloride, and 40mEq oral potassium chloride. After one hour, the QT interval had shortened (QTc 428 ms) (Image C) but retained the T wave morphology change. The patient was observed in the ED for several more hours, and discharged home with a next day follow-up to have her electrolyte levels reassessed. The patient’s chlorthalidone and albuterol were discontinued.
CPC-EM Capsule
What do we already know about this clinical entity?
Long QT Syndrome can predispose patients to Torsades de Pointes. Certain medications are known to further prolong the QT interval.
What makes this presentation of disease reportable?
The patient’s underlying Long QT syndrome was effectively unmasked in the emergency department (ED) in the context of albuterol treatment and electrolyte changes from diuretic use.
What is the major learning point?
Be vigilant of the QT prolonging effects of certain medications and electrolyte derangements to further prolong the QT interval. Genetic Long QT Syndrome may only be “unmasked” briefly.
How might this improve emergency medicine practice?
Genetic Long QT Syndrome can be identified in the ED and potentially life-saving referrals can be made.
The patient was referred to an electrophysiologist and ultimately diagnosed with Type 1 LQTS. The patient’s family was referred for genetic counseling. Despite the patient’s asthma being a contraindication, after a risk-and-benefit conversation she was initiated on low-dose beta blocker therapy which was well tolerated. She declined placement of an ICD. The importance of close monitoring of her electrolytes was stressed, particularly during situations in which electrolyte loss is possible (diarrhea, vomiting, exercise).
DISCUSSION
This case was unique in that it contained elements of both genetic and acquired LQTS. Given her normal ECG at presentation, this represents a case of electrocardiographically silent LQTS. Only after provocation with albuterol did she have demonstrable prolonged QT on ECG. In addition, the electrolyte abnormalities caused by the chlorthalidone lowered the threshold for abnormalities in the repolarization phase. The computer-calculated QTc should always be checked with a manual QTc. This can be done by using Bazett’s equation. This should be repeated with multiple different beats in different leads, preferably lead II and V5. After correction the patient’s QT was calculated to be 633 ms. See Image 1 for our calculation.
Patients with congenital LQTS most commonly have mutations to the Kv11.1 and Kv7.1 potassium channel proteins, responsible for the rapid (IKR) and slow (IKS) delayed potassium rectifier currents, respectively.8 These altered IKR and IKS currents can lead to excessive local extracellular potassium levels and ultimately repolarization abnormalities.12 Should these gradients worsen, the patient is at risk for entering torsades de pointes.
The figure is a schematic demonstrating the action potential of a cardiac myocyte.13 As described above, IKR and IKS are the most commonly affected currents in congenital LQTS. These will directly affect phase three, causing a delay in repolarization. On the ECG, this corresponds to the altered T wave morphology and subsequently the prolonged QT interval.
In addition, generalized sympathetic stimulation can prolong the QT interval. In fact, in electrophysiology laboratory testing, patients are given epinephrine boluses to elicit sympathetic stimulation to unmask LQTS.3 The albuterol “challenge” that was administered in the ED certainly could have had a similar sympathomimetic effect. Indeed, a study by Thottathil et al showed beta-2 agonist use by patients with LQTS is a risk factor for cardiac events.14 Asthmatic patients with LQTS who need beta-2 agonists should have electrolyte levels monitored and repleted as necessary. When not contraindicated, the provider should also consider using a beta blocker as there is decreased risk of cardiac events when beta blockers are used.14
CONCLUSION
In conclusion, this is a cautionary tale in which a patient with an underlying cardiac channelopathy was administered a QT prolonging agent in the context of multiple electrolyte abnormalities induced by a recently started thiazide diuretic. Caution should be exercised in administering patients a medication with known QT prolonging effects. It is not infrequent that several medications with the potential for QT prolongation may be used simultaneously in the ED setting (eg, an agitated elderly patient with chronic obstructive pulmonary disease found to have pneumonia). In patients receiving these medications, consider first obtaining an ECG and/or placing the patient on a cardiac monitor.
Section Editor: Manish Amin, DO
Full text available through open access at http://escholarship.org/uc/uciem_cpcem
Patient consent has been obtained and filed for the publication of this case report.
Conflicts of Interest: By the CPC-EM article submission agreement, all authors are required to disclose all affiliations, funding sources and financial or management relationships that could be perceived as potential sources of bias. The authors disclosed none. “The views expressed in this case report are those of the authors and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, or the United States Government. We are military service members. This work was prepared as part of our official duties. Title 17 U.S.C. 105 provides that “Copyright protection under this title is not available for any work of the United States Government.” Title 17 U.S.C. 101 defines a United States Government work as a work prepared by a military service member or employee of the United States Government as part of that person’s official duties.”
Figure Cardiac Myocyte Action Potential. Slow delayed rectifier potassium current (IKS) and rapid delayed potassium rectifier current (IKR) are responsible for efflux of potassium ion during the repolarization phase of the cardiac myocyte (Phase 3). Abnormal serum potassium levels can further affect repolarization in the context of dysfunctional potassium channels.
K+, potassium; Na+, sodium; Cl−, chloride; Ca2+, calcium; IK1, inward rectifier potassium current; INa, inward sodium channel; Ito1,2, transient outward potassium current; ICa-L, L-type calcium current; IKS, slow delayed rectifier potassium current; IKR, rapid delayed potassium rectifier current; ms, milliseconds.
*Adapted and modified from Wikimedia Commons with permission.
Image Serial electrocardiograms (ECG) demonstrating QT prolongation after albuterol use. ECG A demonstrates the patient’s baseline with no acute dysrhythmia or ischemia and QTc of 423 milliseconds (ms). ECG B demonstrates a QTc interval of 633 ms and T wave morphology change. ECG C demonstrates QTc return to 428ms, with retention of the T wave morphology. | Recovered | ReactionOutcome | CC BY | 33560961 | 18,999,127 | 2021-02 |
What was the outcome of reaction 'Electrocardiogram QT prolonged'? | Unmasking Long QT Syndrome in the Emergency Department: A Case Report.
BACKGROUND
Long QT syndrome (LQTS) is an uncommon disorder that can lead to potentially life-threatening dysrhythmias. LQTS can be genetic, acquired, or both.
METHODS
A 44-year-old female with well-controlled hypertension and asthma presented with chest tightness. An initial electrocardiogram yielded a normal corrected QT interval of 423 milliseconds (ms) (normal <480 ms in females). Albuterol was administered and induced agitation, tremulousness, and tachycardia. Follow-up electrocardiograms demonstrated extreme prolongation of the corrected QT interval to 633 ms and morphology change of the T wave. Lab values were later notable for hypokalemia and hypomagnesemia, attributable to a recently started thiazide diuretic. The patient was ultimately diagnosed with congenital LQTS after initial unmasking by albuterol in the emergency department.
CONCLUSIONS
LQTS can be unmasked or exacerbated by electrolyte abnormalities and QT prolonging medications.
INTRODUCTION
Long QT syndrome (LQTS) is a rare condition in which cardiac myocytes are predisposed to repolarization phase abnormalities, which can lead to life-threatening torsades de pointes.1 It is one of the leading causes of unexplained sudden cardiac death.1 Long QT syndrome can be congenital, acquired, or both.
The prevalence of congenital LQTS is estimated at 1 in 2000 births.2 This does not account for patients with electrocardiographically silent LQTS and those who are genotype positive but phenotype negative.2 Thus, the true prevalence of the LQTS gene is likely higher. Patients may have electrocardiographically silent LQTS, only to be unmasked by certain QT prolonging medications, electrolyte abnormalities, or sympathetic stimulation.3 Type 1 LQTS, one of the most common forms of congenital LQTS, is particularly susceptible to sympathetic stimulation.3
Several classes of medications have been demonstrated to lengthen the repolarization phase of cardiac myocytes, thus lengthening the QT interval. Medications classically known to prolong the QT interval include certain antiarrhythmics, calcium antagonists, anti-psychotics, antihistamines, macrolide and fluoroquinolone antibiotics, certain antifungals, and antiretroviral medications (a complete list can be found at crediblemeds.org.).4–6 In addition, electrolyte abnormalities can similarly affect the repolarization phase. Alterations in serum potassium levels are the most likely to alter the QT interval, however magnesium, calcium and sodium are contributory as well.4 Sympathetic stimulation has also been implicated, most notably in sudden exposure to cold water, accounting for a large proportion of sudden cardiac death occurring during swimming.3,7 In fact, during provocative electrophysiology testing, epinephrine boluses are sometimes used to directly affect the QT interval due to its sympathomimetic effect.7 Bradycardia, structural heart diseases, female gender, impaired hepatic and renal function, and advanced age are also known risk factors.8,9
Due to the above-mentioned risk of sudden death, it is crucially important to recognize LQTS and subsequently follow an appropriate treatment plan. All patients with any significant prolongation of the QT interval, whether transient or persistent, should undergo genetic testing to determine whether they have an underlying channelopathy.10 If an underlying genetic alteration is identified, family members should be counseled on the need for further testing and evaluation.10 Treatment for patients with acquired QT prolongation includes withholding medications with known QT prolonging effects and avoiding serum electrolyte perturbations. Treatments for patients with congenital prolonged QT include the above strategies, observation, beta blocker therapy, avoidance of high intensity sports, or implantable cardiac defibrillator (ICD) placement.11
CASE REPORT
A 44-year-old female with a history of well-controlled asthma and hypertension presented to the emergency department (ED) with “chest tightness”, which the patient described as inability to take a full breath with occasional pressure-like sensation across the precordium. The patient denied exertional component, leg swelling, history of coagulopathy, thrombotic risk factors, family history for coronary artery disease, cough, fever, vomiting, or abdominal pain. One week prior to ED presentation, the patient had a routine checkup with her family physician and was started on chlorthalidone for her hypertension. She was prescribed the following home medications: montelukast, fluticasone, chlorthalidone, loratidine, ascorbic acid, ferrous sulfate, and albuterol.
The patient’s initial presenting vital signs were the following: pulse 82 beats per minute; blood pressure of 123/73 millimeters of mercury; respirations 18 per minute; oxygen saturation 100%; temperature 98.2 degrees Fahrenheit. On physical exam, breath sounds were mildly diminished in all lung fields. A subtle end expiratory wheeze was appreciated. There was no accessory muscle use or increased respiratory effort. There was no evidence of stridor or upper airway swelling. Cardiac auscultation demonstrated a regular rate and rhythm with no murmur appreciated. The abdomen was soft, nontender and nondistended. Pulses were equally present and strong in all four extremities. No lower extremity swelling was appreciated. A chest radiograph was within normal limits. An initial electrocardiogram (ECG) (Image A) demonstrated no acute ischemia or dysrhythmia (Bazett QTc 423 milliseconds [ms]).
A troponin was similarly negative after days of symptoms, lowering concern for acute coronary syndrome. A trial of albuterol was instituted as some of her symptoms were considered to be attributable to her otherwise well-controlled asthma. Shortly after receiving the nebulized albuterol treatment, the patient became tachycardic and very tremulous. A repeat ECG was obtained (Image B) and notable for a significantly prolonged QT interval (Bazett QTc 633 ms) with distinct morphology change of the T wave. Laboratory studies were reviewed and notable for hypokalemia of 3.2 milliequivalents per liter (mEq/L) (reference range 3.4–5.1 mEq/L) and hypomagnesemia of 1.6 milligrams per deciliter (milligrams per deciliter [mg]/dL) (reference range 1.7–2.2 mg/dL). The albuterol treatment was terminated. The patient was immediately treated with 2 grams intravenous (IV) magnesium sulfate, 20 mEq IV potassium chloride, and 40mEq oral potassium chloride. After one hour, the QT interval had shortened (QTc 428 ms) (Image C) but retained the T wave morphology change. The patient was observed in the ED for several more hours, and discharged home with a next day follow-up to have her electrolyte levels reassessed. The patient’s chlorthalidone and albuterol were discontinued.
CPC-EM Capsule
What do we already know about this clinical entity?
Long QT Syndrome can predispose patients to Torsades de Pointes. Certain medications are known to further prolong the QT interval.
What makes this presentation of disease reportable?
The patient’s underlying Long QT syndrome was effectively unmasked in the emergency department (ED) in the context of albuterol treatment and electrolyte changes from diuretic use.
What is the major learning point?
Be vigilant of the QT prolonging effects of certain medications and electrolyte derangements to further prolong the QT interval. Genetic Long QT Syndrome may only be “unmasked” briefly.
How might this improve emergency medicine practice?
Genetic Long QT Syndrome can be identified in the ED and potentially life-saving referrals can be made.
The patient was referred to an electrophysiologist and ultimately diagnosed with Type 1 LQTS. The patient’s family was referred for genetic counseling. Despite the patient’s asthma being a contraindication, after a risk-and-benefit conversation she was initiated on low-dose beta blocker therapy which was well tolerated. She declined placement of an ICD. The importance of close monitoring of her electrolytes was stressed, particularly during situations in which electrolyte loss is possible (diarrhea, vomiting, exercise).
DISCUSSION
This case was unique in that it contained elements of both genetic and acquired LQTS. Given her normal ECG at presentation, this represents a case of electrocardiographically silent LQTS. Only after provocation with albuterol did she have demonstrable prolonged QT on ECG. In addition, the electrolyte abnormalities caused by the chlorthalidone lowered the threshold for abnormalities in the repolarization phase. The computer-calculated QTc should always be checked with a manual QTc. This can be done by using Bazett’s equation. This should be repeated with multiple different beats in different leads, preferably lead II and V5. After correction the patient’s QT was calculated to be 633 ms. See Image 1 for our calculation.
Patients with congenital LQTS most commonly have mutations to the Kv11.1 and Kv7.1 potassium channel proteins, responsible for the rapid (IKR) and slow (IKS) delayed potassium rectifier currents, respectively.8 These altered IKR and IKS currents can lead to excessive local extracellular potassium levels and ultimately repolarization abnormalities.12 Should these gradients worsen, the patient is at risk for entering torsades de pointes.
The figure is a schematic demonstrating the action potential of a cardiac myocyte.13 As described above, IKR and IKS are the most commonly affected currents in congenital LQTS. These will directly affect phase three, causing a delay in repolarization. On the ECG, this corresponds to the altered T wave morphology and subsequently the prolonged QT interval.
In addition, generalized sympathetic stimulation can prolong the QT interval. In fact, in electrophysiology laboratory testing, patients are given epinephrine boluses to elicit sympathetic stimulation to unmask LQTS.3 The albuterol “challenge” that was administered in the ED certainly could have had a similar sympathomimetic effect. Indeed, a study by Thottathil et al showed beta-2 agonist use by patients with LQTS is a risk factor for cardiac events.14 Asthmatic patients with LQTS who need beta-2 agonists should have electrolyte levels monitored and repleted as necessary. When not contraindicated, the provider should also consider using a beta blocker as there is decreased risk of cardiac events when beta blockers are used.14
CONCLUSION
In conclusion, this is a cautionary tale in which a patient with an underlying cardiac channelopathy was administered a QT prolonging agent in the context of multiple electrolyte abnormalities induced by a recently started thiazide diuretic. Caution should be exercised in administering patients a medication with known QT prolonging effects. It is not infrequent that several medications with the potential for QT prolongation may be used simultaneously in the ED setting (eg, an agitated elderly patient with chronic obstructive pulmonary disease found to have pneumonia). In patients receiving these medications, consider first obtaining an ECG and/or placing the patient on a cardiac monitor.
Section Editor: Manish Amin, DO
Full text available through open access at http://escholarship.org/uc/uciem_cpcem
Patient consent has been obtained and filed for the publication of this case report.
Conflicts of Interest: By the CPC-EM article submission agreement, all authors are required to disclose all affiliations, funding sources and financial or management relationships that could be perceived as potential sources of bias. The authors disclosed none. “The views expressed in this case report are those of the authors and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, or the United States Government. We are military service members. This work was prepared as part of our official duties. Title 17 U.S.C. 105 provides that “Copyright protection under this title is not available for any work of the United States Government.” Title 17 U.S.C. 101 defines a United States Government work as a work prepared by a military service member or employee of the United States Government as part of that person’s official duties.”
Figure Cardiac Myocyte Action Potential. Slow delayed rectifier potassium current (IKS) and rapid delayed potassium rectifier current (IKR) are responsible for efflux of potassium ion during the repolarization phase of the cardiac myocyte (Phase 3). Abnormal serum potassium levels can further affect repolarization in the context of dysfunctional potassium channels.
K+, potassium; Na+, sodium; Cl−, chloride; Ca2+, calcium; IK1, inward rectifier potassium current; INa, inward sodium channel; Ito1,2, transient outward potassium current; ICa-L, L-type calcium current; IKS, slow delayed rectifier potassium current; IKR, rapid delayed potassium rectifier current; ms, milliseconds.
*Adapted and modified from Wikimedia Commons with permission.
Image Serial electrocardiograms (ECG) demonstrating QT prolongation after albuterol use. ECG A demonstrates the patient’s baseline with no acute dysrhythmia or ischemia and QTc of 423 milliseconds (ms). ECG B demonstrates a QTc interval of 633 ms and T wave morphology change. ECG C demonstrates QTc return to 428ms, with retention of the T wave morphology. | Recovered | ReactionOutcome | CC BY | 33560961 | 18,924,576 | 2021-02 |
What was the outcome of reaction 'Long QT syndrome'? | Unmasking Long QT Syndrome in the Emergency Department: A Case Report.
BACKGROUND
Long QT syndrome (LQTS) is an uncommon disorder that can lead to potentially life-threatening dysrhythmias. LQTS can be genetic, acquired, or both.
METHODS
A 44-year-old female with well-controlled hypertension and asthma presented with chest tightness. An initial electrocardiogram yielded a normal corrected QT interval of 423 milliseconds (ms) (normal <480 ms in females). Albuterol was administered and induced agitation, tremulousness, and tachycardia. Follow-up electrocardiograms demonstrated extreme prolongation of the corrected QT interval to 633 ms and morphology change of the T wave. Lab values were later notable for hypokalemia and hypomagnesemia, attributable to a recently started thiazide diuretic. The patient was ultimately diagnosed with congenital LQTS after initial unmasking by albuterol in the emergency department.
CONCLUSIONS
LQTS can be unmasked or exacerbated by electrolyte abnormalities and QT prolonging medications.
INTRODUCTION
Long QT syndrome (LQTS) is a rare condition in which cardiac myocytes are predisposed to repolarization phase abnormalities, which can lead to life-threatening torsades de pointes.1 It is one of the leading causes of unexplained sudden cardiac death.1 Long QT syndrome can be congenital, acquired, or both.
The prevalence of congenital LQTS is estimated at 1 in 2000 births.2 This does not account for patients with electrocardiographically silent LQTS and those who are genotype positive but phenotype negative.2 Thus, the true prevalence of the LQTS gene is likely higher. Patients may have electrocardiographically silent LQTS, only to be unmasked by certain QT prolonging medications, electrolyte abnormalities, or sympathetic stimulation.3 Type 1 LQTS, one of the most common forms of congenital LQTS, is particularly susceptible to sympathetic stimulation.3
Several classes of medications have been demonstrated to lengthen the repolarization phase of cardiac myocytes, thus lengthening the QT interval. Medications classically known to prolong the QT interval include certain antiarrhythmics, calcium antagonists, anti-psychotics, antihistamines, macrolide and fluoroquinolone antibiotics, certain antifungals, and antiretroviral medications (a complete list can be found at crediblemeds.org.).4–6 In addition, electrolyte abnormalities can similarly affect the repolarization phase. Alterations in serum potassium levels are the most likely to alter the QT interval, however magnesium, calcium and sodium are contributory as well.4 Sympathetic stimulation has also been implicated, most notably in sudden exposure to cold water, accounting for a large proportion of sudden cardiac death occurring during swimming.3,7 In fact, during provocative electrophysiology testing, epinephrine boluses are sometimes used to directly affect the QT interval due to its sympathomimetic effect.7 Bradycardia, structural heart diseases, female gender, impaired hepatic and renal function, and advanced age are also known risk factors.8,9
Due to the above-mentioned risk of sudden death, it is crucially important to recognize LQTS and subsequently follow an appropriate treatment plan. All patients with any significant prolongation of the QT interval, whether transient or persistent, should undergo genetic testing to determine whether they have an underlying channelopathy.10 If an underlying genetic alteration is identified, family members should be counseled on the need for further testing and evaluation.10 Treatment for patients with acquired QT prolongation includes withholding medications with known QT prolonging effects and avoiding serum electrolyte perturbations. Treatments for patients with congenital prolonged QT include the above strategies, observation, beta blocker therapy, avoidance of high intensity sports, or implantable cardiac defibrillator (ICD) placement.11
CASE REPORT
A 44-year-old female with a history of well-controlled asthma and hypertension presented to the emergency department (ED) with “chest tightness”, which the patient described as inability to take a full breath with occasional pressure-like sensation across the precordium. The patient denied exertional component, leg swelling, history of coagulopathy, thrombotic risk factors, family history for coronary artery disease, cough, fever, vomiting, or abdominal pain. One week prior to ED presentation, the patient had a routine checkup with her family physician and was started on chlorthalidone for her hypertension. She was prescribed the following home medications: montelukast, fluticasone, chlorthalidone, loratidine, ascorbic acid, ferrous sulfate, and albuterol.
The patient’s initial presenting vital signs were the following: pulse 82 beats per minute; blood pressure of 123/73 millimeters of mercury; respirations 18 per minute; oxygen saturation 100%; temperature 98.2 degrees Fahrenheit. On physical exam, breath sounds were mildly diminished in all lung fields. A subtle end expiratory wheeze was appreciated. There was no accessory muscle use or increased respiratory effort. There was no evidence of stridor or upper airway swelling. Cardiac auscultation demonstrated a regular rate and rhythm with no murmur appreciated. The abdomen was soft, nontender and nondistended. Pulses were equally present and strong in all four extremities. No lower extremity swelling was appreciated. A chest radiograph was within normal limits. An initial electrocardiogram (ECG) (Image A) demonstrated no acute ischemia or dysrhythmia (Bazett QTc 423 milliseconds [ms]).
A troponin was similarly negative after days of symptoms, lowering concern for acute coronary syndrome. A trial of albuterol was instituted as some of her symptoms were considered to be attributable to her otherwise well-controlled asthma. Shortly after receiving the nebulized albuterol treatment, the patient became tachycardic and very tremulous. A repeat ECG was obtained (Image B) and notable for a significantly prolonged QT interval (Bazett QTc 633 ms) with distinct morphology change of the T wave. Laboratory studies were reviewed and notable for hypokalemia of 3.2 milliequivalents per liter (mEq/L) (reference range 3.4–5.1 mEq/L) and hypomagnesemia of 1.6 milligrams per deciliter (milligrams per deciliter [mg]/dL) (reference range 1.7–2.2 mg/dL). The albuterol treatment was terminated. The patient was immediately treated with 2 grams intravenous (IV) magnesium sulfate, 20 mEq IV potassium chloride, and 40mEq oral potassium chloride. After one hour, the QT interval had shortened (QTc 428 ms) (Image C) but retained the T wave morphology change. The patient was observed in the ED for several more hours, and discharged home with a next day follow-up to have her electrolyte levels reassessed. The patient’s chlorthalidone and albuterol were discontinued.
CPC-EM Capsule
What do we already know about this clinical entity?
Long QT Syndrome can predispose patients to Torsades de Pointes. Certain medications are known to further prolong the QT interval.
What makes this presentation of disease reportable?
The patient’s underlying Long QT syndrome was effectively unmasked in the emergency department (ED) in the context of albuterol treatment and electrolyte changes from diuretic use.
What is the major learning point?
Be vigilant of the QT prolonging effects of certain medications and electrolyte derangements to further prolong the QT interval. Genetic Long QT Syndrome may only be “unmasked” briefly.
How might this improve emergency medicine practice?
Genetic Long QT Syndrome can be identified in the ED and potentially life-saving referrals can be made.
The patient was referred to an electrophysiologist and ultimately diagnosed with Type 1 LQTS. The patient’s family was referred for genetic counseling. Despite the patient’s asthma being a contraindication, after a risk-and-benefit conversation she was initiated on low-dose beta blocker therapy which was well tolerated. She declined placement of an ICD. The importance of close monitoring of her electrolytes was stressed, particularly during situations in which electrolyte loss is possible (diarrhea, vomiting, exercise).
DISCUSSION
This case was unique in that it contained elements of both genetic and acquired LQTS. Given her normal ECG at presentation, this represents a case of electrocardiographically silent LQTS. Only after provocation with albuterol did she have demonstrable prolonged QT on ECG. In addition, the electrolyte abnormalities caused by the chlorthalidone lowered the threshold for abnormalities in the repolarization phase. The computer-calculated QTc should always be checked with a manual QTc. This can be done by using Bazett’s equation. This should be repeated with multiple different beats in different leads, preferably lead II and V5. After correction the patient’s QT was calculated to be 633 ms. See Image 1 for our calculation.
Patients with congenital LQTS most commonly have mutations to the Kv11.1 and Kv7.1 potassium channel proteins, responsible for the rapid (IKR) and slow (IKS) delayed potassium rectifier currents, respectively.8 These altered IKR and IKS currents can lead to excessive local extracellular potassium levels and ultimately repolarization abnormalities.12 Should these gradients worsen, the patient is at risk for entering torsades de pointes.
The figure is a schematic demonstrating the action potential of a cardiac myocyte.13 As described above, IKR and IKS are the most commonly affected currents in congenital LQTS. These will directly affect phase three, causing a delay in repolarization. On the ECG, this corresponds to the altered T wave morphology and subsequently the prolonged QT interval.
In addition, generalized sympathetic stimulation can prolong the QT interval. In fact, in electrophysiology laboratory testing, patients are given epinephrine boluses to elicit sympathetic stimulation to unmask LQTS.3 The albuterol “challenge” that was administered in the ED certainly could have had a similar sympathomimetic effect. Indeed, a study by Thottathil et al showed beta-2 agonist use by patients with LQTS is a risk factor for cardiac events.14 Asthmatic patients with LQTS who need beta-2 agonists should have electrolyte levels monitored and repleted as necessary. When not contraindicated, the provider should also consider using a beta blocker as there is decreased risk of cardiac events when beta blockers are used.14
CONCLUSION
In conclusion, this is a cautionary tale in which a patient with an underlying cardiac channelopathy was administered a QT prolonging agent in the context of multiple electrolyte abnormalities induced by a recently started thiazide diuretic. Caution should be exercised in administering patients a medication with known QT prolonging effects. It is not infrequent that several medications with the potential for QT prolongation may be used simultaneously in the ED setting (eg, an agitated elderly patient with chronic obstructive pulmonary disease found to have pneumonia). In patients receiving these medications, consider first obtaining an ECG and/or placing the patient on a cardiac monitor.
Section Editor: Manish Amin, DO
Full text available through open access at http://escholarship.org/uc/uciem_cpcem
Patient consent has been obtained and filed for the publication of this case report.
Conflicts of Interest: By the CPC-EM article submission agreement, all authors are required to disclose all affiliations, funding sources and financial or management relationships that could be perceived as potential sources of bias. The authors disclosed none. “The views expressed in this case report are those of the authors and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, or the United States Government. We are military service members. This work was prepared as part of our official duties. Title 17 U.S.C. 105 provides that “Copyright protection under this title is not available for any work of the United States Government.” Title 17 U.S.C. 101 defines a United States Government work as a work prepared by a military service member or employee of the United States Government as part of that person’s official duties.”
Figure Cardiac Myocyte Action Potential. Slow delayed rectifier potassium current (IKS) and rapid delayed potassium rectifier current (IKR) are responsible for efflux of potassium ion during the repolarization phase of the cardiac myocyte (Phase 3). Abnormal serum potassium levels can further affect repolarization in the context of dysfunctional potassium channels.
K+, potassium; Na+, sodium; Cl−, chloride; Ca2+, calcium; IK1, inward rectifier potassium current; INa, inward sodium channel; Ito1,2, transient outward potassium current; ICa-L, L-type calcium current; IKS, slow delayed rectifier potassium current; IKR, rapid delayed potassium rectifier current; ms, milliseconds.
*Adapted and modified from Wikimedia Commons with permission.
Image Serial electrocardiograms (ECG) demonstrating QT prolongation after albuterol use. ECG A demonstrates the patient’s baseline with no acute dysrhythmia or ischemia and QTc of 423 milliseconds (ms). ECG B demonstrates a QTc interval of 633 ms and T wave morphology change. ECG C demonstrates QTc return to 428ms, with retention of the T wave morphology. | Recovered | ReactionOutcome | CC BY | 33560961 | 18,999,127 | 2021-02 |
What was the outcome of reaction 'Tremor'? | Unmasking Long QT Syndrome in the Emergency Department: A Case Report.
BACKGROUND
Long QT syndrome (LQTS) is an uncommon disorder that can lead to potentially life-threatening dysrhythmias. LQTS can be genetic, acquired, or both.
METHODS
A 44-year-old female with well-controlled hypertension and asthma presented with chest tightness. An initial electrocardiogram yielded a normal corrected QT interval of 423 milliseconds (ms) (normal <480 ms in females). Albuterol was administered and induced agitation, tremulousness, and tachycardia. Follow-up electrocardiograms demonstrated extreme prolongation of the corrected QT interval to 633 ms and morphology change of the T wave. Lab values were later notable for hypokalemia and hypomagnesemia, attributable to a recently started thiazide diuretic. The patient was ultimately diagnosed with congenital LQTS after initial unmasking by albuterol in the emergency department.
CONCLUSIONS
LQTS can be unmasked or exacerbated by electrolyte abnormalities and QT prolonging medications.
INTRODUCTION
Long QT syndrome (LQTS) is a rare condition in which cardiac myocytes are predisposed to repolarization phase abnormalities, which can lead to life-threatening torsades de pointes.1 It is one of the leading causes of unexplained sudden cardiac death.1 Long QT syndrome can be congenital, acquired, or both.
The prevalence of congenital LQTS is estimated at 1 in 2000 births.2 This does not account for patients with electrocardiographically silent LQTS and those who are genotype positive but phenotype negative.2 Thus, the true prevalence of the LQTS gene is likely higher. Patients may have electrocardiographically silent LQTS, only to be unmasked by certain QT prolonging medications, electrolyte abnormalities, or sympathetic stimulation.3 Type 1 LQTS, one of the most common forms of congenital LQTS, is particularly susceptible to sympathetic stimulation.3
Several classes of medications have been demonstrated to lengthen the repolarization phase of cardiac myocytes, thus lengthening the QT interval. Medications classically known to prolong the QT interval include certain antiarrhythmics, calcium antagonists, anti-psychotics, antihistamines, macrolide and fluoroquinolone antibiotics, certain antifungals, and antiretroviral medications (a complete list can be found at crediblemeds.org.).4–6 In addition, electrolyte abnormalities can similarly affect the repolarization phase. Alterations in serum potassium levels are the most likely to alter the QT interval, however magnesium, calcium and sodium are contributory as well.4 Sympathetic stimulation has also been implicated, most notably in sudden exposure to cold water, accounting for a large proportion of sudden cardiac death occurring during swimming.3,7 In fact, during provocative electrophysiology testing, epinephrine boluses are sometimes used to directly affect the QT interval due to its sympathomimetic effect.7 Bradycardia, structural heart diseases, female gender, impaired hepatic and renal function, and advanced age are also known risk factors.8,9
Due to the above-mentioned risk of sudden death, it is crucially important to recognize LQTS and subsequently follow an appropriate treatment plan. All patients with any significant prolongation of the QT interval, whether transient or persistent, should undergo genetic testing to determine whether they have an underlying channelopathy.10 If an underlying genetic alteration is identified, family members should be counseled on the need for further testing and evaluation.10 Treatment for patients with acquired QT prolongation includes withholding medications with known QT prolonging effects and avoiding serum electrolyte perturbations. Treatments for patients with congenital prolonged QT include the above strategies, observation, beta blocker therapy, avoidance of high intensity sports, or implantable cardiac defibrillator (ICD) placement.11
CASE REPORT
A 44-year-old female with a history of well-controlled asthma and hypertension presented to the emergency department (ED) with “chest tightness”, which the patient described as inability to take a full breath with occasional pressure-like sensation across the precordium. The patient denied exertional component, leg swelling, history of coagulopathy, thrombotic risk factors, family history for coronary artery disease, cough, fever, vomiting, or abdominal pain. One week prior to ED presentation, the patient had a routine checkup with her family physician and was started on chlorthalidone for her hypertension. She was prescribed the following home medications: montelukast, fluticasone, chlorthalidone, loratidine, ascorbic acid, ferrous sulfate, and albuterol.
The patient’s initial presenting vital signs were the following: pulse 82 beats per minute; blood pressure of 123/73 millimeters of mercury; respirations 18 per minute; oxygen saturation 100%; temperature 98.2 degrees Fahrenheit. On physical exam, breath sounds were mildly diminished in all lung fields. A subtle end expiratory wheeze was appreciated. There was no accessory muscle use or increased respiratory effort. There was no evidence of stridor or upper airway swelling. Cardiac auscultation demonstrated a regular rate and rhythm with no murmur appreciated. The abdomen was soft, nontender and nondistended. Pulses were equally present and strong in all four extremities. No lower extremity swelling was appreciated. A chest radiograph was within normal limits. An initial electrocardiogram (ECG) (Image A) demonstrated no acute ischemia or dysrhythmia (Bazett QTc 423 milliseconds [ms]).
A troponin was similarly negative after days of symptoms, lowering concern for acute coronary syndrome. A trial of albuterol was instituted as some of her symptoms were considered to be attributable to her otherwise well-controlled asthma. Shortly after receiving the nebulized albuterol treatment, the patient became tachycardic and very tremulous. A repeat ECG was obtained (Image B) and notable for a significantly prolonged QT interval (Bazett QTc 633 ms) with distinct morphology change of the T wave. Laboratory studies were reviewed and notable for hypokalemia of 3.2 milliequivalents per liter (mEq/L) (reference range 3.4–5.1 mEq/L) and hypomagnesemia of 1.6 milligrams per deciliter (milligrams per deciliter [mg]/dL) (reference range 1.7–2.2 mg/dL). The albuterol treatment was terminated. The patient was immediately treated with 2 grams intravenous (IV) magnesium sulfate, 20 mEq IV potassium chloride, and 40mEq oral potassium chloride. After one hour, the QT interval had shortened (QTc 428 ms) (Image C) but retained the T wave morphology change. The patient was observed in the ED for several more hours, and discharged home with a next day follow-up to have her electrolyte levels reassessed. The patient’s chlorthalidone and albuterol were discontinued.
CPC-EM Capsule
What do we already know about this clinical entity?
Long QT Syndrome can predispose patients to Torsades de Pointes. Certain medications are known to further prolong the QT interval.
What makes this presentation of disease reportable?
The patient’s underlying Long QT syndrome was effectively unmasked in the emergency department (ED) in the context of albuterol treatment and electrolyte changes from diuretic use.
What is the major learning point?
Be vigilant of the QT prolonging effects of certain medications and electrolyte derangements to further prolong the QT interval. Genetic Long QT Syndrome may only be “unmasked” briefly.
How might this improve emergency medicine practice?
Genetic Long QT Syndrome can be identified in the ED and potentially life-saving referrals can be made.
The patient was referred to an electrophysiologist and ultimately diagnosed with Type 1 LQTS. The patient’s family was referred for genetic counseling. Despite the patient’s asthma being a contraindication, after a risk-and-benefit conversation she was initiated on low-dose beta blocker therapy which was well tolerated. She declined placement of an ICD. The importance of close monitoring of her electrolytes was stressed, particularly during situations in which electrolyte loss is possible (diarrhea, vomiting, exercise).
DISCUSSION
This case was unique in that it contained elements of both genetic and acquired LQTS. Given her normal ECG at presentation, this represents a case of electrocardiographically silent LQTS. Only after provocation with albuterol did she have demonstrable prolonged QT on ECG. In addition, the electrolyte abnormalities caused by the chlorthalidone lowered the threshold for abnormalities in the repolarization phase. The computer-calculated QTc should always be checked with a manual QTc. This can be done by using Bazett’s equation. This should be repeated with multiple different beats in different leads, preferably lead II and V5. After correction the patient’s QT was calculated to be 633 ms. See Image 1 for our calculation.
Patients with congenital LQTS most commonly have mutations to the Kv11.1 and Kv7.1 potassium channel proteins, responsible for the rapid (IKR) and slow (IKS) delayed potassium rectifier currents, respectively.8 These altered IKR and IKS currents can lead to excessive local extracellular potassium levels and ultimately repolarization abnormalities.12 Should these gradients worsen, the patient is at risk for entering torsades de pointes.
The figure is a schematic demonstrating the action potential of a cardiac myocyte.13 As described above, IKR and IKS are the most commonly affected currents in congenital LQTS. These will directly affect phase three, causing a delay in repolarization. On the ECG, this corresponds to the altered T wave morphology and subsequently the prolonged QT interval.
In addition, generalized sympathetic stimulation can prolong the QT interval. In fact, in electrophysiology laboratory testing, patients are given epinephrine boluses to elicit sympathetic stimulation to unmask LQTS.3 The albuterol “challenge” that was administered in the ED certainly could have had a similar sympathomimetic effect. Indeed, a study by Thottathil et al showed beta-2 agonist use by patients with LQTS is a risk factor for cardiac events.14 Asthmatic patients with LQTS who need beta-2 agonists should have electrolyte levels monitored and repleted as necessary. When not contraindicated, the provider should also consider using a beta blocker as there is decreased risk of cardiac events when beta blockers are used.14
CONCLUSION
In conclusion, this is a cautionary tale in which a patient with an underlying cardiac channelopathy was administered a QT prolonging agent in the context of multiple electrolyte abnormalities induced by a recently started thiazide diuretic. Caution should be exercised in administering patients a medication with known QT prolonging effects. It is not infrequent that several medications with the potential for QT prolongation may be used simultaneously in the ED setting (eg, an agitated elderly patient with chronic obstructive pulmonary disease found to have pneumonia). In patients receiving these medications, consider first obtaining an ECG and/or placing the patient on a cardiac monitor.
Section Editor: Manish Amin, DO
Full text available through open access at http://escholarship.org/uc/uciem_cpcem
Patient consent has been obtained and filed for the publication of this case report.
Conflicts of Interest: By the CPC-EM article submission agreement, all authors are required to disclose all affiliations, funding sources and financial or management relationships that could be perceived as potential sources of bias. The authors disclosed none. “The views expressed in this case report are those of the authors and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, or the United States Government. We are military service members. This work was prepared as part of our official duties. Title 17 U.S.C. 105 provides that “Copyright protection under this title is not available for any work of the United States Government.” Title 17 U.S.C. 101 defines a United States Government work as a work prepared by a military service member or employee of the United States Government as part of that person’s official duties.”
Figure Cardiac Myocyte Action Potential. Slow delayed rectifier potassium current (IKS) and rapid delayed potassium rectifier current (IKR) are responsible for efflux of potassium ion during the repolarization phase of the cardiac myocyte (Phase 3). Abnormal serum potassium levels can further affect repolarization in the context of dysfunctional potassium channels.
K+, potassium; Na+, sodium; Cl−, chloride; Ca2+, calcium; IK1, inward rectifier potassium current; INa, inward sodium channel; Ito1,2, transient outward potassium current; ICa-L, L-type calcium current; IKS, slow delayed rectifier potassium current; IKR, rapid delayed potassium rectifier current; ms, milliseconds.
*Adapted and modified from Wikimedia Commons with permission.
Image Serial electrocardiograms (ECG) demonstrating QT prolongation after albuterol use. ECG A demonstrates the patient’s baseline with no acute dysrhythmia or ischemia and QTc of 423 milliseconds (ms). ECG B demonstrates a QTc interval of 633 ms and T wave morphology change. ECG C demonstrates QTc return to 428ms, with retention of the T wave morphology. | Recovered | ReactionOutcome | CC BY | 33560961 | 18,999,127 | 2021-02 |
Give an alphabetized list of all active substances of drugs taken by the patient who experienced 'Acute kidney injury'. | Novel Mutations in a Lethal Case of Lymphomatous Adult T Cell Lymphoma with Cryptic Myocardial Involvement.
The autopsy of a 65-year-old diabetic African American male revealed significant left myocardial involvement by adult T-cell leukemia/lymphoma (ATLL) despite normal pre-mortem fluorodeoxyglucose (FDG) uptake by positron emission tomography/computed tomography (PET/CT). Due to pre-existing diabetic cardiomyopathy with reduced ejection fraction (EF) and compatible imaging studies, cardiac lymphomatous involvement was not suspected. While peripheral blood was negative for leukemia, next-generation sequencing of a lymph node revealed at least eight novel mutations (AXIN1, R712Q, BARD1 R749K, CTNNB1 I315V, CUX1 P102T, DNMT3A S199R, FGFR2 S431L, LRP1B Y2560C and STAG2 I771M). These findings underscore a diagnostic pitfall in a rare lymphomatous variant of ATLL infiltrating myocardium and contribute to its molecular characterization.
1. Introduction
The World Health Organization (WHO) defines adult T-cell leukemia/lymphoma (ATLL) as a mature T-cell neoplasm composed of highly pleomorphic lymphoid cells and thought to be initiated by the retrovirus human T-cell leukemia virus type-1 (HTLV-1), which is necessary but not sufficient for its pathogenesis [1,2]. In North America, out of the four clinical variants of the disease (acute, lymphomatous, chronic and smoldering), the first two are the most common (~90% of cases) and carry a worse prognosis [3]. The lymphomatous type is characterized by prominent lymphadenopathy without peripheral blood involvement and by less frequent dermatologic manifestations or hypercalcemia [3]. Heart involvement by ATLL tends to be asymptomatic or oligosymptomatic. In autopsy series, few patients show cardiac symptoms like shortness of breath or palpitations, and massive cardiomegaly with extensive myocardial lymphomatous infiltration has seldom been reported [4,5,6].
The epidemiology of HTLV-1 in ATLL has been extensively studied. Geographic ATLL clustering overlaps endemic areas for the virus, such as southwestern Japan, the Caribbean basin and parts of central Africa. HTLV-1 is transmitted through blood products and breast feeding, and development of the disease follows a long (over 30 years) latency period after infection [7], which suggest that besides the causal role of viral oncogenes, host genetic and epigenetic factors are also necessary for tumorigenesis [8]. Two HTLV-1 proteins Tax and basic leucine zipper (HBZ) lead to transcriptional activation and T-cell proliferation, and both are able to transform in mouse models [9,10]. Tax-induced T-cell receptor (TCR)/nuclear factor kB (NF-kB) signaling has been well-documented in the development of ATLL [11]. However, Tax expression is silenced in a high proportion of ATLL cases, which illustrates its dispensable role in lymphomagenesis. In contrast, HBZ is the only viral protein consistently expressed in ATLL, and plays pleotropic roles modulating cell growth, T-cell differentiation and immune response, which contribute to oncogenesis. While most studies on the genetic alterations in ATLL have focused on Asian cases, recently, North American cases were analyzed in detail, demonstrating a unique frequency of epigenetic and histone modifying gene changes [12]. Conversely, the frequency of mutations in the JAK/STAT and the TCR/NF-kB pathway genes were lower when compared with the Japanese cases [12]. Therefore, it would be important to further analyze North American cases to confirm these findings, and to identify preclinical druggable target candidates. Here we present a lethal lymphomatous case of North American ATLL with extensive cardiac involvement and next-generation sequencing (NGS) data demonstrating several novel mutations that may hold promise in the diagnostic and therapeutic strategy.
2. Result
A 65-year-old diabetic African American male followed at the Washington DC Veterans Affairs Medical Center for hypertension and complications of diabetes mellitus, including heart failure with 40% ejection fraction (EF), chronic renal failure and neuropathy, developed poor appetite, abdominal pain and weight loss of 15 pounds (6.8 kg) in May 2019. The patient was hospitalized due to exertional orthopnea, severe gastrointestinal reflux disease and worsening shortness of breath.
Physical examination revealed mild obesity, unremarkable pulmonary and cardiovascular examination and no organomegaly or palpable lymphadenopathy. Imaging studies (including CT of the abdomen and pelvis with contrast) revealed infiltrating hypodense masses involving both kidneys, mesenteric lymphadenopathy and innumerable ground glass nodules with random distribution in the lung bases. The electrocardiogram was unremarkable. Multigated acquisition scan showed concentric left ventricular wall hypertrophy and hypokinesia, compatible with known cardiomyopathy. PET scan revealed innumerable foci of intense fluorodeoxyglucose (FDG) uptake in lungs, peritoneal cavity, kidneys, nodal basins (above and below the diaphragm), subcutaneous soft tissues and bones. However, normal FDG uptake within the myocardium was detected. Peripheral white blood cell counts were within the normal range. Serum calcium, sodium and potassium were also normal. Lactate dehydrogenase was markedly elevated at 1600 U/L, and serum HTLV-I antibody test was positive.
An enlarged supraclavicular lymph node was excised, and the diagnosis of ATLL was made based on histomorphology and positivity for CD45, CD2, CD3, CD4 and CD25 by immunohistochemistry. Ki-67 proliferative rate was very high (>80%). Other markers, including CD7 (aberrant loss), CD8, CD10, CD56, EBV and CD30, were negative. Careful examination of peripheral blood failed to detect atypical large lymphocytes, which was confirmed by a flow cytometric analysis showing no lymphomatous involvement. The diagnosis of lymphomatous variant of ATLL was confirmed, and NGS was performed by Foundation Medicine (comprehensive DNA and RNA analysis) and interpreted following the guidelines of the American College of Medical Genetics. This analysis revealed an intermediate tumor mutational burden (nine mutations per megabase) and stable microsatellite status. The following somatic mutations (Table 1) were also identified: AXIN1 R712Q, BARD1 R749K, CBL H42_L43insH, CD36 amplification, CDK6 amplification, CTNNB1 I315V, CUX1 (P102T and R44W), DNMT3A S199R, FAS D228fs*2, FGFR2 S431L, GATA3 loss exons 4–6, HGF amplification, HIST1H2AM loss, HIST1H2BO loss, IRF4 amplification, LRP1B (D1063N and Y2560C), NF1 S665F, PCLO amplification, SDHD F34C, SMO G24A, STAG2 I771M and TP53 H193L.
The patient underwent two cycles of chemotherapy (ESHAP-etoposide, methylprednisolone, cytarabine and cisplatin), but unfortunately had a complicated post-treatment course and developed tumor lysis syndrome, gastrointestinal bleeding, exacerbation of heart failure and unresolved acute kidney injury. Despite intensive care and cardiopulmonary resuscitation, the patient developed cardiac arrest and died 45 days after hospitalization. An autopsy revealed extensive lymphomatous involvement of multiple lymph nodes, including mesenteric, mediastinal, retroperitoneal, cervical and periaortic. In addition, significant involvement of the left myocardium (Figure 1) and multiple other organs (bilateral lungs, stomach, bowels, pancreas, bilateral kidneys, bilateral adrenals and prostate) and patchy involvement of diaphragm, skin and muscle was demonstrated by histomorphology and immunohistochemistry (including sections from the cardiac lymphoma shown in Figure 2).
3. Discussion
ATLL is a malignant lymphoproliferative neoplasm of mature T-cells initiated by monoclonal integration of HTLV-1 in the genome of lymphocytes, which leads to complex multistep events occurring during a long latency period. Despite a greater understanding of the pathogenesis of ATLL, curative treatment is lacking, and the overall prognosis remains dismal.
According to the Shimoyama classification, four variants of ATLL are recognized: acute, lymphomatous, chronic and smoldering [3]. The lymphomatous form is usually clinically aggressive and presents with advanced disease, including prominent lymphadenopathy and infrequent hypercalcemia, as seen in our patient. Although extensive involvement of the spleen and skin are common in lymphomatous ATLL, we did not observe these features. Instead, we detected patchy dermal involvement and extensive myocardial infiltration by ATLL, a rare event typically associated with ominous prognosis and concomitant lymphomatous involvement of the lung [6], as our necropsy illustrated. Of note, cardiac ATLL can be commonly missed pre-mortem even with modern imaging (as performed here) and is associated with chemoresistance [6]. Cutaneous involvement in our case was subclinical, as demonstrated by immunohistochemistry of a few tiny lymphoid aggregates found by microscopic examination, which is also unusual in lymphomatous ATLL.
Despite substantial progress in recent years, the molecular pathogenesis of ATLL remains unclear. After monoclonal integration of HTLV-1 and expression of viral oncogenes, such as Tax and HBZ, dysregulation of signaling pathways related to T-cell proliferation/differentiation and immune surveillance leads to leukemogenesis. Interestingly, Tax is dispensable for transformation and inactivated in a high proportion of cases [9]. However, HBZ is the only viral protein that remains consistently expressed in ATLL cases. Activation of PI3K, JAK/STAT and TCR/NF-kB pathways by genetic and epigenetic mechanisms seem to be crucial for tumor progression, and specific genes are commonly mutated, including CARD22, CCR4, CCR7, CDKN2A (p16), CDK2B (p15), EP300, FAS, FYN, GATA3, IRF4, PLCG1, PRKCB, TP53, STAT3 and VAV1. Accordingly, we observed mutations in genes of the TCR/NF-κB pathway (CBL, CUX1 and FAS), implicated in unrestricted and persistent NF-κB activation leading to the development of autoimmune diseases and neoplasms [13]. Such disbalance between T-cell activation and excessive NF-κB stimulation may have initiated deleterious consequences of TCR signaling, which, without negative regulation of nuclear signaling, may contribute to tumor progression. Interestingly, genetic alterations in genes associated with WNT/beta-catenin (AXIN1, CTNNB1 and SMO) and the RAS/MAPK (NF1), which are less commonly associated with ATLL, were also detected, suggesting possible unique pathogenic associations. As expected, several mutated genes that play a role in genomic stability (BARD1, TP53 and STAG2) and/or transcriptional regulation (HIST1H2AM, HIST1H2BO, IRF4 and GATA3) were seen. Also, genes directly involved in cell cycle control (CDK6) and soluble growth factors (HCF) had mutations in this tumor. Furthermore, trophic pathways related to surface receptors seem to be involved in our case, as suggested by mutations in CD36 (a lipid scavenger receptor) [14], LRP1B (a member of the low-density lipoprotein receptor family) [15] and FGFR2 (fibroblast growth factor receptor 2/CD332) [12]. Furthermore, additional epigenetic regulation may be represented by mutations in DNMT3A, a methyltransferase that may modulate gene expression by altering histones [16]. Finally, we found alterations in genes that have an unclear oncogenic mechanism of action, such as SDHD (a well-known driver gene in Cowden/Cowden-like syndromes) [17] and PCLO (a scaffold protein of the presynaptic cytomatrix at the active zone) [18].
Mutations in some of these genes (CBL, CDK6, DNMT3A, FAS, FGFR2, GATA3, HGF, IRF4, TP53 and STAG2) are well known in association with ATLL [12], but the specific alterations found are novel (CBL H42_L43insH, DNMT3A S199R, FGFR2 S431L, GATA3 loss of exons 4–6 and STAG2 I771M). Other genes have been described [18,19,20] in association with different hematopoietic or solid tumors (AXIN1, BARD1, CUX1, NF1, PCLO, SDHD and SMO), but are reported here for the first time in association with ATLL. Of interest, eight mutations (AXIN1, R712Q, BARD1 R749K, CTNNB1 I315V, CUX1 P102T, DNMT3A S199R, FGFR2 S431L, LRP1B Y2560C and STAG2 I771M) have not been reported before to the best of our knowledge after extensive literature/database searches. Current molecular pathogenesis of ATLL postulates important processes related to HTLV-1-mediated proliferation and immune evasion based on unclear stochastic genetic alterations necessary for full-blown disease. Accordingly, mutations belonging to major well-characterized pathways were found in this study. Focusing on the novel point mutations in the TCR/NF-kB (CUX1 P102T), epigenetic/methylation regulatory (DNMT3A S199R) and genetic stability (BARD1 and STAG2) pathways, our findings suggest commonalities with prior reports [12]. Similarly, various novel mutations belonging to the category of trophic proliferative signaling (FGFR2 S431L and LRP1B Y2560C) were sequenced. However, we also found novel mutations in the WNT/beta-catenin pathway (AXIN1, R712Q and CTNNB1 I315V), which is underappreciated in ATLL. Overexpression of Wnt5a (an activator of beta-catenin/CTNNB1 not found in our case) has been proposed as a mediator of hypercalcemia [21] and suggests that the beta-catenin (CTNNB1 I315V) defect we observed may have abrogated this mechanism, since our patient remained normocalcemic. Likewise, AXIN1 inactivation may have contributed to such normocalcemic phenotype, since this tumor suppressor regulates G-protein coupled signaling upstream of beta-catenin [20].
In summary, we present a clinically unusual lethal case of ATLL with several novel mutations (AXIN1, R712Q, BARD1 R749K, CTNNB1 I315V, CUX1 P102T, DNMT3A S199R, FGFR2 S431L, LRP1B Y2560C and STAG2 I771M) and unexpected myocardial involvement, which probably contributed to the fatal outcome.
Author Contributions
Conceptualization, V.E.N.; methodology, R.A. and T.H.Z.; formal analysis R.A. and T.H.Z.; investigation, V.E.N., R.A., T.H.Z. and B.C.B.; data curation, R.A.; writing—original draft preparation, T.H.Z.; writing—review and editing, R.A., V.E.N. and B.C.B. All authors have read and agreed to the published version of the manuscript.
Funding
This research received no external funding.
Conflicts of Interest
The authors declare no conflict of interest.
Figure 1 Gross appearance of the heart. The left myocardium shows and focal thickening and white-brown discoloration (arrow) that corresponds to leukemic infiltration.
Figure 2 (A) Adult T-cell leukemia/lymphoma (ATLL) infiltration of endocardium and myocardium (H&E, 20×). (B) Higher magnification of infiltrating lymphoma showing pleomorphism, scant eosinophilic cytoplasm, irregular nuclear contours with coarse chromatin and variably prominent nucleoli (H&E, 200×). The lymphoma cells were strongly positive for CD4 (C) and CD25 (D) by immunohistochemistry (20×).
curroncol-28-00079-t001_Table 1 Table 1 Somatic mutations identified by next-generation sequencing (NGS).
Gene Somatic Mutation Allele Frequency (%)
AXIN1 R712Q 44.94
BARD1 R749K 24.75
CBL H42_L43insH 17.61
CTNNB1 I315V 76.45
CUX1 R44W 36.15
CUX1 P102T 26.84
DNMT3A S199R 39.04
FAS D228fs*2 45.37
FGFR2 S431L 26.61
LRP1B D1063N 68.28
LRP1B Y2560C 46.64
NF1 S665F 31.97
SDHD F34C 29.79
SMO G24A 48.98
STAG2 I771M 40.98
TP53 H193L 70.02
Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations. | CISPLATIN, CYTARABINE, ETOPOSIDE, METHYLPREDNISOLONE | DrugsGivenReaction | CC BY | 33562071 | 19,160,898 | 2021-02-06 |
Give an alphabetized list of all active substances of drugs taken by the patient who experienced 'Cardiac arrest'. | Novel Mutations in a Lethal Case of Lymphomatous Adult T Cell Lymphoma with Cryptic Myocardial Involvement.
The autopsy of a 65-year-old diabetic African American male revealed significant left myocardial involvement by adult T-cell leukemia/lymphoma (ATLL) despite normal pre-mortem fluorodeoxyglucose (FDG) uptake by positron emission tomography/computed tomography (PET/CT). Due to pre-existing diabetic cardiomyopathy with reduced ejection fraction (EF) and compatible imaging studies, cardiac lymphomatous involvement was not suspected. While peripheral blood was negative for leukemia, next-generation sequencing of a lymph node revealed at least eight novel mutations (AXIN1, R712Q, BARD1 R749K, CTNNB1 I315V, CUX1 P102T, DNMT3A S199R, FGFR2 S431L, LRP1B Y2560C and STAG2 I771M). These findings underscore a diagnostic pitfall in a rare lymphomatous variant of ATLL infiltrating myocardium and contribute to its molecular characterization.
1. Introduction
The World Health Organization (WHO) defines adult T-cell leukemia/lymphoma (ATLL) as a mature T-cell neoplasm composed of highly pleomorphic lymphoid cells and thought to be initiated by the retrovirus human T-cell leukemia virus type-1 (HTLV-1), which is necessary but not sufficient for its pathogenesis [1,2]. In North America, out of the four clinical variants of the disease (acute, lymphomatous, chronic and smoldering), the first two are the most common (~90% of cases) and carry a worse prognosis [3]. The lymphomatous type is characterized by prominent lymphadenopathy without peripheral blood involvement and by less frequent dermatologic manifestations or hypercalcemia [3]. Heart involvement by ATLL tends to be asymptomatic or oligosymptomatic. In autopsy series, few patients show cardiac symptoms like shortness of breath or palpitations, and massive cardiomegaly with extensive myocardial lymphomatous infiltration has seldom been reported [4,5,6].
The epidemiology of HTLV-1 in ATLL has been extensively studied. Geographic ATLL clustering overlaps endemic areas for the virus, such as southwestern Japan, the Caribbean basin and parts of central Africa. HTLV-1 is transmitted through blood products and breast feeding, and development of the disease follows a long (over 30 years) latency period after infection [7], which suggest that besides the causal role of viral oncogenes, host genetic and epigenetic factors are also necessary for tumorigenesis [8]. Two HTLV-1 proteins Tax and basic leucine zipper (HBZ) lead to transcriptional activation and T-cell proliferation, and both are able to transform in mouse models [9,10]. Tax-induced T-cell receptor (TCR)/nuclear factor kB (NF-kB) signaling has been well-documented in the development of ATLL [11]. However, Tax expression is silenced in a high proportion of ATLL cases, which illustrates its dispensable role in lymphomagenesis. In contrast, HBZ is the only viral protein consistently expressed in ATLL, and plays pleotropic roles modulating cell growth, T-cell differentiation and immune response, which contribute to oncogenesis. While most studies on the genetic alterations in ATLL have focused on Asian cases, recently, North American cases were analyzed in detail, demonstrating a unique frequency of epigenetic and histone modifying gene changes [12]. Conversely, the frequency of mutations in the JAK/STAT and the TCR/NF-kB pathway genes were lower when compared with the Japanese cases [12]. Therefore, it would be important to further analyze North American cases to confirm these findings, and to identify preclinical druggable target candidates. Here we present a lethal lymphomatous case of North American ATLL with extensive cardiac involvement and next-generation sequencing (NGS) data demonstrating several novel mutations that may hold promise in the diagnostic and therapeutic strategy.
2. Result
A 65-year-old diabetic African American male followed at the Washington DC Veterans Affairs Medical Center for hypertension and complications of diabetes mellitus, including heart failure with 40% ejection fraction (EF), chronic renal failure and neuropathy, developed poor appetite, abdominal pain and weight loss of 15 pounds (6.8 kg) in May 2019. The patient was hospitalized due to exertional orthopnea, severe gastrointestinal reflux disease and worsening shortness of breath.
Physical examination revealed mild obesity, unremarkable pulmonary and cardiovascular examination and no organomegaly or palpable lymphadenopathy. Imaging studies (including CT of the abdomen and pelvis with contrast) revealed infiltrating hypodense masses involving both kidneys, mesenteric lymphadenopathy and innumerable ground glass nodules with random distribution in the lung bases. The electrocardiogram was unremarkable. Multigated acquisition scan showed concentric left ventricular wall hypertrophy and hypokinesia, compatible with known cardiomyopathy. PET scan revealed innumerable foci of intense fluorodeoxyglucose (FDG) uptake in lungs, peritoneal cavity, kidneys, nodal basins (above and below the diaphragm), subcutaneous soft tissues and bones. However, normal FDG uptake within the myocardium was detected. Peripheral white blood cell counts were within the normal range. Serum calcium, sodium and potassium were also normal. Lactate dehydrogenase was markedly elevated at 1600 U/L, and serum HTLV-I antibody test was positive.
An enlarged supraclavicular lymph node was excised, and the diagnosis of ATLL was made based on histomorphology and positivity for CD45, CD2, CD3, CD4 and CD25 by immunohistochemistry. Ki-67 proliferative rate was very high (>80%). Other markers, including CD7 (aberrant loss), CD8, CD10, CD56, EBV and CD30, were negative. Careful examination of peripheral blood failed to detect atypical large lymphocytes, which was confirmed by a flow cytometric analysis showing no lymphomatous involvement. The diagnosis of lymphomatous variant of ATLL was confirmed, and NGS was performed by Foundation Medicine (comprehensive DNA and RNA analysis) and interpreted following the guidelines of the American College of Medical Genetics. This analysis revealed an intermediate tumor mutational burden (nine mutations per megabase) and stable microsatellite status. The following somatic mutations (Table 1) were also identified: AXIN1 R712Q, BARD1 R749K, CBL H42_L43insH, CD36 amplification, CDK6 amplification, CTNNB1 I315V, CUX1 (P102T and R44W), DNMT3A S199R, FAS D228fs*2, FGFR2 S431L, GATA3 loss exons 4–6, HGF amplification, HIST1H2AM loss, HIST1H2BO loss, IRF4 amplification, LRP1B (D1063N and Y2560C), NF1 S665F, PCLO amplification, SDHD F34C, SMO G24A, STAG2 I771M and TP53 H193L.
The patient underwent two cycles of chemotherapy (ESHAP-etoposide, methylprednisolone, cytarabine and cisplatin), but unfortunately had a complicated post-treatment course and developed tumor lysis syndrome, gastrointestinal bleeding, exacerbation of heart failure and unresolved acute kidney injury. Despite intensive care and cardiopulmonary resuscitation, the patient developed cardiac arrest and died 45 days after hospitalization. An autopsy revealed extensive lymphomatous involvement of multiple lymph nodes, including mesenteric, mediastinal, retroperitoneal, cervical and periaortic. In addition, significant involvement of the left myocardium (Figure 1) and multiple other organs (bilateral lungs, stomach, bowels, pancreas, bilateral kidneys, bilateral adrenals and prostate) and patchy involvement of diaphragm, skin and muscle was demonstrated by histomorphology and immunohistochemistry (including sections from the cardiac lymphoma shown in Figure 2).
3. Discussion
ATLL is a malignant lymphoproliferative neoplasm of mature T-cells initiated by monoclonal integration of HTLV-1 in the genome of lymphocytes, which leads to complex multistep events occurring during a long latency period. Despite a greater understanding of the pathogenesis of ATLL, curative treatment is lacking, and the overall prognosis remains dismal.
According to the Shimoyama classification, four variants of ATLL are recognized: acute, lymphomatous, chronic and smoldering [3]. The lymphomatous form is usually clinically aggressive and presents with advanced disease, including prominent lymphadenopathy and infrequent hypercalcemia, as seen in our patient. Although extensive involvement of the spleen and skin are common in lymphomatous ATLL, we did not observe these features. Instead, we detected patchy dermal involvement and extensive myocardial infiltration by ATLL, a rare event typically associated with ominous prognosis and concomitant lymphomatous involvement of the lung [6], as our necropsy illustrated. Of note, cardiac ATLL can be commonly missed pre-mortem even with modern imaging (as performed here) and is associated with chemoresistance [6]. Cutaneous involvement in our case was subclinical, as demonstrated by immunohistochemistry of a few tiny lymphoid aggregates found by microscopic examination, which is also unusual in lymphomatous ATLL.
Despite substantial progress in recent years, the molecular pathogenesis of ATLL remains unclear. After monoclonal integration of HTLV-1 and expression of viral oncogenes, such as Tax and HBZ, dysregulation of signaling pathways related to T-cell proliferation/differentiation and immune surveillance leads to leukemogenesis. Interestingly, Tax is dispensable for transformation and inactivated in a high proportion of cases [9]. However, HBZ is the only viral protein that remains consistently expressed in ATLL cases. Activation of PI3K, JAK/STAT and TCR/NF-kB pathways by genetic and epigenetic mechanisms seem to be crucial for tumor progression, and specific genes are commonly mutated, including CARD22, CCR4, CCR7, CDKN2A (p16), CDK2B (p15), EP300, FAS, FYN, GATA3, IRF4, PLCG1, PRKCB, TP53, STAT3 and VAV1. Accordingly, we observed mutations in genes of the TCR/NF-κB pathway (CBL, CUX1 and FAS), implicated in unrestricted and persistent NF-κB activation leading to the development of autoimmune diseases and neoplasms [13]. Such disbalance between T-cell activation and excessive NF-κB stimulation may have initiated deleterious consequences of TCR signaling, which, without negative regulation of nuclear signaling, may contribute to tumor progression. Interestingly, genetic alterations in genes associated with WNT/beta-catenin (AXIN1, CTNNB1 and SMO) and the RAS/MAPK (NF1), which are less commonly associated with ATLL, were also detected, suggesting possible unique pathogenic associations. As expected, several mutated genes that play a role in genomic stability (BARD1, TP53 and STAG2) and/or transcriptional regulation (HIST1H2AM, HIST1H2BO, IRF4 and GATA3) were seen. Also, genes directly involved in cell cycle control (CDK6) and soluble growth factors (HCF) had mutations in this tumor. Furthermore, trophic pathways related to surface receptors seem to be involved in our case, as suggested by mutations in CD36 (a lipid scavenger receptor) [14], LRP1B (a member of the low-density lipoprotein receptor family) [15] and FGFR2 (fibroblast growth factor receptor 2/CD332) [12]. Furthermore, additional epigenetic regulation may be represented by mutations in DNMT3A, a methyltransferase that may modulate gene expression by altering histones [16]. Finally, we found alterations in genes that have an unclear oncogenic mechanism of action, such as SDHD (a well-known driver gene in Cowden/Cowden-like syndromes) [17] and PCLO (a scaffold protein of the presynaptic cytomatrix at the active zone) [18].
Mutations in some of these genes (CBL, CDK6, DNMT3A, FAS, FGFR2, GATA3, HGF, IRF4, TP53 and STAG2) are well known in association with ATLL [12], but the specific alterations found are novel (CBL H42_L43insH, DNMT3A S199R, FGFR2 S431L, GATA3 loss of exons 4–6 and STAG2 I771M). Other genes have been described [18,19,20] in association with different hematopoietic or solid tumors (AXIN1, BARD1, CUX1, NF1, PCLO, SDHD and SMO), but are reported here for the first time in association with ATLL. Of interest, eight mutations (AXIN1, R712Q, BARD1 R749K, CTNNB1 I315V, CUX1 P102T, DNMT3A S199R, FGFR2 S431L, LRP1B Y2560C and STAG2 I771M) have not been reported before to the best of our knowledge after extensive literature/database searches. Current molecular pathogenesis of ATLL postulates important processes related to HTLV-1-mediated proliferation and immune evasion based on unclear stochastic genetic alterations necessary for full-blown disease. Accordingly, mutations belonging to major well-characterized pathways were found in this study. Focusing on the novel point mutations in the TCR/NF-kB (CUX1 P102T), epigenetic/methylation regulatory (DNMT3A S199R) and genetic stability (BARD1 and STAG2) pathways, our findings suggest commonalities with prior reports [12]. Similarly, various novel mutations belonging to the category of trophic proliferative signaling (FGFR2 S431L and LRP1B Y2560C) were sequenced. However, we also found novel mutations in the WNT/beta-catenin pathway (AXIN1, R712Q and CTNNB1 I315V), which is underappreciated in ATLL. Overexpression of Wnt5a (an activator of beta-catenin/CTNNB1 not found in our case) has been proposed as a mediator of hypercalcemia [21] and suggests that the beta-catenin (CTNNB1 I315V) defect we observed may have abrogated this mechanism, since our patient remained normocalcemic. Likewise, AXIN1 inactivation may have contributed to such normocalcemic phenotype, since this tumor suppressor regulates G-protein coupled signaling upstream of beta-catenin [20].
In summary, we present a clinically unusual lethal case of ATLL with several novel mutations (AXIN1, R712Q, BARD1 R749K, CTNNB1 I315V, CUX1 P102T, DNMT3A S199R, FGFR2 S431L, LRP1B Y2560C and STAG2 I771M) and unexpected myocardial involvement, which probably contributed to the fatal outcome.
Author Contributions
Conceptualization, V.E.N.; methodology, R.A. and T.H.Z.; formal analysis R.A. and T.H.Z.; investigation, V.E.N., R.A., T.H.Z. and B.C.B.; data curation, R.A.; writing—original draft preparation, T.H.Z.; writing—review and editing, R.A., V.E.N. and B.C.B. All authors have read and agreed to the published version of the manuscript.
Funding
This research received no external funding.
Conflicts of Interest
The authors declare no conflict of interest.
Figure 1 Gross appearance of the heart. The left myocardium shows and focal thickening and white-brown discoloration (arrow) that corresponds to leukemic infiltration.
Figure 2 (A) Adult T-cell leukemia/lymphoma (ATLL) infiltration of endocardium and myocardium (H&E, 20×). (B) Higher magnification of infiltrating lymphoma showing pleomorphism, scant eosinophilic cytoplasm, irregular nuclear contours with coarse chromatin and variably prominent nucleoli (H&E, 200×). The lymphoma cells were strongly positive for CD4 (C) and CD25 (D) by immunohistochemistry (20×).
curroncol-28-00079-t001_Table 1 Table 1 Somatic mutations identified by next-generation sequencing (NGS).
Gene Somatic Mutation Allele Frequency (%)
AXIN1 R712Q 44.94
BARD1 R749K 24.75
CBL H42_L43insH 17.61
CTNNB1 I315V 76.45
CUX1 R44W 36.15
CUX1 P102T 26.84
DNMT3A S199R 39.04
FAS D228fs*2 45.37
FGFR2 S431L 26.61
LRP1B D1063N 68.28
LRP1B Y2560C 46.64
NF1 S665F 31.97
SDHD F34C 29.79
SMO G24A 48.98
STAG2 I771M 40.98
TP53 H193L 70.02
Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations. | CISPLATIN, CYTARABINE, ETOPOSIDE, METHYLPREDNISOLONE | DrugsGivenReaction | CC BY | 33562071 | 19,160,898 | 2021-02-06 |
Give an alphabetized list of all active substances of drugs taken by the patient who experienced 'Cardiac failure'. | Novel Mutations in a Lethal Case of Lymphomatous Adult T Cell Lymphoma with Cryptic Myocardial Involvement.
The autopsy of a 65-year-old diabetic African American male revealed significant left myocardial involvement by adult T-cell leukemia/lymphoma (ATLL) despite normal pre-mortem fluorodeoxyglucose (FDG) uptake by positron emission tomography/computed tomography (PET/CT). Due to pre-existing diabetic cardiomyopathy with reduced ejection fraction (EF) and compatible imaging studies, cardiac lymphomatous involvement was not suspected. While peripheral blood was negative for leukemia, next-generation sequencing of a lymph node revealed at least eight novel mutations (AXIN1, R712Q, BARD1 R749K, CTNNB1 I315V, CUX1 P102T, DNMT3A S199R, FGFR2 S431L, LRP1B Y2560C and STAG2 I771M). These findings underscore a diagnostic pitfall in a rare lymphomatous variant of ATLL infiltrating myocardium and contribute to its molecular characterization.
1. Introduction
The World Health Organization (WHO) defines adult T-cell leukemia/lymphoma (ATLL) as a mature T-cell neoplasm composed of highly pleomorphic lymphoid cells and thought to be initiated by the retrovirus human T-cell leukemia virus type-1 (HTLV-1), which is necessary but not sufficient for its pathogenesis [1,2]. In North America, out of the four clinical variants of the disease (acute, lymphomatous, chronic and smoldering), the first two are the most common (~90% of cases) and carry a worse prognosis [3]. The lymphomatous type is characterized by prominent lymphadenopathy without peripheral blood involvement and by less frequent dermatologic manifestations or hypercalcemia [3]. Heart involvement by ATLL tends to be asymptomatic or oligosymptomatic. In autopsy series, few patients show cardiac symptoms like shortness of breath or palpitations, and massive cardiomegaly with extensive myocardial lymphomatous infiltration has seldom been reported [4,5,6].
The epidemiology of HTLV-1 in ATLL has been extensively studied. Geographic ATLL clustering overlaps endemic areas for the virus, such as southwestern Japan, the Caribbean basin and parts of central Africa. HTLV-1 is transmitted through blood products and breast feeding, and development of the disease follows a long (over 30 years) latency period after infection [7], which suggest that besides the causal role of viral oncogenes, host genetic and epigenetic factors are also necessary for tumorigenesis [8]. Two HTLV-1 proteins Tax and basic leucine zipper (HBZ) lead to transcriptional activation and T-cell proliferation, and both are able to transform in mouse models [9,10]. Tax-induced T-cell receptor (TCR)/nuclear factor kB (NF-kB) signaling has been well-documented in the development of ATLL [11]. However, Tax expression is silenced in a high proportion of ATLL cases, which illustrates its dispensable role in lymphomagenesis. In contrast, HBZ is the only viral protein consistently expressed in ATLL, and plays pleotropic roles modulating cell growth, T-cell differentiation and immune response, which contribute to oncogenesis. While most studies on the genetic alterations in ATLL have focused on Asian cases, recently, North American cases were analyzed in detail, demonstrating a unique frequency of epigenetic and histone modifying gene changes [12]. Conversely, the frequency of mutations in the JAK/STAT and the TCR/NF-kB pathway genes were lower when compared with the Japanese cases [12]. Therefore, it would be important to further analyze North American cases to confirm these findings, and to identify preclinical druggable target candidates. Here we present a lethal lymphomatous case of North American ATLL with extensive cardiac involvement and next-generation sequencing (NGS) data demonstrating several novel mutations that may hold promise in the diagnostic and therapeutic strategy.
2. Result
A 65-year-old diabetic African American male followed at the Washington DC Veterans Affairs Medical Center for hypertension and complications of diabetes mellitus, including heart failure with 40% ejection fraction (EF), chronic renal failure and neuropathy, developed poor appetite, abdominal pain and weight loss of 15 pounds (6.8 kg) in May 2019. The patient was hospitalized due to exertional orthopnea, severe gastrointestinal reflux disease and worsening shortness of breath.
Physical examination revealed mild obesity, unremarkable pulmonary and cardiovascular examination and no organomegaly or palpable lymphadenopathy. Imaging studies (including CT of the abdomen and pelvis with contrast) revealed infiltrating hypodense masses involving both kidneys, mesenteric lymphadenopathy and innumerable ground glass nodules with random distribution in the lung bases. The electrocardiogram was unremarkable. Multigated acquisition scan showed concentric left ventricular wall hypertrophy and hypokinesia, compatible with known cardiomyopathy. PET scan revealed innumerable foci of intense fluorodeoxyglucose (FDG) uptake in lungs, peritoneal cavity, kidneys, nodal basins (above and below the diaphragm), subcutaneous soft tissues and bones. However, normal FDG uptake within the myocardium was detected. Peripheral white blood cell counts were within the normal range. Serum calcium, sodium and potassium were also normal. Lactate dehydrogenase was markedly elevated at 1600 U/L, and serum HTLV-I antibody test was positive.
An enlarged supraclavicular lymph node was excised, and the diagnosis of ATLL was made based on histomorphology and positivity for CD45, CD2, CD3, CD4 and CD25 by immunohistochemistry. Ki-67 proliferative rate was very high (>80%). Other markers, including CD7 (aberrant loss), CD8, CD10, CD56, EBV and CD30, were negative. Careful examination of peripheral blood failed to detect atypical large lymphocytes, which was confirmed by a flow cytometric analysis showing no lymphomatous involvement. The diagnosis of lymphomatous variant of ATLL was confirmed, and NGS was performed by Foundation Medicine (comprehensive DNA and RNA analysis) and interpreted following the guidelines of the American College of Medical Genetics. This analysis revealed an intermediate tumor mutational burden (nine mutations per megabase) and stable microsatellite status. The following somatic mutations (Table 1) were also identified: AXIN1 R712Q, BARD1 R749K, CBL H42_L43insH, CD36 amplification, CDK6 amplification, CTNNB1 I315V, CUX1 (P102T and R44W), DNMT3A S199R, FAS D228fs*2, FGFR2 S431L, GATA3 loss exons 4–6, HGF amplification, HIST1H2AM loss, HIST1H2BO loss, IRF4 amplification, LRP1B (D1063N and Y2560C), NF1 S665F, PCLO amplification, SDHD F34C, SMO G24A, STAG2 I771M and TP53 H193L.
The patient underwent two cycles of chemotherapy (ESHAP-etoposide, methylprednisolone, cytarabine and cisplatin), but unfortunately had a complicated post-treatment course and developed tumor lysis syndrome, gastrointestinal bleeding, exacerbation of heart failure and unresolved acute kidney injury. Despite intensive care and cardiopulmonary resuscitation, the patient developed cardiac arrest and died 45 days after hospitalization. An autopsy revealed extensive lymphomatous involvement of multiple lymph nodes, including mesenteric, mediastinal, retroperitoneal, cervical and periaortic. In addition, significant involvement of the left myocardium (Figure 1) and multiple other organs (bilateral lungs, stomach, bowels, pancreas, bilateral kidneys, bilateral adrenals and prostate) and patchy involvement of diaphragm, skin and muscle was demonstrated by histomorphology and immunohistochemistry (including sections from the cardiac lymphoma shown in Figure 2).
3. Discussion
ATLL is a malignant lymphoproliferative neoplasm of mature T-cells initiated by monoclonal integration of HTLV-1 in the genome of lymphocytes, which leads to complex multistep events occurring during a long latency period. Despite a greater understanding of the pathogenesis of ATLL, curative treatment is lacking, and the overall prognosis remains dismal.
According to the Shimoyama classification, four variants of ATLL are recognized: acute, lymphomatous, chronic and smoldering [3]. The lymphomatous form is usually clinically aggressive and presents with advanced disease, including prominent lymphadenopathy and infrequent hypercalcemia, as seen in our patient. Although extensive involvement of the spleen and skin are common in lymphomatous ATLL, we did not observe these features. Instead, we detected patchy dermal involvement and extensive myocardial infiltration by ATLL, a rare event typically associated with ominous prognosis and concomitant lymphomatous involvement of the lung [6], as our necropsy illustrated. Of note, cardiac ATLL can be commonly missed pre-mortem even with modern imaging (as performed here) and is associated with chemoresistance [6]. Cutaneous involvement in our case was subclinical, as demonstrated by immunohistochemistry of a few tiny lymphoid aggregates found by microscopic examination, which is also unusual in lymphomatous ATLL.
Despite substantial progress in recent years, the molecular pathogenesis of ATLL remains unclear. After monoclonal integration of HTLV-1 and expression of viral oncogenes, such as Tax and HBZ, dysregulation of signaling pathways related to T-cell proliferation/differentiation and immune surveillance leads to leukemogenesis. Interestingly, Tax is dispensable for transformation and inactivated in a high proportion of cases [9]. However, HBZ is the only viral protein that remains consistently expressed in ATLL cases. Activation of PI3K, JAK/STAT and TCR/NF-kB pathways by genetic and epigenetic mechanisms seem to be crucial for tumor progression, and specific genes are commonly mutated, including CARD22, CCR4, CCR7, CDKN2A (p16), CDK2B (p15), EP300, FAS, FYN, GATA3, IRF4, PLCG1, PRKCB, TP53, STAT3 and VAV1. Accordingly, we observed mutations in genes of the TCR/NF-κB pathway (CBL, CUX1 and FAS), implicated in unrestricted and persistent NF-κB activation leading to the development of autoimmune diseases and neoplasms [13]. Such disbalance between T-cell activation and excessive NF-κB stimulation may have initiated deleterious consequences of TCR signaling, which, without negative regulation of nuclear signaling, may contribute to tumor progression. Interestingly, genetic alterations in genes associated with WNT/beta-catenin (AXIN1, CTNNB1 and SMO) and the RAS/MAPK (NF1), which are less commonly associated with ATLL, were also detected, suggesting possible unique pathogenic associations. As expected, several mutated genes that play a role in genomic stability (BARD1, TP53 and STAG2) and/or transcriptional regulation (HIST1H2AM, HIST1H2BO, IRF4 and GATA3) were seen. Also, genes directly involved in cell cycle control (CDK6) and soluble growth factors (HCF) had mutations in this tumor. Furthermore, trophic pathways related to surface receptors seem to be involved in our case, as suggested by mutations in CD36 (a lipid scavenger receptor) [14], LRP1B (a member of the low-density lipoprotein receptor family) [15] and FGFR2 (fibroblast growth factor receptor 2/CD332) [12]. Furthermore, additional epigenetic regulation may be represented by mutations in DNMT3A, a methyltransferase that may modulate gene expression by altering histones [16]. Finally, we found alterations in genes that have an unclear oncogenic mechanism of action, such as SDHD (a well-known driver gene in Cowden/Cowden-like syndromes) [17] and PCLO (a scaffold protein of the presynaptic cytomatrix at the active zone) [18].
Mutations in some of these genes (CBL, CDK6, DNMT3A, FAS, FGFR2, GATA3, HGF, IRF4, TP53 and STAG2) are well known in association with ATLL [12], but the specific alterations found are novel (CBL H42_L43insH, DNMT3A S199R, FGFR2 S431L, GATA3 loss of exons 4–6 and STAG2 I771M). Other genes have been described [18,19,20] in association with different hematopoietic or solid tumors (AXIN1, BARD1, CUX1, NF1, PCLO, SDHD and SMO), but are reported here for the first time in association with ATLL. Of interest, eight mutations (AXIN1, R712Q, BARD1 R749K, CTNNB1 I315V, CUX1 P102T, DNMT3A S199R, FGFR2 S431L, LRP1B Y2560C and STAG2 I771M) have not been reported before to the best of our knowledge after extensive literature/database searches. Current molecular pathogenesis of ATLL postulates important processes related to HTLV-1-mediated proliferation and immune evasion based on unclear stochastic genetic alterations necessary for full-blown disease. Accordingly, mutations belonging to major well-characterized pathways were found in this study. Focusing on the novel point mutations in the TCR/NF-kB (CUX1 P102T), epigenetic/methylation regulatory (DNMT3A S199R) and genetic stability (BARD1 and STAG2) pathways, our findings suggest commonalities with prior reports [12]. Similarly, various novel mutations belonging to the category of trophic proliferative signaling (FGFR2 S431L and LRP1B Y2560C) were sequenced. However, we also found novel mutations in the WNT/beta-catenin pathway (AXIN1, R712Q and CTNNB1 I315V), which is underappreciated in ATLL. Overexpression of Wnt5a (an activator of beta-catenin/CTNNB1 not found in our case) has been proposed as a mediator of hypercalcemia [21] and suggests that the beta-catenin (CTNNB1 I315V) defect we observed may have abrogated this mechanism, since our patient remained normocalcemic. Likewise, AXIN1 inactivation may have contributed to such normocalcemic phenotype, since this tumor suppressor regulates G-protein coupled signaling upstream of beta-catenin [20].
In summary, we present a clinically unusual lethal case of ATLL with several novel mutations (AXIN1, R712Q, BARD1 R749K, CTNNB1 I315V, CUX1 P102T, DNMT3A S199R, FGFR2 S431L, LRP1B Y2560C and STAG2 I771M) and unexpected myocardial involvement, which probably contributed to the fatal outcome.
Author Contributions
Conceptualization, V.E.N.; methodology, R.A. and T.H.Z.; formal analysis R.A. and T.H.Z.; investigation, V.E.N., R.A., T.H.Z. and B.C.B.; data curation, R.A.; writing—original draft preparation, T.H.Z.; writing—review and editing, R.A., V.E.N. and B.C.B. All authors have read and agreed to the published version of the manuscript.
Funding
This research received no external funding.
Conflicts of Interest
The authors declare no conflict of interest.
Figure 1 Gross appearance of the heart. The left myocardium shows and focal thickening and white-brown discoloration (arrow) that corresponds to leukemic infiltration.
Figure 2 (A) Adult T-cell leukemia/lymphoma (ATLL) infiltration of endocardium and myocardium (H&E, 20×). (B) Higher magnification of infiltrating lymphoma showing pleomorphism, scant eosinophilic cytoplasm, irregular nuclear contours with coarse chromatin and variably prominent nucleoli (H&E, 200×). The lymphoma cells were strongly positive for CD4 (C) and CD25 (D) by immunohistochemistry (20×).
curroncol-28-00079-t001_Table 1 Table 1 Somatic mutations identified by next-generation sequencing (NGS).
Gene Somatic Mutation Allele Frequency (%)
AXIN1 R712Q 44.94
BARD1 R749K 24.75
CBL H42_L43insH 17.61
CTNNB1 I315V 76.45
CUX1 R44W 36.15
CUX1 P102T 26.84
DNMT3A S199R 39.04
FAS D228fs*2 45.37
FGFR2 S431L 26.61
LRP1B D1063N 68.28
LRP1B Y2560C 46.64
NF1 S665F 31.97
SDHD F34C 29.79
SMO G24A 48.98
STAG2 I771M 40.98
TP53 H193L 70.02
Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations. | CISPLATIN, CYTARABINE, ETOPOSIDE, METHYLPREDNISOLONE | DrugsGivenReaction | CC BY | 33562071 | 19,160,898 | 2021-02-06 |
Give an alphabetized list of all active substances of drugs taken by the patient who experienced 'Gastrointestinal haemorrhage'. | Novel Mutations in a Lethal Case of Lymphomatous Adult T Cell Lymphoma with Cryptic Myocardial Involvement.
The autopsy of a 65-year-old diabetic African American male revealed significant left myocardial involvement by adult T-cell leukemia/lymphoma (ATLL) despite normal pre-mortem fluorodeoxyglucose (FDG) uptake by positron emission tomography/computed tomography (PET/CT). Due to pre-existing diabetic cardiomyopathy with reduced ejection fraction (EF) and compatible imaging studies, cardiac lymphomatous involvement was not suspected. While peripheral blood was negative for leukemia, next-generation sequencing of a lymph node revealed at least eight novel mutations (AXIN1, R712Q, BARD1 R749K, CTNNB1 I315V, CUX1 P102T, DNMT3A S199R, FGFR2 S431L, LRP1B Y2560C and STAG2 I771M). These findings underscore a diagnostic pitfall in a rare lymphomatous variant of ATLL infiltrating myocardium and contribute to its molecular characterization.
1. Introduction
The World Health Organization (WHO) defines adult T-cell leukemia/lymphoma (ATLL) as a mature T-cell neoplasm composed of highly pleomorphic lymphoid cells and thought to be initiated by the retrovirus human T-cell leukemia virus type-1 (HTLV-1), which is necessary but not sufficient for its pathogenesis [1,2]. In North America, out of the four clinical variants of the disease (acute, lymphomatous, chronic and smoldering), the first two are the most common (~90% of cases) and carry a worse prognosis [3]. The lymphomatous type is characterized by prominent lymphadenopathy without peripheral blood involvement and by less frequent dermatologic manifestations or hypercalcemia [3]. Heart involvement by ATLL tends to be asymptomatic or oligosymptomatic. In autopsy series, few patients show cardiac symptoms like shortness of breath or palpitations, and massive cardiomegaly with extensive myocardial lymphomatous infiltration has seldom been reported [4,5,6].
The epidemiology of HTLV-1 in ATLL has been extensively studied. Geographic ATLL clustering overlaps endemic areas for the virus, such as southwestern Japan, the Caribbean basin and parts of central Africa. HTLV-1 is transmitted through blood products and breast feeding, and development of the disease follows a long (over 30 years) latency period after infection [7], which suggest that besides the causal role of viral oncogenes, host genetic and epigenetic factors are also necessary for tumorigenesis [8]. Two HTLV-1 proteins Tax and basic leucine zipper (HBZ) lead to transcriptional activation and T-cell proliferation, and both are able to transform in mouse models [9,10]. Tax-induced T-cell receptor (TCR)/nuclear factor kB (NF-kB) signaling has been well-documented in the development of ATLL [11]. However, Tax expression is silenced in a high proportion of ATLL cases, which illustrates its dispensable role in lymphomagenesis. In contrast, HBZ is the only viral protein consistently expressed in ATLL, and plays pleotropic roles modulating cell growth, T-cell differentiation and immune response, which contribute to oncogenesis. While most studies on the genetic alterations in ATLL have focused on Asian cases, recently, North American cases were analyzed in detail, demonstrating a unique frequency of epigenetic and histone modifying gene changes [12]. Conversely, the frequency of mutations in the JAK/STAT and the TCR/NF-kB pathway genes were lower when compared with the Japanese cases [12]. Therefore, it would be important to further analyze North American cases to confirm these findings, and to identify preclinical druggable target candidates. Here we present a lethal lymphomatous case of North American ATLL with extensive cardiac involvement and next-generation sequencing (NGS) data demonstrating several novel mutations that may hold promise in the diagnostic and therapeutic strategy.
2. Result
A 65-year-old diabetic African American male followed at the Washington DC Veterans Affairs Medical Center for hypertension and complications of diabetes mellitus, including heart failure with 40% ejection fraction (EF), chronic renal failure and neuropathy, developed poor appetite, abdominal pain and weight loss of 15 pounds (6.8 kg) in May 2019. The patient was hospitalized due to exertional orthopnea, severe gastrointestinal reflux disease and worsening shortness of breath.
Physical examination revealed mild obesity, unremarkable pulmonary and cardiovascular examination and no organomegaly or palpable lymphadenopathy. Imaging studies (including CT of the abdomen and pelvis with contrast) revealed infiltrating hypodense masses involving both kidneys, mesenteric lymphadenopathy and innumerable ground glass nodules with random distribution in the lung bases. The electrocardiogram was unremarkable. Multigated acquisition scan showed concentric left ventricular wall hypertrophy and hypokinesia, compatible with known cardiomyopathy. PET scan revealed innumerable foci of intense fluorodeoxyglucose (FDG) uptake in lungs, peritoneal cavity, kidneys, nodal basins (above and below the diaphragm), subcutaneous soft tissues and bones. However, normal FDG uptake within the myocardium was detected. Peripheral white blood cell counts were within the normal range. Serum calcium, sodium and potassium were also normal. Lactate dehydrogenase was markedly elevated at 1600 U/L, and serum HTLV-I antibody test was positive.
An enlarged supraclavicular lymph node was excised, and the diagnosis of ATLL was made based on histomorphology and positivity for CD45, CD2, CD3, CD4 and CD25 by immunohistochemistry. Ki-67 proliferative rate was very high (>80%). Other markers, including CD7 (aberrant loss), CD8, CD10, CD56, EBV and CD30, were negative. Careful examination of peripheral blood failed to detect atypical large lymphocytes, which was confirmed by a flow cytometric analysis showing no lymphomatous involvement. The diagnosis of lymphomatous variant of ATLL was confirmed, and NGS was performed by Foundation Medicine (comprehensive DNA and RNA analysis) and interpreted following the guidelines of the American College of Medical Genetics. This analysis revealed an intermediate tumor mutational burden (nine mutations per megabase) and stable microsatellite status. The following somatic mutations (Table 1) were also identified: AXIN1 R712Q, BARD1 R749K, CBL H42_L43insH, CD36 amplification, CDK6 amplification, CTNNB1 I315V, CUX1 (P102T and R44W), DNMT3A S199R, FAS D228fs*2, FGFR2 S431L, GATA3 loss exons 4–6, HGF amplification, HIST1H2AM loss, HIST1H2BO loss, IRF4 amplification, LRP1B (D1063N and Y2560C), NF1 S665F, PCLO amplification, SDHD F34C, SMO G24A, STAG2 I771M and TP53 H193L.
The patient underwent two cycles of chemotherapy (ESHAP-etoposide, methylprednisolone, cytarabine and cisplatin), but unfortunately had a complicated post-treatment course and developed tumor lysis syndrome, gastrointestinal bleeding, exacerbation of heart failure and unresolved acute kidney injury. Despite intensive care and cardiopulmonary resuscitation, the patient developed cardiac arrest and died 45 days after hospitalization. An autopsy revealed extensive lymphomatous involvement of multiple lymph nodes, including mesenteric, mediastinal, retroperitoneal, cervical and periaortic. In addition, significant involvement of the left myocardium (Figure 1) and multiple other organs (bilateral lungs, stomach, bowels, pancreas, bilateral kidneys, bilateral adrenals and prostate) and patchy involvement of diaphragm, skin and muscle was demonstrated by histomorphology and immunohistochemistry (including sections from the cardiac lymphoma shown in Figure 2).
3. Discussion
ATLL is a malignant lymphoproliferative neoplasm of mature T-cells initiated by monoclonal integration of HTLV-1 in the genome of lymphocytes, which leads to complex multistep events occurring during a long latency period. Despite a greater understanding of the pathogenesis of ATLL, curative treatment is lacking, and the overall prognosis remains dismal.
According to the Shimoyama classification, four variants of ATLL are recognized: acute, lymphomatous, chronic and smoldering [3]. The lymphomatous form is usually clinically aggressive and presents with advanced disease, including prominent lymphadenopathy and infrequent hypercalcemia, as seen in our patient. Although extensive involvement of the spleen and skin are common in lymphomatous ATLL, we did not observe these features. Instead, we detected patchy dermal involvement and extensive myocardial infiltration by ATLL, a rare event typically associated with ominous prognosis and concomitant lymphomatous involvement of the lung [6], as our necropsy illustrated. Of note, cardiac ATLL can be commonly missed pre-mortem even with modern imaging (as performed here) and is associated with chemoresistance [6]. Cutaneous involvement in our case was subclinical, as demonstrated by immunohistochemistry of a few tiny lymphoid aggregates found by microscopic examination, which is also unusual in lymphomatous ATLL.
Despite substantial progress in recent years, the molecular pathogenesis of ATLL remains unclear. After monoclonal integration of HTLV-1 and expression of viral oncogenes, such as Tax and HBZ, dysregulation of signaling pathways related to T-cell proliferation/differentiation and immune surveillance leads to leukemogenesis. Interestingly, Tax is dispensable for transformation and inactivated in a high proportion of cases [9]. However, HBZ is the only viral protein that remains consistently expressed in ATLL cases. Activation of PI3K, JAK/STAT and TCR/NF-kB pathways by genetic and epigenetic mechanisms seem to be crucial for tumor progression, and specific genes are commonly mutated, including CARD22, CCR4, CCR7, CDKN2A (p16), CDK2B (p15), EP300, FAS, FYN, GATA3, IRF4, PLCG1, PRKCB, TP53, STAT3 and VAV1. Accordingly, we observed mutations in genes of the TCR/NF-κB pathway (CBL, CUX1 and FAS), implicated in unrestricted and persistent NF-κB activation leading to the development of autoimmune diseases and neoplasms [13]. Such disbalance between T-cell activation and excessive NF-κB stimulation may have initiated deleterious consequences of TCR signaling, which, without negative regulation of nuclear signaling, may contribute to tumor progression. Interestingly, genetic alterations in genes associated with WNT/beta-catenin (AXIN1, CTNNB1 and SMO) and the RAS/MAPK (NF1), which are less commonly associated with ATLL, were also detected, suggesting possible unique pathogenic associations. As expected, several mutated genes that play a role in genomic stability (BARD1, TP53 and STAG2) and/or transcriptional regulation (HIST1H2AM, HIST1H2BO, IRF4 and GATA3) were seen. Also, genes directly involved in cell cycle control (CDK6) and soluble growth factors (HCF) had mutations in this tumor. Furthermore, trophic pathways related to surface receptors seem to be involved in our case, as suggested by mutations in CD36 (a lipid scavenger receptor) [14], LRP1B (a member of the low-density lipoprotein receptor family) [15] and FGFR2 (fibroblast growth factor receptor 2/CD332) [12]. Furthermore, additional epigenetic regulation may be represented by mutations in DNMT3A, a methyltransferase that may modulate gene expression by altering histones [16]. Finally, we found alterations in genes that have an unclear oncogenic mechanism of action, such as SDHD (a well-known driver gene in Cowden/Cowden-like syndromes) [17] and PCLO (a scaffold protein of the presynaptic cytomatrix at the active zone) [18].
Mutations in some of these genes (CBL, CDK6, DNMT3A, FAS, FGFR2, GATA3, HGF, IRF4, TP53 and STAG2) are well known in association with ATLL [12], but the specific alterations found are novel (CBL H42_L43insH, DNMT3A S199R, FGFR2 S431L, GATA3 loss of exons 4–6 and STAG2 I771M). Other genes have been described [18,19,20] in association with different hematopoietic or solid tumors (AXIN1, BARD1, CUX1, NF1, PCLO, SDHD and SMO), but are reported here for the first time in association with ATLL. Of interest, eight mutations (AXIN1, R712Q, BARD1 R749K, CTNNB1 I315V, CUX1 P102T, DNMT3A S199R, FGFR2 S431L, LRP1B Y2560C and STAG2 I771M) have not been reported before to the best of our knowledge after extensive literature/database searches. Current molecular pathogenesis of ATLL postulates important processes related to HTLV-1-mediated proliferation and immune evasion based on unclear stochastic genetic alterations necessary for full-blown disease. Accordingly, mutations belonging to major well-characterized pathways were found in this study. Focusing on the novel point mutations in the TCR/NF-kB (CUX1 P102T), epigenetic/methylation regulatory (DNMT3A S199R) and genetic stability (BARD1 and STAG2) pathways, our findings suggest commonalities with prior reports [12]. Similarly, various novel mutations belonging to the category of trophic proliferative signaling (FGFR2 S431L and LRP1B Y2560C) were sequenced. However, we also found novel mutations in the WNT/beta-catenin pathway (AXIN1, R712Q and CTNNB1 I315V), which is underappreciated in ATLL. Overexpression of Wnt5a (an activator of beta-catenin/CTNNB1 not found in our case) has been proposed as a mediator of hypercalcemia [21] and suggests that the beta-catenin (CTNNB1 I315V) defect we observed may have abrogated this mechanism, since our patient remained normocalcemic. Likewise, AXIN1 inactivation may have contributed to such normocalcemic phenotype, since this tumor suppressor regulates G-protein coupled signaling upstream of beta-catenin [20].
In summary, we present a clinically unusual lethal case of ATLL with several novel mutations (AXIN1, R712Q, BARD1 R749K, CTNNB1 I315V, CUX1 P102T, DNMT3A S199R, FGFR2 S431L, LRP1B Y2560C and STAG2 I771M) and unexpected myocardial involvement, which probably contributed to the fatal outcome.
Author Contributions
Conceptualization, V.E.N.; methodology, R.A. and T.H.Z.; formal analysis R.A. and T.H.Z.; investigation, V.E.N., R.A., T.H.Z. and B.C.B.; data curation, R.A.; writing—original draft preparation, T.H.Z.; writing—review and editing, R.A., V.E.N. and B.C.B. All authors have read and agreed to the published version of the manuscript.
Funding
This research received no external funding.
Conflicts of Interest
The authors declare no conflict of interest.
Figure 1 Gross appearance of the heart. The left myocardium shows and focal thickening and white-brown discoloration (arrow) that corresponds to leukemic infiltration.
Figure 2 (A) Adult T-cell leukemia/lymphoma (ATLL) infiltration of endocardium and myocardium (H&E, 20×). (B) Higher magnification of infiltrating lymphoma showing pleomorphism, scant eosinophilic cytoplasm, irregular nuclear contours with coarse chromatin and variably prominent nucleoli (H&E, 200×). The lymphoma cells were strongly positive for CD4 (C) and CD25 (D) by immunohistochemistry (20×).
curroncol-28-00079-t001_Table 1 Table 1 Somatic mutations identified by next-generation sequencing (NGS).
Gene Somatic Mutation Allele Frequency (%)
AXIN1 R712Q 44.94
BARD1 R749K 24.75
CBL H42_L43insH 17.61
CTNNB1 I315V 76.45
CUX1 R44W 36.15
CUX1 P102T 26.84
DNMT3A S199R 39.04
FAS D228fs*2 45.37
FGFR2 S431L 26.61
LRP1B D1063N 68.28
LRP1B Y2560C 46.64
NF1 S665F 31.97
SDHD F34C 29.79
SMO G24A 48.98
STAG2 I771M 40.98
TP53 H193L 70.02
Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations. | CISPLATIN, CYTARABINE, ETOPOSIDE, METHYLPREDNISOLONE | DrugsGivenReaction | CC BY | 33562071 | 19,160,898 | 2021-02-06 |
Give an alphabetized list of all active substances of drugs taken by the patient who experienced 'Tumour lysis syndrome'. | Novel Mutations in a Lethal Case of Lymphomatous Adult T Cell Lymphoma with Cryptic Myocardial Involvement.
The autopsy of a 65-year-old diabetic African American male revealed significant left myocardial involvement by adult T-cell leukemia/lymphoma (ATLL) despite normal pre-mortem fluorodeoxyglucose (FDG) uptake by positron emission tomography/computed tomography (PET/CT). Due to pre-existing diabetic cardiomyopathy with reduced ejection fraction (EF) and compatible imaging studies, cardiac lymphomatous involvement was not suspected. While peripheral blood was negative for leukemia, next-generation sequencing of a lymph node revealed at least eight novel mutations (AXIN1, R712Q, BARD1 R749K, CTNNB1 I315V, CUX1 P102T, DNMT3A S199R, FGFR2 S431L, LRP1B Y2560C and STAG2 I771M). These findings underscore a diagnostic pitfall in a rare lymphomatous variant of ATLL infiltrating myocardium and contribute to its molecular characterization.
1. Introduction
The World Health Organization (WHO) defines adult T-cell leukemia/lymphoma (ATLL) as a mature T-cell neoplasm composed of highly pleomorphic lymphoid cells and thought to be initiated by the retrovirus human T-cell leukemia virus type-1 (HTLV-1), which is necessary but not sufficient for its pathogenesis [1,2]. In North America, out of the four clinical variants of the disease (acute, lymphomatous, chronic and smoldering), the first two are the most common (~90% of cases) and carry a worse prognosis [3]. The lymphomatous type is characterized by prominent lymphadenopathy without peripheral blood involvement and by less frequent dermatologic manifestations or hypercalcemia [3]. Heart involvement by ATLL tends to be asymptomatic or oligosymptomatic. In autopsy series, few patients show cardiac symptoms like shortness of breath or palpitations, and massive cardiomegaly with extensive myocardial lymphomatous infiltration has seldom been reported [4,5,6].
The epidemiology of HTLV-1 in ATLL has been extensively studied. Geographic ATLL clustering overlaps endemic areas for the virus, such as southwestern Japan, the Caribbean basin and parts of central Africa. HTLV-1 is transmitted through blood products and breast feeding, and development of the disease follows a long (over 30 years) latency period after infection [7], which suggest that besides the causal role of viral oncogenes, host genetic and epigenetic factors are also necessary for tumorigenesis [8]. Two HTLV-1 proteins Tax and basic leucine zipper (HBZ) lead to transcriptional activation and T-cell proliferation, and both are able to transform in mouse models [9,10]. Tax-induced T-cell receptor (TCR)/nuclear factor kB (NF-kB) signaling has been well-documented in the development of ATLL [11]. However, Tax expression is silenced in a high proportion of ATLL cases, which illustrates its dispensable role in lymphomagenesis. In contrast, HBZ is the only viral protein consistently expressed in ATLL, and plays pleotropic roles modulating cell growth, T-cell differentiation and immune response, which contribute to oncogenesis. While most studies on the genetic alterations in ATLL have focused on Asian cases, recently, North American cases were analyzed in detail, demonstrating a unique frequency of epigenetic and histone modifying gene changes [12]. Conversely, the frequency of mutations in the JAK/STAT and the TCR/NF-kB pathway genes were lower when compared with the Japanese cases [12]. Therefore, it would be important to further analyze North American cases to confirm these findings, and to identify preclinical druggable target candidates. Here we present a lethal lymphomatous case of North American ATLL with extensive cardiac involvement and next-generation sequencing (NGS) data demonstrating several novel mutations that may hold promise in the diagnostic and therapeutic strategy.
2. Result
A 65-year-old diabetic African American male followed at the Washington DC Veterans Affairs Medical Center for hypertension and complications of diabetes mellitus, including heart failure with 40% ejection fraction (EF), chronic renal failure and neuropathy, developed poor appetite, abdominal pain and weight loss of 15 pounds (6.8 kg) in May 2019. The patient was hospitalized due to exertional orthopnea, severe gastrointestinal reflux disease and worsening shortness of breath.
Physical examination revealed mild obesity, unremarkable pulmonary and cardiovascular examination and no organomegaly or palpable lymphadenopathy. Imaging studies (including CT of the abdomen and pelvis with contrast) revealed infiltrating hypodense masses involving both kidneys, mesenteric lymphadenopathy and innumerable ground glass nodules with random distribution in the lung bases. The electrocardiogram was unremarkable. Multigated acquisition scan showed concentric left ventricular wall hypertrophy and hypokinesia, compatible with known cardiomyopathy. PET scan revealed innumerable foci of intense fluorodeoxyglucose (FDG) uptake in lungs, peritoneal cavity, kidneys, nodal basins (above and below the diaphragm), subcutaneous soft tissues and bones. However, normal FDG uptake within the myocardium was detected. Peripheral white blood cell counts were within the normal range. Serum calcium, sodium and potassium were also normal. Lactate dehydrogenase was markedly elevated at 1600 U/L, and serum HTLV-I antibody test was positive.
An enlarged supraclavicular lymph node was excised, and the diagnosis of ATLL was made based on histomorphology and positivity for CD45, CD2, CD3, CD4 and CD25 by immunohistochemistry. Ki-67 proliferative rate was very high (>80%). Other markers, including CD7 (aberrant loss), CD8, CD10, CD56, EBV and CD30, were negative. Careful examination of peripheral blood failed to detect atypical large lymphocytes, which was confirmed by a flow cytometric analysis showing no lymphomatous involvement. The diagnosis of lymphomatous variant of ATLL was confirmed, and NGS was performed by Foundation Medicine (comprehensive DNA and RNA analysis) and interpreted following the guidelines of the American College of Medical Genetics. This analysis revealed an intermediate tumor mutational burden (nine mutations per megabase) and stable microsatellite status. The following somatic mutations (Table 1) were also identified: AXIN1 R712Q, BARD1 R749K, CBL H42_L43insH, CD36 amplification, CDK6 amplification, CTNNB1 I315V, CUX1 (P102T and R44W), DNMT3A S199R, FAS D228fs*2, FGFR2 S431L, GATA3 loss exons 4–6, HGF amplification, HIST1H2AM loss, HIST1H2BO loss, IRF4 amplification, LRP1B (D1063N and Y2560C), NF1 S665F, PCLO amplification, SDHD F34C, SMO G24A, STAG2 I771M and TP53 H193L.
The patient underwent two cycles of chemotherapy (ESHAP-etoposide, methylprednisolone, cytarabine and cisplatin), but unfortunately had a complicated post-treatment course and developed tumor lysis syndrome, gastrointestinal bleeding, exacerbation of heart failure and unresolved acute kidney injury. Despite intensive care and cardiopulmonary resuscitation, the patient developed cardiac arrest and died 45 days after hospitalization. An autopsy revealed extensive lymphomatous involvement of multiple lymph nodes, including mesenteric, mediastinal, retroperitoneal, cervical and periaortic. In addition, significant involvement of the left myocardium (Figure 1) and multiple other organs (bilateral lungs, stomach, bowels, pancreas, bilateral kidneys, bilateral adrenals and prostate) and patchy involvement of diaphragm, skin and muscle was demonstrated by histomorphology and immunohistochemistry (including sections from the cardiac lymphoma shown in Figure 2).
3. Discussion
ATLL is a malignant lymphoproliferative neoplasm of mature T-cells initiated by monoclonal integration of HTLV-1 in the genome of lymphocytes, which leads to complex multistep events occurring during a long latency period. Despite a greater understanding of the pathogenesis of ATLL, curative treatment is lacking, and the overall prognosis remains dismal.
According to the Shimoyama classification, four variants of ATLL are recognized: acute, lymphomatous, chronic and smoldering [3]. The lymphomatous form is usually clinically aggressive and presents with advanced disease, including prominent lymphadenopathy and infrequent hypercalcemia, as seen in our patient. Although extensive involvement of the spleen and skin are common in lymphomatous ATLL, we did not observe these features. Instead, we detected patchy dermal involvement and extensive myocardial infiltration by ATLL, a rare event typically associated with ominous prognosis and concomitant lymphomatous involvement of the lung [6], as our necropsy illustrated. Of note, cardiac ATLL can be commonly missed pre-mortem even with modern imaging (as performed here) and is associated with chemoresistance [6]. Cutaneous involvement in our case was subclinical, as demonstrated by immunohistochemistry of a few tiny lymphoid aggregates found by microscopic examination, which is also unusual in lymphomatous ATLL.
Despite substantial progress in recent years, the molecular pathogenesis of ATLL remains unclear. After monoclonal integration of HTLV-1 and expression of viral oncogenes, such as Tax and HBZ, dysregulation of signaling pathways related to T-cell proliferation/differentiation and immune surveillance leads to leukemogenesis. Interestingly, Tax is dispensable for transformation and inactivated in a high proportion of cases [9]. However, HBZ is the only viral protein that remains consistently expressed in ATLL cases. Activation of PI3K, JAK/STAT and TCR/NF-kB pathways by genetic and epigenetic mechanisms seem to be crucial for tumor progression, and specific genes are commonly mutated, including CARD22, CCR4, CCR7, CDKN2A (p16), CDK2B (p15), EP300, FAS, FYN, GATA3, IRF4, PLCG1, PRKCB, TP53, STAT3 and VAV1. Accordingly, we observed mutations in genes of the TCR/NF-κB pathway (CBL, CUX1 and FAS), implicated in unrestricted and persistent NF-κB activation leading to the development of autoimmune diseases and neoplasms [13]. Such disbalance between T-cell activation and excessive NF-κB stimulation may have initiated deleterious consequences of TCR signaling, which, without negative regulation of nuclear signaling, may contribute to tumor progression. Interestingly, genetic alterations in genes associated with WNT/beta-catenin (AXIN1, CTNNB1 and SMO) and the RAS/MAPK (NF1), which are less commonly associated with ATLL, were also detected, suggesting possible unique pathogenic associations. As expected, several mutated genes that play a role in genomic stability (BARD1, TP53 and STAG2) and/or transcriptional regulation (HIST1H2AM, HIST1H2BO, IRF4 and GATA3) were seen. Also, genes directly involved in cell cycle control (CDK6) and soluble growth factors (HCF) had mutations in this tumor. Furthermore, trophic pathways related to surface receptors seem to be involved in our case, as suggested by mutations in CD36 (a lipid scavenger receptor) [14], LRP1B (a member of the low-density lipoprotein receptor family) [15] and FGFR2 (fibroblast growth factor receptor 2/CD332) [12]. Furthermore, additional epigenetic regulation may be represented by mutations in DNMT3A, a methyltransferase that may modulate gene expression by altering histones [16]. Finally, we found alterations in genes that have an unclear oncogenic mechanism of action, such as SDHD (a well-known driver gene in Cowden/Cowden-like syndromes) [17] and PCLO (a scaffold protein of the presynaptic cytomatrix at the active zone) [18].
Mutations in some of these genes (CBL, CDK6, DNMT3A, FAS, FGFR2, GATA3, HGF, IRF4, TP53 and STAG2) are well known in association with ATLL [12], but the specific alterations found are novel (CBL H42_L43insH, DNMT3A S199R, FGFR2 S431L, GATA3 loss of exons 4–6 and STAG2 I771M). Other genes have been described [18,19,20] in association with different hematopoietic or solid tumors (AXIN1, BARD1, CUX1, NF1, PCLO, SDHD and SMO), but are reported here for the first time in association with ATLL. Of interest, eight mutations (AXIN1, R712Q, BARD1 R749K, CTNNB1 I315V, CUX1 P102T, DNMT3A S199R, FGFR2 S431L, LRP1B Y2560C and STAG2 I771M) have not been reported before to the best of our knowledge after extensive literature/database searches. Current molecular pathogenesis of ATLL postulates important processes related to HTLV-1-mediated proliferation and immune evasion based on unclear stochastic genetic alterations necessary for full-blown disease. Accordingly, mutations belonging to major well-characterized pathways were found in this study. Focusing on the novel point mutations in the TCR/NF-kB (CUX1 P102T), epigenetic/methylation regulatory (DNMT3A S199R) and genetic stability (BARD1 and STAG2) pathways, our findings suggest commonalities with prior reports [12]. Similarly, various novel mutations belonging to the category of trophic proliferative signaling (FGFR2 S431L and LRP1B Y2560C) were sequenced. However, we also found novel mutations in the WNT/beta-catenin pathway (AXIN1, R712Q and CTNNB1 I315V), which is underappreciated in ATLL. Overexpression of Wnt5a (an activator of beta-catenin/CTNNB1 not found in our case) has been proposed as a mediator of hypercalcemia [21] and suggests that the beta-catenin (CTNNB1 I315V) defect we observed may have abrogated this mechanism, since our patient remained normocalcemic. Likewise, AXIN1 inactivation may have contributed to such normocalcemic phenotype, since this tumor suppressor regulates G-protein coupled signaling upstream of beta-catenin [20].
In summary, we present a clinically unusual lethal case of ATLL with several novel mutations (AXIN1, R712Q, BARD1 R749K, CTNNB1 I315V, CUX1 P102T, DNMT3A S199R, FGFR2 S431L, LRP1B Y2560C and STAG2 I771M) and unexpected myocardial involvement, which probably contributed to the fatal outcome.
Author Contributions
Conceptualization, V.E.N.; methodology, R.A. and T.H.Z.; formal analysis R.A. and T.H.Z.; investigation, V.E.N., R.A., T.H.Z. and B.C.B.; data curation, R.A.; writing—original draft preparation, T.H.Z.; writing—review and editing, R.A., V.E.N. and B.C.B. All authors have read and agreed to the published version of the manuscript.
Funding
This research received no external funding.
Conflicts of Interest
The authors declare no conflict of interest.
Figure 1 Gross appearance of the heart. The left myocardium shows and focal thickening and white-brown discoloration (arrow) that corresponds to leukemic infiltration.
Figure 2 (A) Adult T-cell leukemia/lymphoma (ATLL) infiltration of endocardium and myocardium (H&E, 20×). (B) Higher magnification of infiltrating lymphoma showing pleomorphism, scant eosinophilic cytoplasm, irregular nuclear contours with coarse chromatin and variably prominent nucleoli (H&E, 200×). The lymphoma cells were strongly positive for CD4 (C) and CD25 (D) by immunohistochemistry (20×).
curroncol-28-00079-t001_Table 1 Table 1 Somatic mutations identified by next-generation sequencing (NGS).
Gene Somatic Mutation Allele Frequency (%)
AXIN1 R712Q 44.94
BARD1 R749K 24.75
CBL H42_L43insH 17.61
CTNNB1 I315V 76.45
CUX1 R44W 36.15
CUX1 P102T 26.84
DNMT3A S199R 39.04
FAS D228fs*2 45.37
FGFR2 S431L 26.61
LRP1B D1063N 68.28
LRP1B Y2560C 46.64
NF1 S665F 31.97
SDHD F34C 29.79
SMO G24A 48.98
STAG2 I771M 40.98
TP53 H193L 70.02
Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations. | CISPLATIN, CYTARABINE, ETOPOSIDE, METHYLPREDNISOLONE | DrugsGivenReaction | CC BY | 33562071 | 19,160,898 | 2021-02-06 |
What was the outcome of reaction 'Acute kidney injury'? | Novel Mutations in a Lethal Case of Lymphomatous Adult T Cell Lymphoma with Cryptic Myocardial Involvement.
The autopsy of a 65-year-old diabetic African American male revealed significant left myocardial involvement by adult T-cell leukemia/lymphoma (ATLL) despite normal pre-mortem fluorodeoxyglucose (FDG) uptake by positron emission tomography/computed tomography (PET/CT). Due to pre-existing diabetic cardiomyopathy with reduced ejection fraction (EF) and compatible imaging studies, cardiac lymphomatous involvement was not suspected. While peripheral blood was negative for leukemia, next-generation sequencing of a lymph node revealed at least eight novel mutations (AXIN1, R712Q, BARD1 R749K, CTNNB1 I315V, CUX1 P102T, DNMT3A S199R, FGFR2 S431L, LRP1B Y2560C and STAG2 I771M). These findings underscore a diagnostic pitfall in a rare lymphomatous variant of ATLL infiltrating myocardium and contribute to its molecular characterization.
1. Introduction
The World Health Organization (WHO) defines adult T-cell leukemia/lymphoma (ATLL) as a mature T-cell neoplasm composed of highly pleomorphic lymphoid cells and thought to be initiated by the retrovirus human T-cell leukemia virus type-1 (HTLV-1), which is necessary but not sufficient for its pathogenesis [1,2]. In North America, out of the four clinical variants of the disease (acute, lymphomatous, chronic and smoldering), the first two are the most common (~90% of cases) and carry a worse prognosis [3]. The lymphomatous type is characterized by prominent lymphadenopathy without peripheral blood involvement and by less frequent dermatologic manifestations or hypercalcemia [3]. Heart involvement by ATLL tends to be asymptomatic or oligosymptomatic. In autopsy series, few patients show cardiac symptoms like shortness of breath or palpitations, and massive cardiomegaly with extensive myocardial lymphomatous infiltration has seldom been reported [4,5,6].
The epidemiology of HTLV-1 in ATLL has been extensively studied. Geographic ATLL clustering overlaps endemic areas for the virus, such as southwestern Japan, the Caribbean basin and parts of central Africa. HTLV-1 is transmitted through blood products and breast feeding, and development of the disease follows a long (over 30 years) latency period after infection [7], which suggest that besides the causal role of viral oncogenes, host genetic and epigenetic factors are also necessary for tumorigenesis [8]. Two HTLV-1 proteins Tax and basic leucine zipper (HBZ) lead to transcriptional activation and T-cell proliferation, and both are able to transform in mouse models [9,10]. Tax-induced T-cell receptor (TCR)/nuclear factor kB (NF-kB) signaling has been well-documented in the development of ATLL [11]. However, Tax expression is silenced in a high proportion of ATLL cases, which illustrates its dispensable role in lymphomagenesis. In contrast, HBZ is the only viral protein consistently expressed in ATLL, and plays pleotropic roles modulating cell growth, T-cell differentiation and immune response, which contribute to oncogenesis. While most studies on the genetic alterations in ATLL have focused on Asian cases, recently, North American cases were analyzed in detail, demonstrating a unique frequency of epigenetic and histone modifying gene changes [12]. Conversely, the frequency of mutations in the JAK/STAT and the TCR/NF-kB pathway genes were lower when compared with the Japanese cases [12]. Therefore, it would be important to further analyze North American cases to confirm these findings, and to identify preclinical druggable target candidates. Here we present a lethal lymphomatous case of North American ATLL with extensive cardiac involvement and next-generation sequencing (NGS) data demonstrating several novel mutations that may hold promise in the diagnostic and therapeutic strategy.
2. Result
A 65-year-old diabetic African American male followed at the Washington DC Veterans Affairs Medical Center for hypertension and complications of diabetes mellitus, including heart failure with 40% ejection fraction (EF), chronic renal failure and neuropathy, developed poor appetite, abdominal pain and weight loss of 15 pounds (6.8 kg) in May 2019. The patient was hospitalized due to exertional orthopnea, severe gastrointestinal reflux disease and worsening shortness of breath.
Physical examination revealed mild obesity, unremarkable pulmonary and cardiovascular examination and no organomegaly or palpable lymphadenopathy. Imaging studies (including CT of the abdomen and pelvis with contrast) revealed infiltrating hypodense masses involving both kidneys, mesenteric lymphadenopathy and innumerable ground glass nodules with random distribution in the lung bases. The electrocardiogram was unremarkable. Multigated acquisition scan showed concentric left ventricular wall hypertrophy and hypokinesia, compatible with known cardiomyopathy. PET scan revealed innumerable foci of intense fluorodeoxyglucose (FDG) uptake in lungs, peritoneal cavity, kidneys, nodal basins (above and below the diaphragm), subcutaneous soft tissues and bones. However, normal FDG uptake within the myocardium was detected. Peripheral white blood cell counts were within the normal range. Serum calcium, sodium and potassium were also normal. Lactate dehydrogenase was markedly elevated at 1600 U/L, and serum HTLV-I antibody test was positive.
An enlarged supraclavicular lymph node was excised, and the diagnosis of ATLL was made based on histomorphology and positivity for CD45, CD2, CD3, CD4 and CD25 by immunohistochemistry. Ki-67 proliferative rate was very high (>80%). Other markers, including CD7 (aberrant loss), CD8, CD10, CD56, EBV and CD30, were negative. Careful examination of peripheral blood failed to detect atypical large lymphocytes, which was confirmed by a flow cytometric analysis showing no lymphomatous involvement. The diagnosis of lymphomatous variant of ATLL was confirmed, and NGS was performed by Foundation Medicine (comprehensive DNA and RNA analysis) and interpreted following the guidelines of the American College of Medical Genetics. This analysis revealed an intermediate tumor mutational burden (nine mutations per megabase) and stable microsatellite status. The following somatic mutations (Table 1) were also identified: AXIN1 R712Q, BARD1 R749K, CBL H42_L43insH, CD36 amplification, CDK6 amplification, CTNNB1 I315V, CUX1 (P102T and R44W), DNMT3A S199R, FAS D228fs*2, FGFR2 S431L, GATA3 loss exons 4–6, HGF amplification, HIST1H2AM loss, HIST1H2BO loss, IRF4 amplification, LRP1B (D1063N and Y2560C), NF1 S665F, PCLO amplification, SDHD F34C, SMO G24A, STAG2 I771M and TP53 H193L.
The patient underwent two cycles of chemotherapy (ESHAP-etoposide, methylprednisolone, cytarabine and cisplatin), but unfortunately had a complicated post-treatment course and developed tumor lysis syndrome, gastrointestinal bleeding, exacerbation of heart failure and unresolved acute kidney injury. Despite intensive care and cardiopulmonary resuscitation, the patient developed cardiac arrest and died 45 days after hospitalization. An autopsy revealed extensive lymphomatous involvement of multiple lymph nodes, including mesenteric, mediastinal, retroperitoneal, cervical and periaortic. In addition, significant involvement of the left myocardium (Figure 1) and multiple other organs (bilateral lungs, stomach, bowels, pancreas, bilateral kidneys, bilateral adrenals and prostate) and patchy involvement of diaphragm, skin and muscle was demonstrated by histomorphology and immunohistochemistry (including sections from the cardiac lymphoma shown in Figure 2).
3. Discussion
ATLL is a malignant lymphoproliferative neoplasm of mature T-cells initiated by monoclonal integration of HTLV-1 in the genome of lymphocytes, which leads to complex multistep events occurring during a long latency period. Despite a greater understanding of the pathogenesis of ATLL, curative treatment is lacking, and the overall prognosis remains dismal.
According to the Shimoyama classification, four variants of ATLL are recognized: acute, lymphomatous, chronic and smoldering [3]. The lymphomatous form is usually clinically aggressive and presents with advanced disease, including prominent lymphadenopathy and infrequent hypercalcemia, as seen in our patient. Although extensive involvement of the spleen and skin are common in lymphomatous ATLL, we did not observe these features. Instead, we detected patchy dermal involvement and extensive myocardial infiltration by ATLL, a rare event typically associated with ominous prognosis and concomitant lymphomatous involvement of the lung [6], as our necropsy illustrated. Of note, cardiac ATLL can be commonly missed pre-mortem even with modern imaging (as performed here) and is associated with chemoresistance [6]. Cutaneous involvement in our case was subclinical, as demonstrated by immunohistochemistry of a few tiny lymphoid aggregates found by microscopic examination, which is also unusual in lymphomatous ATLL.
Despite substantial progress in recent years, the molecular pathogenesis of ATLL remains unclear. After monoclonal integration of HTLV-1 and expression of viral oncogenes, such as Tax and HBZ, dysregulation of signaling pathways related to T-cell proliferation/differentiation and immune surveillance leads to leukemogenesis. Interestingly, Tax is dispensable for transformation and inactivated in a high proportion of cases [9]. However, HBZ is the only viral protein that remains consistently expressed in ATLL cases. Activation of PI3K, JAK/STAT and TCR/NF-kB pathways by genetic and epigenetic mechanisms seem to be crucial for tumor progression, and specific genes are commonly mutated, including CARD22, CCR4, CCR7, CDKN2A (p16), CDK2B (p15), EP300, FAS, FYN, GATA3, IRF4, PLCG1, PRKCB, TP53, STAT3 and VAV1. Accordingly, we observed mutations in genes of the TCR/NF-κB pathway (CBL, CUX1 and FAS), implicated in unrestricted and persistent NF-κB activation leading to the development of autoimmune diseases and neoplasms [13]. Such disbalance between T-cell activation and excessive NF-κB stimulation may have initiated deleterious consequences of TCR signaling, which, without negative regulation of nuclear signaling, may contribute to tumor progression. Interestingly, genetic alterations in genes associated with WNT/beta-catenin (AXIN1, CTNNB1 and SMO) and the RAS/MAPK (NF1), which are less commonly associated with ATLL, were also detected, suggesting possible unique pathogenic associations. As expected, several mutated genes that play a role in genomic stability (BARD1, TP53 and STAG2) and/or transcriptional regulation (HIST1H2AM, HIST1H2BO, IRF4 and GATA3) were seen. Also, genes directly involved in cell cycle control (CDK6) and soluble growth factors (HCF) had mutations in this tumor. Furthermore, trophic pathways related to surface receptors seem to be involved in our case, as suggested by mutations in CD36 (a lipid scavenger receptor) [14], LRP1B (a member of the low-density lipoprotein receptor family) [15] and FGFR2 (fibroblast growth factor receptor 2/CD332) [12]. Furthermore, additional epigenetic regulation may be represented by mutations in DNMT3A, a methyltransferase that may modulate gene expression by altering histones [16]. Finally, we found alterations in genes that have an unclear oncogenic mechanism of action, such as SDHD (a well-known driver gene in Cowden/Cowden-like syndromes) [17] and PCLO (a scaffold protein of the presynaptic cytomatrix at the active zone) [18].
Mutations in some of these genes (CBL, CDK6, DNMT3A, FAS, FGFR2, GATA3, HGF, IRF4, TP53 and STAG2) are well known in association with ATLL [12], but the specific alterations found are novel (CBL H42_L43insH, DNMT3A S199R, FGFR2 S431L, GATA3 loss of exons 4–6 and STAG2 I771M). Other genes have been described [18,19,20] in association with different hematopoietic or solid tumors (AXIN1, BARD1, CUX1, NF1, PCLO, SDHD and SMO), but are reported here for the first time in association with ATLL. Of interest, eight mutations (AXIN1, R712Q, BARD1 R749K, CTNNB1 I315V, CUX1 P102T, DNMT3A S199R, FGFR2 S431L, LRP1B Y2560C and STAG2 I771M) have not been reported before to the best of our knowledge after extensive literature/database searches. Current molecular pathogenesis of ATLL postulates important processes related to HTLV-1-mediated proliferation and immune evasion based on unclear stochastic genetic alterations necessary for full-blown disease. Accordingly, mutations belonging to major well-characterized pathways were found in this study. Focusing on the novel point mutations in the TCR/NF-kB (CUX1 P102T), epigenetic/methylation regulatory (DNMT3A S199R) and genetic stability (BARD1 and STAG2) pathways, our findings suggest commonalities with prior reports [12]. Similarly, various novel mutations belonging to the category of trophic proliferative signaling (FGFR2 S431L and LRP1B Y2560C) were sequenced. However, we also found novel mutations in the WNT/beta-catenin pathway (AXIN1, R712Q and CTNNB1 I315V), which is underappreciated in ATLL. Overexpression of Wnt5a (an activator of beta-catenin/CTNNB1 not found in our case) has been proposed as a mediator of hypercalcemia [21] and suggests that the beta-catenin (CTNNB1 I315V) defect we observed may have abrogated this mechanism, since our patient remained normocalcemic. Likewise, AXIN1 inactivation may have contributed to such normocalcemic phenotype, since this tumor suppressor regulates G-protein coupled signaling upstream of beta-catenin [20].
In summary, we present a clinically unusual lethal case of ATLL with several novel mutations (AXIN1, R712Q, BARD1 R749K, CTNNB1 I315V, CUX1 P102T, DNMT3A S199R, FGFR2 S431L, LRP1B Y2560C and STAG2 I771M) and unexpected myocardial involvement, which probably contributed to the fatal outcome.
Author Contributions
Conceptualization, V.E.N.; methodology, R.A. and T.H.Z.; formal analysis R.A. and T.H.Z.; investigation, V.E.N., R.A., T.H.Z. and B.C.B.; data curation, R.A.; writing—original draft preparation, T.H.Z.; writing—review and editing, R.A., V.E.N. and B.C.B. All authors have read and agreed to the published version of the manuscript.
Funding
This research received no external funding.
Conflicts of Interest
The authors declare no conflict of interest.
Figure 1 Gross appearance of the heart. The left myocardium shows and focal thickening and white-brown discoloration (arrow) that corresponds to leukemic infiltration.
Figure 2 (A) Adult T-cell leukemia/lymphoma (ATLL) infiltration of endocardium and myocardium (H&E, 20×). (B) Higher magnification of infiltrating lymphoma showing pleomorphism, scant eosinophilic cytoplasm, irregular nuclear contours with coarse chromatin and variably prominent nucleoli (H&E, 200×). The lymphoma cells were strongly positive for CD4 (C) and CD25 (D) by immunohistochemistry (20×).
curroncol-28-00079-t001_Table 1 Table 1 Somatic mutations identified by next-generation sequencing (NGS).
Gene Somatic Mutation Allele Frequency (%)
AXIN1 R712Q 44.94
BARD1 R749K 24.75
CBL H42_L43insH 17.61
CTNNB1 I315V 76.45
CUX1 R44W 36.15
CUX1 P102T 26.84
DNMT3A S199R 39.04
FAS D228fs*2 45.37
FGFR2 S431L 26.61
LRP1B D1063N 68.28
LRP1B Y2560C 46.64
NF1 S665F 31.97
SDHD F34C 29.79
SMO G24A 48.98
STAG2 I771M 40.98
TP53 H193L 70.02
Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations. | Not recovered | ReactionOutcome | CC BY | 33562071 | 19,160,898 | 2021-02-06 |
What was the outcome of reaction 'Cardiac arrest'? | Novel Mutations in a Lethal Case of Lymphomatous Adult T Cell Lymphoma with Cryptic Myocardial Involvement.
The autopsy of a 65-year-old diabetic African American male revealed significant left myocardial involvement by adult T-cell leukemia/lymphoma (ATLL) despite normal pre-mortem fluorodeoxyglucose (FDG) uptake by positron emission tomography/computed tomography (PET/CT). Due to pre-existing diabetic cardiomyopathy with reduced ejection fraction (EF) and compatible imaging studies, cardiac lymphomatous involvement was not suspected. While peripheral blood was negative for leukemia, next-generation sequencing of a lymph node revealed at least eight novel mutations (AXIN1, R712Q, BARD1 R749K, CTNNB1 I315V, CUX1 P102T, DNMT3A S199R, FGFR2 S431L, LRP1B Y2560C and STAG2 I771M). These findings underscore a diagnostic pitfall in a rare lymphomatous variant of ATLL infiltrating myocardium and contribute to its molecular characterization.
1. Introduction
The World Health Organization (WHO) defines adult T-cell leukemia/lymphoma (ATLL) as a mature T-cell neoplasm composed of highly pleomorphic lymphoid cells and thought to be initiated by the retrovirus human T-cell leukemia virus type-1 (HTLV-1), which is necessary but not sufficient for its pathogenesis [1,2]. In North America, out of the four clinical variants of the disease (acute, lymphomatous, chronic and smoldering), the first two are the most common (~90% of cases) and carry a worse prognosis [3]. The lymphomatous type is characterized by prominent lymphadenopathy without peripheral blood involvement and by less frequent dermatologic manifestations or hypercalcemia [3]. Heart involvement by ATLL tends to be asymptomatic or oligosymptomatic. In autopsy series, few patients show cardiac symptoms like shortness of breath or palpitations, and massive cardiomegaly with extensive myocardial lymphomatous infiltration has seldom been reported [4,5,6].
The epidemiology of HTLV-1 in ATLL has been extensively studied. Geographic ATLL clustering overlaps endemic areas for the virus, such as southwestern Japan, the Caribbean basin and parts of central Africa. HTLV-1 is transmitted through blood products and breast feeding, and development of the disease follows a long (over 30 years) latency period after infection [7], which suggest that besides the causal role of viral oncogenes, host genetic and epigenetic factors are also necessary for tumorigenesis [8]. Two HTLV-1 proteins Tax and basic leucine zipper (HBZ) lead to transcriptional activation and T-cell proliferation, and both are able to transform in mouse models [9,10]. Tax-induced T-cell receptor (TCR)/nuclear factor kB (NF-kB) signaling has been well-documented in the development of ATLL [11]. However, Tax expression is silenced in a high proportion of ATLL cases, which illustrates its dispensable role in lymphomagenesis. In contrast, HBZ is the only viral protein consistently expressed in ATLL, and plays pleotropic roles modulating cell growth, T-cell differentiation and immune response, which contribute to oncogenesis. While most studies on the genetic alterations in ATLL have focused on Asian cases, recently, North American cases were analyzed in detail, demonstrating a unique frequency of epigenetic and histone modifying gene changes [12]. Conversely, the frequency of mutations in the JAK/STAT and the TCR/NF-kB pathway genes were lower when compared with the Japanese cases [12]. Therefore, it would be important to further analyze North American cases to confirm these findings, and to identify preclinical druggable target candidates. Here we present a lethal lymphomatous case of North American ATLL with extensive cardiac involvement and next-generation sequencing (NGS) data demonstrating several novel mutations that may hold promise in the diagnostic and therapeutic strategy.
2. Result
A 65-year-old diabetic African American male followed at the Washington DC Veterans Affairs Medical Center for hypertension and complications of diabetes mellitus, including heart failure with 40% ejection fraction (EF), chronic renal failure and neuropathy, developed poor appetite, abdominal pain and weight loss of 15 pounds (6.8 kg) in May 2019. The patient was hospitalized due to exertional orthopnea, severe gastrointestinal reflux disease and worsening shortness of breath.
Physical examination revealed mild obesity, unremarkable pulmonary and cardiovascular examination and no organomegaly or palpable lymphadenopathy. Imaging studies (including CT of the abdomen and pelvis with contrast) revealed infiltrating hypodense masses involving both kidneys, mesenteric lymphadenopathy and innumerable ground glass nodules with random distribution in the lung bases. The electrocardiogram was unremarkable. Multigated acquisition scan showed concentric left ventricular wall hypertrophy and hypokinesia, compatible with known cardiomyopathy. PET scan revealed innumerable foci of intense fluorodeoxyglucose (FDG) uptake in lungs, peritoneal cavity, kidneys, nodal basins (above and below the diaphragm), subcutaneous soft tissues and bones. However, normal FDG uptake within the myocardium was detected. Peripheral white blood cell counts were within the normal range. Serum calcium, sodium and potassium were also normal. Lactate dehydrogenase was markedly elevated at 1600 U/L, and serum HTLV-I antibody test was positive.
An enlarged supraclavicular lymph node was excised, and the diagnosis of ATLL was made based on histomorphology and positivity for CD45, CD2, CD3, CD4 and CD25 by immunohistochemistry. Ki-67 proliferative rate was very high (>80%). Other markers, including CD7 (aberrant loss), CD8, CD10, CD56, EBV and CD30, were negative. Careful examination of peripheral blood failed to detect atypical large lymphocytes, which was confirmed by a flow cytometric analysis showing no lymphomatous involvement. The diagnosis of lymphomatous variant of ATLL was confirmed, and NGS was performed by Foundation Medicine (comprehensive DNA and RNA analysis) and interpreted following the guidelines of the American College of Medical Genetics. This analysis revealed an intermediate tumor mutational burden (nine mutations per megabase) and stable microsatellite status. The following somatic mutations (Table 1) were also identified: AXIN1 R712Q, BARD1 R749K, CBL H42_L43insH, CD36 amplification, CDK6 amplification, CTNNB1 I315V, CUX1 (P102T and R44W), DNMT3A S199R, FAS D228fs*2, FGFR2 S431L, GATA3 loss exons 4–6, HGF amplification, HIST1H2AM loss, HIST1H2BO loss, IRF4 amplification, LRP1B (D1063N and Y2560C), NF1 S665F, PCLO amplification, SDHD F34C, SMO G24A, STAG2 I771M and TP53 H193L.
The patient underwent two cycles of chemotherapy (ESHAP-etoposide, methylprednisolone, cytarabine and cisplatin), but unfortunately had a complicated post-treatment course and developed tumor lysis syndrome, gastrointestinal bleeding, exacerbation of heart failure and unresolved acute kidney injury. Despite intensive care and cardiopulmonary resuscitation, the patient developed cardiac arrest and died 45 days after hospitalization. An autopsy revealed extensive lymphomatous involvement of multiple lymph nodes, including mesenteric, mediastinal, retroperitoneal, cervical and periaortic. In addition, significant involvement of the left myocardium (Figure 1) and multiple other organs (bilateral lungs, stomach, bowels, pancreas, bilateral kidneys, bilateral adrenals and prostate) and patchy involvement of diaphragm, skin and muscle was demonstrated by histomorphology and immunohistochemistry (including sections from the cardiac lymphoma shown in Figure 2).
3. Discussion
ATLL is a malignant lymphoproliferative neoplasm of mature T-cells initiated by monoclonal integration of HTLV-1 in the genome of lymphocytes, which leads to complex multistep events occurring during a long latency period. Despite a greater understanding of the pathogenesis of ATLL, curative treatment is lacking, and the overall prognosis remains dismal.
According to the Shimoyama classification, four variants of ATLL are recognized: acute, lymphomatous, chronic and smoldering [3]. The lymphomatous form is usually clinically aggressive and presents with advanced disease, including prominent lymphadenopathy and infrequent hypercalcemia, as seen in our patient. Although extensive involvement of the spleen and skin are common in lymphomatous ATLL, we did not observe these features. Instead, we detected patchy dermal involvement and extensive myocardial infiltration by ATLL, a rare event typically associated with ominous prognosis and concomitant lymphomatous involvement of the lung [6], as our necropsy illustrated. Of note, cardiac ATLL can be commonly missed pre-mortem even with modern imaging (as performed here) and is associated with chemoresistance [6]. Cutaneous involvement in our case was subclinical, as demonstrated by immunohistochemistry of a few tiny lymphoid aggregates found by microscopic examination, which is also unusual in lymphomatous ATLL.
Despite substantial progress in recent years, the molecular pathogenesis of ATLL remains unclear. After monoclonal integration of HTLV-1 and expression of viral oncogenes, such as Tax and HBZ, dysregulation of signaling pathways related to T-cell proliferation/differentiation and immune surveillance leads to leukemogenesis. Interestingly, Tax is dispensable for transformation and inactivated in a high proportion of cases [9]. However, HBZ is the only viral protein that remains consistently expressed in ATLL cases. Activation of PI3K, JAK/STAT and TCR/NF-kB pathways by genetic and epigenetic mechanisms seem to be crucial for tumor progression, and specific genes are commonly mutated, including CARD22, CCR4, CCR7, CDKN2A (p16), CDK2B (p15), EP300, FAS, FYN, GATA3, IRF4, PLCG1, PRKCB, TP53, STAT3 and VAV1. Accordingly, we observed mutations in genes of the TCR/NF-κB pathway (CBL, CUX1 and FAS), implicated in unrestricted and persistent NF-κB activation leading to the development of autoimmune diseases and neoplasms [13]. Such disbalance between T-cell activation and excessive NF-κB stimulation may have initiated deleterious consequences of TCR signaling, which, without negative regulation of nuclear signaling, may contribute to tumor progression. Interestingly, genetic alterations in genes associated with WNT/beta-catenin (AXIN1, CTNNB1 and SMO) and the RAS/MAPK (NF1), which are less commonly associated with ATLL, were also detected, suggesting possible unique pathogenic associations. As expected, several mutated genes that play a role in genomic stability (BARD1, TP53 and STAG2) and/or transcriptional regulation (HIST1H2AM, HIST1H2BO, IRF4 and GATA3) were seen. Also, genes directly involved in cell cycle control (CDK6) and soluble growth factors (HCF) had mutations in this tumor. Furthermore, trophic pathways related to surface receptors seem to be involved in our case, as suggested by mutations in CD36 (a lipid scavenger receptor) [14], LRP1B (a member of the low-density lipoprotein receptor family) [15] and FGFR2 (fibroblast growth factor receptor 2/CD332) [12]. Furthermore, additional epigenetic regulation may be represented by mutations in DNMT3A, a methyltransferase that may modulate gene expression by altering histones [16]. Finally, we found alterations in genes that have an unclear oncogenic mechanism of action, such as SDHD (a well-known driver gene in Cowden/Cowden-like syndromes) [17] and PCLO (a scaffold protein of the presynaptic cytomatrix at the active zone) [18].
Mutations in some of these genes (CBL, CDK6, DNMT3A, FAS, FGFR2, GATA3, HGF, IRF4, TP53 and STAG2) are well known in association with ATLL [12], but the specific alterations found are novel (CBL H42_L43insH, DNMT3A S199R, FGFR2 S431L, GATA3 loss of exons 4–6 and STAG2 I771M). Other genes have been described [18,19,20] in association with different hematopoietic or solid tumors (AXIN1, BARD1, CUX1, NF1, PCLO, SDHD and SMO), but are reported here for the first time in association with ATLL. Of interest, eight mutations (AXIN1, R712Q, BARD1 R749K, CTNNB1 I315V, CUX1 P102T, DNMT3A S199R, FGFR2 S431L, LRP1B Y2560C and STAG2 I771M) have not been reported before to the best of our knowledge after extensive literature/database searches. Current molecular pathogenesis of ATLL postulates important processes related to HTLV-1-mediated proliferation and immune evasion based on unclear stochastic genetic alterations necessary for full-blown disease. Accordingly, mutations belonging to major well-characterized pathways were found in this study. Focusing on the novel point mutations in the TCR/NF-kB (CUX1 P102T), epigenetic/methylation regulatory (DNMT3A S199R) and genetic stability (BARD1 and STAG2) pathways, our findings suggest commonalities with prior reports [12]. Similarly, various novel mutations belonging to the category of trophic proliferative signaling (FGFR2 S431L and LRP1B Y2560C) were sequenced. However, we also found novel mutations in the WNT/beta-catenin pathway (AXIN1, R712Q and CTNNB1 I315V), which is underappreciated in ATLL. Overexpression of Wnt5a (an activator of beta-catenin/CTNNB1 not found in our case) has been proposed as a mediator of hypercalcemia [21] and suggests that the beta-catenin (CTNNB1 I315V) defect we observed may have abrogated this mechanism, since our patient remained normocalcemic. Likewise, AXIN1 inactivation may have contributed to such normocalcemic phenotype, since this tumor suppressor regulates G-protein coupled signaling upstream of beta-catenin [20].
In summary, we present a clinically unusual lethal case of ATLL with several novel mutations (AXIN1, R712Q, BARD1 R749K, CTNNB1 I315V, CUX1 P102T, DNMT3A S199R, FGFR2 S431L, LRP1B Y2560C and STAG2 I771M) and unexpected myocardial involvement, which probably contributed to the fatal outcome.
Author Contributions
Conceptualization, V.E.N.; methodology, R.A. and T.H.Z.; formal analysis R.A. and T.H.Z.; investigation, V.E.N., R.A., T.H.Z. and B.C.B.; data curation, R.A.; writing—original draft preparation, T.H.Z.; writing—review and editing, R.A., V.E.N. and B.C.B. All authors have read and agreed to the published version of the manuscript.
Funding
This research received no external funding.
Conflicts of Interest
The authors declare no conflict of interest.
Figure 1 Gross appearance of the heart. The left myocardium shows and focal thickening and white-brown discoloration (arrow) that corresponds to leukemic infiltration.
Figure 2 (A) Adult T-cell leukemia/lymphoma (ATLL) infiltration of endocardium and myocardium (H&E, 20×). (B) Higher magnification of infiltrating lymphoma showing pleomorphism, scant eosinophilic cytoplasm, irregular nuclear contours with coarse chromatin and variably prominent nucleoli (H&E, 200×). The lymphoma cells were strongly positive for CD4 (C) and CD25 (D) by immunohistochemistry (20×).
curroncol-28-00079-t001_Table 1 Table 1 Somatic mutations identified by next-generation sequencing (NGS).
Gene Somatic Mutation Allele Frequency (%)
AXIN1 R712Q 44.94
BARD1 R749K 24.75
CBL H42_L43insH 17.61
CTNNB1 I315V 76.45
CUX1 R44W 36.15
CUX1 P102T 26.84
DNMT3A S199R 39.04
FAS D228fs*2 45.37
FGFR2 S431L 26.61
LRP1B D1063N 68.28
LRP1B Y2560C 46.64
NF1 S665F 31.97
SDHD F34C 29.79
SMO G24A 48.98
STAG2 I771M 40.98
TP53 H193L 70.02
Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations. | Fatal | ReactionOutcome | CC BY | 33562071 | 20,134,169 | 2021-02-06 |
What was the outcome of reaction 'Cardiac failure'? | Novel Mutations in a Lethal Case of Lymphomatous Adult T Cell Lymphoma with Cryptic Myocardial Involvement.
The autopsy of a 65-year-old diabetic African American male revealed significant left myocardial involvement by adult T-cell leukemia/lymphoma (ATLL) despite normal pre-mortem fluorodeoxyglucose (FDG) uptake by positron emission tomography/computed tomography (PET/CT). Due to pre-existing diabetic cardiomyopathy with reduced ejection fraction (EF) and compatible imaging studies, cardiac lymphomatous involvement was not suspected. While peripheral blood was negative for leukemia, next-generation sequencing of a lymph node revealed at least eight novel mutations (AXIN1, R712Q, BARD1 R749K, CTNNB1 I315V, CUX1 P102T, DNMT3A S199R, FGFR2 S431L, LRP1B Y2560C and STAG2 I771M). These findings underscore a diagnostic pitfall in a rare lymphomatous variant of ATLL infiltrating myocardium and contribute to its molecular characterization.
1. Introduction
The World Health Organization (WHO) defines adult T-cell leukemia/lymphoma (ATLL) as a mature T-cell neoplasm composed of highly pleomorphic lymphoid cells and thought to be initiated by the retrovirus human T-cell leukemia virus type-1 (HTLV-1), which is necessary but not sufficient for its pathogenesis [1,2]. In North America, out of the four clinical variants of the disease (acute, lymphomatous, chronic and smoldering), the first two are the most common (~90% of cases) and carry a worse prognosis [3]. The lymphomatous type is characterized by prominent lymphadenopathy without peripheral blood involvement and by less frequent dermatologic manifestations or hypercalcemia [3]. Heart involvement by ATLL tends to be asymptomatic or oligosymptomatic. In autopsy series, few patients show cardiac symptoms like shortness of breath or palpitations, and massive cardiomegaly with extensive myocardial lymphomatous infiltration has seldom been reported [4,5,6].
The epidemiology of HTLV-1 in ATLL has been extensively studied. Geographic ATLL clustering overlaps endemic areas for the virus, such as southwestern Japan, the Caribbean basin and parts of central Africa. HTLV-1 is transmitted through blood products and breast feeding, and development of the disease follows a long (over 30 years) latency period after infection [7], which suggest that besides the causal role of viral oncogenes, host genetic and epigenetic factors are also necessary for tumorigenesis [8]. Two HTLV-1 proteins Tax and basic leucine zipper (HBZ) lead to transcriptional activation and T-cell proliferation, and both are able to transform in mouse models [9,10]. Tax-induced T-cell receptor (TCR)/nuclear factor kB (NF-kB) signaling has been well-documented in the development of ATLL [11]. However, Tax expression is silenced in a high proportion of ATLL cases, which illustrates its dispensable role in lymphomagenesis. In contrast, HBZ is the only viral protein consistently expressed in ATLL, and plays pleotropic roles modulating cell growth, T-cell differentiation and immune response, which contribute to oncogenesis. While most studies on the genetic alterations in ATLL have focused on Asian cases, recently, North American cases were analyzed in detail, demonstrating a unique frequency of epigenetic and histone modifying gene changes [12]. Conversely, the frequency of mutations in the JAK/STAT and the TCR/NF-kB pathway genes were lower when compared with the Japanese cases [12]. Therefore, it would be important to further analyze North American cases to confirm these findings, and to identify preclinical druggable target candidates. Here we present a lethal lymphomatous case of North American ATLL with extensive cardiac involvement and next-generation sequencing (NGS) data demonstrating several novel mutations that may hold promise in the diagnostic and therapeutic strategy.
2. Result
A 65-year-old diabetic African American male followed at the Washington DC Veterans Affairs Medical Center for hypertension and complications of diabetes mellitus, including heart failure with 40% ejection fraction (EF), chronic renal failure and neuropathy, developed poor appetite, abdominal pain and weight loss of 15 pounds (6.8 kg) in May 2019. The patient was hospitalized due to exertional orthopnea, severe gastrointestinal reflux disease and worsening shortness of breath.
Physical examination revealed mild obesity, unremarkable pulmonary and cardiovascular examination and no organomegaly or palpable lymphadenopathy. Imaging studies (including CT of the abdomen and pelvis with contrast) revealed infiltrating hypodense masses involving both kidneys, mesenteric lymphadenopathy and innumerable ground glass nodules with random distribution in the lung bases. The electrocardiogram was unremarkable. Multigated acquisition scan showed concentric left ventricular wall hypertrophy and hypokinesia, compatible with known cardiomyopathy. PET scan revealed innumerable foci of intense fluorodeoxyglucose (FDG) uptake in lungs, peritoneal cavity, kidneys, nodal basins (above and below the diaphragm), subcutaneous soft tissues and bones. However, normal FDG uptake within the myocardium was detected. Peripheral white blood cell counts were within the normal range. Serum calcium, sodium and potassium were also normal. Lactate dehydrogenase was markedly elevated at 1600 U/L, and serum HTLV-I antibody test was positive.
An enlarged supraclavicular lymph node was excised, and the diagnosis of ATLL was made based on histomorphology and positivity for CD45, CD2, CD3, CD4 and CD25 by immunohistochemistry. Ki-67 proliferative rate was very high (>80%). Other markers, including CD7 (aberrant loss), CD8, CD10, CD56, EBV and CD30, were negative. Careful examination of peripheral blood failed to detect atypical large lymphocytes, which was confirmed by a flow cytometric analysis showing no lymphomatous involvement. The diagnosis of lymphomatous variant of ATLL was confirmed, and NGS was performed by Foundation Medicine (comprehensive DNA and RNA analysis) and interpreted following the guidelines of the American College of Medical Genetics. This analysis revealed an intermediate tumor mutational burden (nine mutations per megabase) and stable microsatellite status. The following somatic mutations (Table 1) were also identified: AXIN1 R712Q, BARD1 R749K, CBL H42_L43insH, CD36 amplification, CDK6 amplification, CTNNB1 I315V, CUX1 (P102T and R44W), DNMT3A S199R, FAS D228fs*2, FGFR2 S431L, GATA3 loss exons 4–6, HGF amplification, HIST1H2AM loss, HIST1H2BO loss, IRF4 amplification, LRP1B (D1063N and Y2560C), NF1 S665F, PCLO amplification, SDHD F34C, SMO G24A, STAG2 I771M and TP53 H193L.
The patient underwent two cycles of chemotherapy (ESHAP-etoposide, methylprednisolone, cytarabine and cisplatin), but unfortunately had a complicated post-treatment course and developed tumor lysis syndrome, gastrointestinal bleeding, exacerbation of heart failure and unresolved acute kidney injury. Despite intensive care and cardiopulmonary resuscitation, the patient developed cardiac arrest and died 45 days after hospitalization. An autopsy revealed extensive lymphomatous involvement of multiple lymph nodes, including mesenteric, mediastinal, retroperitoneal, cervical and periaortic. In addition, significant involvement of the left myocardium (Figure 1) and multiple other organs (bilateral lungs, stomach, bowels, pancreas, bilateral kidneys, bilateral adrenals and prostate) and patchy involvement of diaphragm, skin and muscle was demonstrated by histomorphology and immunohistochemistry (including sections from the cardiac lymphoma shown in Figure 2).
3. Discussion
ATLL is a malignant lymphoproliferative neoplasm of mature T-cells initiated by monoclonal integration of HTLV-1 in the genome of lymphocytes, which leads to complex multistep events occurring during a long latency period. Despite a greater understanding of the pathogenesis of ATLL, curative treatment is lacking, and the overall prognosis remains dismal.
According to the Shimoyama classification, four variants of ATLL are recognized: acute, lymphomatous, chronic and smoldering [3]. The lymphomatous form is usually clinically aggressive and presents with advanced disease, including prominent lymphadenopathy and infrequent hypercalcemia, as seen in our patient. Although extensive involvement of the spleen and skin are common in lymphomatous ATLL, we did not observe these features. Instead, we detected patchy dermal involvement and extensive myocardial infiltration by ATLL, a rare event typically associated with ominous prognosis and concomitant lymphomatous involvement of the lung [6], as our necropsy illustrated. Of note, cardiac ATLL can be commonly missed pre-mortem even with modern imaging (as performed here) and is associated with chemoresistance [6]. Cutaneous involvement in our case was subclinical, as demonstrated by immunohistochemistry of a few tiny lymphoid aggregates found by microscopic examination, which is also unusual in lymphomatous ATLL.
Despite substantial progress in recent years, the molecular pathogenesis of ATLL remains unclear. After monoclonal integration of HTLV-1 and expression of viral oncogenes, such as Tax and HBZ, dysregulation of signaling pathways related to T-cell proliferation/differentiation and immune surveillance leads to leukemogenesis. Interestingly, Tax is dispensable for transformation and inactivated in a high proportion of cases [9]. However, HBZ is the only viral protein that remains consistently expressed in ATLL cases. Activation of PI3K, JAK/STAT and TCR/NF-kB pathways by genetic and epigenetic mechanisms seem to be crucial for tumor progression, and specific genes are commonly mutated, including CARD22, CCR4, CCR7, CDKN2A (p16), CDK2B (p15), EP300, FAS, FYN, GATA3, IRF4, PLCG1, PRKCB, TP53, STAT3 and VAV1. Accordingly, we observed mutations in genes of the TCR/NF-κB pathway (CBL, CUX1 and FAS), implicated in unrestricted and persistent NF-κB activation leading to the development of autoimmune diseases and neoplasms [13]. Such disbalance between T-cell activation and excessive NF-κB stimulation may have initiated deleterious consequences of TCR signaling, which, without negative regulation of nuclear signaling, may contribute to tumor progression. Interestingly, genetic alterations in genes associated with WNT/beta-catenin (AXIN1, CTNNB1 and SMO) and the RAS/MAPK (NF1), which are less commonly associated with ATLL, were also detected, suggesting possible unique pathogenic associations. As expected, several mutated genes that play a role in genomic stability (BARD1, TP53 and STAG2) and/or transcriptional regulation (HIST1H2AM, HIST1H2BO, IRF4 and GATA3) were seen. Also, genes directly involved in cell cycle control (CDK6) and soluble growth factors (HCF) had mutations in this tumor. Furthermore, trophic pathways related to surface receptors seem to be involved in our case, as suggested by mutations in CD36 (a lipid scavenger receptor) [14], LRP1B (a member of the low-density lipoprotein receptor family) [15] and FGFR2 (fibroblast growth factor receptor 2/CD332) [12]. Furthermore, additional epigenetic regulation may be represented by mutations in DNMT3A, a methyltransferase that may modulate gene expression by altering histones [16]. Finally, we found alterations in genes that have an unclear oncogenic mechanism of action, such as SDHD (a well-known driver gene in Cowden/Cowden-like syndromes) [17] and PCLO (a scaffold protein of the presynaptic cytomatrix at the active zone) [18].
Mutations in some of these genes (CBL, CDK6, DNMT3A, FAS, FGFR2, GATA3, HGF, IRF4, TP53 and STAG2) are well known in association with ATLL [12], but the specific alterations found are novel (CBL H42_L43insH, DNMT3A S199R, FGFR2 S431L, GATA3 loss of exons 4–6 and STAG2 I771M). Other genes have been described [18,19,20] in association with different hematopoietic or solid tumors (AXIN1, BARD1, CUX1, NF1, PCLO, SDHD and SMO), but are reported here for the first time in association with ATLL. Of interest, eight mutations (AXIN1, R712Q, BARD1 R749K, CTNNB1 I315V, CUX1 P102T, DNMT3A S199R, FGFR2 S431L, LRP1B Y2560C and STAG2 I771M) have not been reported before to the best of our knowledge after extensive literature/database searches. Current molecular pathogenesis of ATLL postulates important processes related to HTLV-1-mediated proliferation and immune evasion based on unclear stochastic genetic alterations necessary for full-blown disease. Accordingly, mutations belonging to major well-characterized pathways were found in this study. Focusing on the novel point mutations in the TCR/NF-kB (CUX1 P102T), epigenetic/methylation regulatory (DNMT3A S199R) and genetic stability (BARD1 and STAG2) pathways, our findings suggest commonalities with prior reports [12]. Similarly, various novel mutations belonging to the category of trophic proliferative signaling (FGFR2 S431L and LRP1B Y2560C) were sequenced. However, we also found novel mutations in the WNT/beta-catenin pathway (AXIN1, R712Q and CTNNB1 I315V), which is underappreciated in ATLL. Overexpression of Wnt5a (an activator of beta-catenin/CTNNB1 not found in our case) has been proposed as a mediator of hypercalcemia [21] and suggests that the beta-catenin (CTNNB1 I315V) defect we observed may have abrogated this mechanism, since our patient remained normocalcemic. Likewise, AXIN1 inactivation may have contributed to such normocalcemic phenotype, since this tumor suppressor regulates G-protein coupled signaling upstream of beta-catenin [20].
In summary, we present a clinically unusual lethal case of ATLL with several novel mutations (AXIN1, R712Q, BARD1 R749K, CTNNB1 I315V, CUX1 P102T, DNMT3A S199R, FGFR2 S431L, LRP1B Y2560C and STAG2 I771M) and unexpected myocardial involvement, which probably contributed to the fatal outcome.
Author Contributions
Conceptualization, V.E.N.; methodology, R.A. and T.H.Z.; formal analysis R.A. and T.H.Z.; investigation, V.E.N., R.A., T.H.Z. and B.C.B.; data curation, R.A.; writing—original draft preparation, T.H.Z.; writing—review and editing, R.A., V.E.N. and B.C.B. All authors have read and agreed to the published version of the manuscript.
Funding
This research received no external funding.
Conflicts of Interest
The authors declare no conflict of interest.
Figure 1 Gross appearance of the heart. The left myocardium shows and focal thickening and white-brown discoloration (arrow) that corresponds to leukemic infiltration.
Figure 2 (A) Adult T-cell leukemia/lymphoma (ATLL) infiltration of endocardium and myocardium (H&E, 20×). (B) Higher magnification of infiltrating lymphoma showing pleomorphism, scant eosinophilic cytoplasm, irregular nuclear contours with coarse chromatin and variably prominent nucleoli (H&E, 200×). The lymphoma cells were strongly positive for CD4 (C) and CD25 (D) by immunohistochemistry (20×).
curroncol-28-00079-t001_Table 1 Table 1 Somatic mutations identified by next-generation sequencing (NGS).
Gene Somatic Mutation Allele Frequency (%)
AXIN1 R712Q 44.94
BARD1 R749K 24.75
CBL H42_L43insH 17.61
CTNNB1 I315V 76.45
CUX1 R44W 36.15
CUX1 P102T 26.84
DNMT3A S199R 39.04
FAS D228fs*2 45.37
FGFR2 S431L 26.61
LRP1B D1063N 68.28
LRP1B Y2560C 46.64
NF1 S665F 31.97
SDHD F34C 29.79
SMO G24A 48.98
STAG2 I771M 40.98
TP53 H193L 70.02
Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations. | Not recovered | ReactionOutcome | CC BY | 33562071 | 20,134,169 | 2021-02-06 |
What was the outcome of reaction 'Gastrointestinal haemorrhage'? | Novel Mutations in a Lethal Case of Lymphomatous Adult T Cell Lymphoma with Cryptic Myocardial Involvement.
The autopsy of a 65-year-old diabetic African American male revealed significant left myocardial involvement by adult T-cell leukemia/lymphoma (ATLL) despite normal pre-mortem fluorodeoxyglucose (FDG) uptake by positron emission tomography/computed tomography (PET/CT). Due to pre-existing diabetic cardiomyopathy with reduced ejection fraction (EF) and compatible imaging studies, cardiac lymphomatous involvement was not suspected. While peripheral blood was negative for leukemia, next-generation sequencing of a lymph node revealed at least eight novel mutations (AXIN1, R712Q, BARD1 R749K, CTNNB1 I315V, CUX1 P102T, DNMT3A S199R, FGFR2 S431L, LRP1B Y2560C and STAG2 I771M). These findings underscore a diagnostic pitfall in a rare lymphomatous variant of ATLL infiltrating myocardium and contribute to its molecular characterization.
1. Introduction
The World Health Organization (WHO) defines adult T-cell leukemia/lymphoma (ATLL) as a mature T-cell neoplasm composed of highly pleomorphic lymphoid cells and thought to be initiated by the retrovirus human T-cell leukemia virus type-1 (HTLV-1), which is necessary but not sufficient for its pathogenesis [1,2]. In North America, out of the four clinical variants of the disease (acute, lymphomatous, chronic and smoldering), the first two are the most common (~90% of cases) and carry a worse prognosis [3]. The lymphomatous type is characterized by prominent lymphadenopathy without peripheral blood involvement and by less frequent dermatologic manifestations or hypercalcemia [3]. Heart involvement by ATLL tends to be asymptomatic or oligosymptomatic. In autopsy series, few patients show cardiac symptoms like shortness of breath or palpitations, and massive cardiomegaly with extensive myocardial lymphomatous infiltration has seldom been reported [4,5,6].
The epidemiology of HTLV-1 in ATLL has been extensively studied. Geographic ATLL clustering overlaps endemic areas for the virus, such as southwestern Japan, the Caribbean basin and parts of central Africa. HTLV-1 is transmitted through blood products and breast feeding, and development of the disease follows a long (over 30 years) latency period after infection [7], which suggest that besides the causal role of viral oncogenes, host genetic and epigenetic factors are also necessary for tumorigenesis [8]. Two HTLV-1 proteins Tax and basic leucine zipper (HBZ) lead to transcriptional activation and T-cell proliferation, and both are able to transform in mouse models [9,10]. Tax-induced T-cell receptor (TCR)/nuclear factor kB (NF-kB) signaling has been well-documented in the development of ATLL [11]. However, Tax expression is silenced in a high proportion of ATLL cases, which illustrates its dispensable role in lymphomagenesis. In contrast, HBZ is the only viral protein consistently expressed in ATLL, and plays pleotropic roles modulating cell growth, T-cell differentiation and immune response, which contribute to oncogenesis. While most studies on the genetic alterations in ATLL have focused on Asian cases, recently, North American cases were analyzed in detail, demonstrating a unique frequency of epigenetic and histone modifying gene changes [12]. Conversely, the frequency of mutations in the JAK/STAT and the TCR/NF-kB pathway genes were lower when compared with the Japanese cases [12]. Therefore, it would be important to further analyze North American cases to confirm these findings, and to identify preclinical druggable target candidates. Here we present a lethal lymphomatous case of North American ATLL with extensive cardiac involvement and next-generation sequencing (NGS) data demonstrating several novel mutations that may hold promise in the diagnostic and therapeutic strategy.
2. Result
A 65-year-old diabetic African American male followed at the Washington DC Veterans Affairs Medical Center for hypertension and complications of diabetes mellitus, including heart failure with 40% ejection fraction (EF), chronic renal failure and neuropathy, developed poor appetite, abdominal pain and weight loss of 15 pounds (6.8 kg) in May 2019. The patient was hospitalized due to exertional orthopnea, severe gastrointestinal reflux disease and worsening shortness of breath.
Physical examination revealed mild obesity, unremarkable pulmonary and cardiovascular examination and no organomegaly or palpable lymphadenopathy. Imaging studies (including CT of the abdomen and pelvis with contrast) revealed infiltrating hypodense masses involving both kidneys, mesenteric lymphadenopathy and innumerable ground glass nodules with random distribution in the lung bases. The electrocardiogram was unremarkable. Multigated acquisition scan showed concentric left ventricular wall hypertrophy and hypokinesia, compatible with known cardiomyopathy. PET scan revealed innumerable foci of intense fluorodeoxyglucose (FDG) uptake in lungs, peritoneal cavity, kidneys, nodal basins (above and below the diaphragm), subcutaneous soft tissues and bones. However, normal FDG uptake within the myocardium was detected. Peripheral white blood cell counts were within the normal range. Serum calcium, sodium and potassium were also normal. Lactate dehydrogenase was markedly elevated at 1600 U/L, and serum HTLV-I antibody test was positive.
An enlarged supraclavicular lymph node was excised, and the diagnosis of ATLL was made based on histomorphology and positivity for CD45, CD2, CD3, CD4 and CD25 by immunohistochemistry. Ki-67 proliferative rate was very high (>80%). Other markers, including CD7 (aberrant loss), CD8, CD10, CD56, EBV and CD30, were negative. Careful examination of peripheral blood failed to detect atypical large lymphocytes, which was confirmed by a flow cytometric analysis showing no lymphomatous involvement. The diagnosis of lymphomatous variant of ATLL was confirmed, and NGS was performed by Foundation Medicine (comprehensive DNA and RNA analysis) and interpreted following the guidelines of the American College of Medical Genetics. This analysis revealed an intermediate tumor mutational burden (nine mutations per megabase) and stable microsatellite status. The following somatic mutations (Table 1) were also identified: AXIN1 R712Q, BARD1 R749K, CBL H42_L43insH, CD36 amplification, CDK6 amplification, CTNNB1 I315V, CUX1 (P102T and R44W), DNMT3A S199R, FAS D228fs*2, FGFR2 S431L, GATA3 loss exons 4–6, HGF amplification, HIST1H2AM loss, HIST1H2BO loss, IRF4 amplification, LRP1B (D1063N and Y2560C), NF1 S665F, PCLO amplification, SDHD F34C, SMO G24A, STAG2 I771M and TP53 H193L.
The patient underwent two cycles of chemotherapy (ESHAP-etoposide, methylprednisolone, cytarabine and cisplatin), but unfortunately had a complicated post-treatment course and developed tumor lysis syndrome, gastrointestinal bleeding, exacerbation of heart failure and unresolved acute kidney injury. Despite intensive care and cardiopulmonary resuscitation, the patient developed cardiac arrest and died 45 days after hospitalization. An autopsy revealed extensive lymphomatous involvement of multiple lymph nodes, including mesenteric, mediastinal, retroperitoneal, cervical and periaortic. In addition, significant involvement of the left myocardium (Figure 1) and multiple other organs (bilateral lungs, stomach, bowels, pancreas, bilateral kidneys, bilateral adrenals and prostate) and patchy involvement of diaphragm, skin and muscle was demonstrated by histomorphology and immunohistochemistry (including sections from the cardiac lymphoma shown in Figure 2).
3. Discussion
ATLL is a malignant lymphoproliferative neoplasm of mature T-cells initiated by monoclonal integration of HTLV-1 in the genome of lymphocytes, which leads to complex multistep events occurring during a long latency period. Despite a greater understanding of the pathogenesis of ATLL, curative treatment is lacking, and the overall prognosis remains dismal.
According to the Shimoyama classification, four variants of ATLL are recognized: acute, lymphomatous, chronic and smoldering [3]. The lymphomatous form is usually clinically aggressive and presents with advanced disease, including prominent lymphadenopathy and infrequent hypercalcemia, as seen in our patient. Although extensive involvement of the spleen and skin are common in lymphomatous ATLL, we did not observe these features. Instead, we detected patchy dermal involvement and extensive myocardial infiltration by ATLL, a rare event typically associated with ominous prognosis and concomitant lymphomatous involvement of the lung [6], as our necropsy illustrated. Of note, cardiac ATLL can be commonly missed pre-mortem even with modern imaging (as performed here) and is associated with chemoresistance [6]. Cutaneous involvement in our case was subclinical, as demonstrated by immunohistochemistry of a few tiny lymphoid aggregates found by microscopic examination, which is also unusual in lymphomatous ATLL.
Despite substantial progress in recent years, the molecular pathogenesis of ATLL remains unclear. After monoclonal integration of HTLV-1 and expression of viral oncogenes, such as Tax and HBZ, dysregulation of signaling pathways related to T-cell proliferation/differentiation and immune surveillance leads to leukemogenesis. Interestingly, Tax is dispensable for transformation and inactivated in a high proportion of cases [9]. However, HBZ is the only viral protein that remains consistently expressed in ATLL cases. Activation of PI3K, JAK/STAT and TCR/NF-kB pathways by genetic and epigenetic mechanisms seem to be crucial for tumor progression, and specific genes are commonly mutated, including CARD22, CCR4, CCR7, CDKN2A (p16), CDK2B (p15), EP300, FAS, FYN, GATA3, IRF4, PLCG1, PRKCB, TP53, STAT3 and VAV1. Accordingly, we observed mutations in genes of the TCR/NF-κB pathway (CBL, CUX1 and FAS), implicated in unrestricted and persistent NF-κB activation leading to the development of autoimmune diseases and neoplasms [13]. Such disbalance between T-cell activation and excessive NF-κB stimulation may have initiated deleterious consequences of TCR signaling, which, without negative regulation of nuclear signaling, may contribute to tumor progression. Interestingly, genetic alterations in genes associated with WNT/beta-catenin (AXIN1, CTNNB1 and SMO) and the RAS/MAPK (NF1), which are less commonly associated with ATLL, were also detected, suggesting possible unique pathogenic associations. As expected, several mutated genes that play a role in genomic stability (BARD1, TP53 and STAG2) and/or transcriptional regulation (HIST1H2AM, HIST1H2BO, IRF4 and GATA3) were seen. Also, genes directly involved in cell cycle control (CDK6) and soluble growth factors (HCF) had mutations in this tumor. Furthermore, trophic pathways related to surface receptors seem to be involved in our case, as suggested by mutations in CD36 (a lipid scavenger receptor) [14], LRP1B (a member of the low-density lipoprotein receptor family) [15] and FGFR2 (fibroblast growth factor receptor 2/CD332) [12]. Furthermore, additional epigenetic regulation may be represented by mutations in DNMT3A, a methyltransferase that may modulate gene expression by altering histones [16]. Finally, we found alterations in genes that have an unclear oncogenic mechanism of action, such as SDHD (a well-known driver gene in Cowden/Cowden-like syndromes) [17] and PCLO (a scaffold protein of the presynaptic cytomatrix at the active zone) [18].
Mutations in some of these genes (CBL, CDK6, DNMT3A, FAS, FGFR2, GATA3, HGF, IRF4, TP53 and STAG2) are well known in association with ATLL [12], but the specific alterations found are novel (CBL H42_L43insH, DNMT3A S199R, FGFR2 S431L, GATA3 loss of exons 4–6 and STAG2 I771M). Other genes have been described [18,19,20] in association with different hematopoietic or solid tumors (AXIN1, BARD1, CUX1, NF1, PCLO, SDHD and SMO), but are reported here for the first time in association with ATLL. Of interest, eight mutations (AXIN1, R712Q, BARD1 R749K, CTNNB1 I315V, CUX1 P102T, DNMT3A S199R, FGFR2 S431L, LRP1B Y2560C and STAG2 I771M) have not been reported before to the best of our knowledge after extensive literature/database searches. Current molecular pathogenesis of ATLL postulates important processes related to HTLV-1-mediated proliferation and immune evasion based on unclear stochastic genetic alterations necessary for full-blown disease. Accordingly, mutations belonging to major well-characterized pathways were found in this study. Focusing on the novel point mutations in the TCR/NF-kB (CUX1 P102T), epigenetic/methylation regulatory (DNMT3A S199R) and genetic stability (BARD1 and STAG2) pathways, our findings suggest commonalities with prior reports [12]. Similarly, various novel mutations belonging to the category of trophic proliferative signaling (FGFR2 S431L and LRP1B Y2560C) were sequenced. However, we also found novel mutations in the WNT/beta-catenin pathway (AXIN1, R712Q and CTNNB1 I315V), which is underappreciated in ATLL. Overexpression of Wnt5a (an activator of beta-catenin/CTNNB1 not found in our case) has been proposed as a mediator of hypercalcemia [21] and suggests that the beta-catenin (CTNNB1 I315V) defect we observed may have abrogated this mechanism, since our patient remained normocalcemic. Likewise, AXIN1 inactivation may have contributed to such normocalcemic phenotype, since this tumor suppressor regulates G-protein coupled signaling upstream of beta-catenin [20].
In summary, we present a clinically unusual lethal case of ATLL with several novel mutations (AXIN1, R712Q, BARD1 R749K, CTNNB1 I315V, CUX1 P102T, DNMT3A S199R, FGFR2 S431L, LRP1B Y2560C and STAG2 I771M) and unexpected myocardial involvement, which probably contributed to the fatal outcome.
Author Contributions
Conceptualization, V.E.N.; methodology, R.A. and T.H.Z.; formal analysis R.A. and T.H.Z.; investigation, V.E.N., R.A., T.H.Z. and B.C.B.; data curation, R.A.; writing—original draft preparation, T.H.Z.; writing—review and editing, R.A., V.E.N. and B.C.B. All authors have read and agreed to the published version of the manuscript.
Funding
This research received no external funding.
Conflicts of Interest
The authors declare no conflict of interest.
Figure 1 Gross appearance of the heart. The left myocardium shows and focal thickening and white-brown discoloration (arrow) that corresponds to leukemic infiltration.
Figure 2 (A) Adult T-cell leukemia/lymphoma (ATLL) infiltration of endocardium and myocardium (H&E, 20×). (B) Higher magnification of infiltrating lymphoma showing pleomorphism, scant eosinophilic cytoplasm, irregular nuclear contours with coarse chromatin and variably prominent nucleoli (H&E, 200×). The lymphoma cells were strongly positive for CD4 (C) and CD25 (D) by immunohistochemistry (20×).
curroncol-28-00079-t001_Table 1 Table 1 Somatic mutations identified by next-generation sequencing (NGS).
Gene Somatic Mutation Allele Frequency (%)
AXIN1 R712Q 44.94
BARD1 R749K 24.75
CBL H42_L43insH 17.61
CTNNB1 I315V 76.45
CUX1 R44W 36.15
CUX1 P102T 26.84
DNMT3A S199R 39.04
FAS D228fs*2 45.37
FGFR2 S431L 26.61
LRP1B D1063N 68.28
LRP1B Y2560C 46.64
NF1 S665F 31.97
SDHD F34C 29.79
SMO G24A 48.98
STAG2 I771M 40.98
TP53 H193L 70.02
Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations. | Not recovered | ReactionOutcome | CC BY | 33562071 | 20,134,169 | 2021-02-06 |
What was the outcome of reaction 'Tumour lysis syndrome'? | Novel Mutations in a Lethal Case of Lymphomatous Adult T Cell Lymphoma with Cryptic Myocardial Involvement.
The autopsy of a 65-year-old diabetic African American male revealed significant left myocardial involvement by adult T-cell leukemia/lymphoma (ATLL) despite normal pre-mortem fluorodeoxyglucose (FDG) uptake by positron emission tomography/computed tomography (PET/CT). Due to pre-existing diabetic cardiomyopathy with reduced ejection fraction (EF) and compatible imaging studies, cardiac lymphomatous involvement was not suspected. While peripheral blood was negative for leukemia, next-generation sequencing of a lymph node revealed at least eight novel mutations (AXIN1, R712Q, BARD1 R749K, CTNNB1 I315V, CUX1 P102T, DNMT3A S199R, FGFR2 S431L, LRP1B Y2560C and STAG2 I771M). These findings underscore a diagnostic pitfall in a rare lymphomatous variant of ATLL infiltrating myocardium and contribute to its molecular characterization.
1. Introduction
The World Health Organization (WHO) defines adult T-cell leukemia/lymphoma (ATLL) as a mature T-cell neoplasm composed of highly pleomorphic lymphoid cells and thought to be initiated by the retrovirus human T-cell leukemia virus type-1 (HTLV-1), which is necessary but not sufficient for its pathogenesis [1,2]. In North America, out of the four clinical variants of the disease (acute, lymphomatous, chronic and smoldering), the first two are the most common (~90% of cases) and carry a worse prognosis [3]. The lymphomatous type is characterized by prominent lymphadenopathy without peripheral blood involvement and by less frequent dermatologic manifestations or hypercalcemia [3]. Heart involvement by ATLL tends to be asymptomatic or oligosymptomatic. In autopsy series, few patients show cardiac symptoms like shortness of breath or palpitations, and massive cardiomegaly with extensive myocardial lymphomatous infiltration has seldom been reported [4,5,6].
The epidemiology of HTLV-1 in ATLL has been extensively studied. Geographic ATLL clustering overlaps endemic areas for the virus, such as southwestern Japan, the Caribbean basin and parts of central Africa. HTLV-1 is transmitted through blood products and breast feeding, and development of the disease follows a long (over 30 years) latency period after infection [7], which suggest that besides the causal role of viral oncogenes, host genetic and epigenetic factors are also necessary for tumorigenesis [8]. Two HTLV-1 proteins Tax and basic leucine zipper (HBZ) lead to transcriptional activation and T-cell proliferation, and both are able to transform in mouse models [9,10]. Tax-induced T-cell receptor (TCR)/nuclear factor kB (NF-kB) signaling has been well-documented in the development of ATLL [11]. However, Tax expression is silenced in a high proportion of ATLL cases, which illustrates its dispensable role in lymphomagenesis. In contrast, HBZ is the only viral protein consistently expressed in ATLL, and plays pleotropic roles modulating cell growth, T-cell differentiation and immune response, which contribute to oncogenesis. While most studies on the genetic alterations in ATLL have focused on Asian cases, recently, North American cases were analyzed in detail, demonstrating a unique frequency of epigenetic and histone modifying gene changes [12]. Conversely, the frequency of mutations in the JAK/STAT and the TCR/NF-kB pathway genes were lower when compared with the Japanese cases [12]. Therefore, it would be important to further analyze North American cases to confirm these findings, and to identify preclinical druggable target candidates. Here we present a lethal lymphomatous case of North American ATLL with extensive cardiac involvement and next-generation sequencing (NGS) data demonstrating several novel mutations that may hold promise in the diagnostic and therapeutic strategy.
2. Result
A 65-year-old diabetic African American male followed at the Washington DC Veterans Affairs Medical Center for hypertension and complications of diabetes mellitus, including heart failure with 40% ejection fraction (EF), chronic renal failure and neuropathy, developed poor appetite, abdominal pain and weight loss of 15 pounds (6.8 kg) in May 2019. The patient was hospitalized due to exertional orthopnea, severe gastrointestinal reflux disease and worsening shortness of breath.
Physical examination revealed mild obesity, unremarkable pulmonary and cardiovascular examination and no organomegaly or palpable lymphadenopathy. Imaging studies (including CT of the abdomen and pelvis with contrast) revealed infiltrating hypodense masses involving both kidneys, mesenteric lymphadenopathy and innumerable ground glass nodules with random distribution in the lung bases. The electrocardiogram was unremarkable. Multigated acquisition scan showed concentric left ventricular wall hypertrophy and hypokinesia, compatible with known cardiomyopathy. PET scan revealed innumerable foci of intense fluorodeoxyglucose (FDG) uptake in lungs, peritoneal cavity, kidneys, nodal basins (above and below the diaphragm), subcutaneous soft tissues and bones. However, normal FDG uptake within the myocardium was detected. Peripheral white blood cell counts were within the normal range. Serum calcium, sodium and potassium were also normal. Lactate dehydrogenase was markedly elevated at 1600 U/L, and serum HTLV-I antibody test was positive.
An enlarged supraclavicular lymph node was excised, and the diagnosis of ATLL was made based on histomorphology and positivity for CD45, CD2, CD3, CD4 and CD25 by immunohistochemistry. Ki-67 proliferative rate was very high (>80%). Other markers, including CD7 (aberrant loss), CD8, CD10, CD56, EBV and CD30, were negative. Careful examination of peripheral blood failed to detect atypical large lymphocytes, which was confirmed by a flow cytometric analysis showing no lymphomatous involvement. The diagnosis of lymphomatous variant of ATLL was confirmed, and NGS was performed by Foundation Medicine (comprehensive DNA and RNA analysis) and interpreted following the guidelines of the American College of Medical Genetics. This analysis revealed an intermediate tumor mutational burden (nine mutations per megabase) and stable microsatellite status. The following somatic mutations (Table 1) were also identified: AXIN1 R712Q, BARD1 R749K, CBL H42_L43insH, CD36 amplification, CDK6 amplification, CTNNB1 I315V, CUX1 (P102T and R44W), DNMT3A S199R, FAS D228fs*2, FGFR2 S431L, GATA3 loss exons 4–6, HGF amplification, HIST1H2AM loss, HIST1H2BO loss, IRF4 amplification, LRP1B (D1063N and Y2560C), NF1 S665F, PCLO amplification, SDHD F34C, SMO G24A, STAG2 I771M and TP53 H193L.
The patient underwent two cycles of chemotherapy (ESHAP-etoposide, methylprednisolone, cytarabine and cisplatin), but unfortunately had a complicated post-treatment course and developed tumor lysis syndrome, gastrointestinal bleeding, exacerbation of heart failure and unresolved acute kidney injury. Despite intensive care and cardiopulmonary resuscitation, the patient developed cardiac arrest and died 45 days after hospitalization. An autopsy revealed extensive lymphomatous involvement of multiple lymph nodes, including mesenteric, mediastinal, retroperitoneal, cervical and periaortic. In addition, significant involvement of the left myocardium (Figure 1) and multiple other organs (bilateral lungs, stomach, bowels, pancreas, bilateral kidneys, bilateral adrenals and prostate) and patchy involvement of diaphragm, skin and muscle was demonstrated by histomorphology and immunohistochemistry (including sections from the cardiac lymphoma shown in Figure 2).
3. Discussion
ATLL is a malignant lymphoproliferative neoplasm of mature T-cells initiated by monoclonal integration of HTLV-1 in the genome of lymphocytes, which leads to complex multistep events occurring during a long latency period. Despite a greater understanding of the pathogenesis of ATLL, curative treatment is lacking, and the overall prognosis remains dismal.
According to the Shimoyama classification, four variants of ATLL are recognized: acute, lymphomatous, chronic and smoldering [3]. The lymphomatous form is usually clinically aggressive and presents with advanced disease, including prominent lymphadenopathy and infrequent hypercalcemia, as seen in our patient. Although extensive involvement of the spleen and skin are common in lymphomatous ATLL, we did not observe these features. Instead, we detected patchy dermal involvement and extensive myocardial infiltration by ATLL, a rare event typically associated with ominous prognosis and concomitant lymphomatous involvement of the lung [6], as our necropsy illustrated. Of note, cardiac ATLL can be commonly missed pre-mortem even with modern imaging (as performed here) and is associated with chemoresistance [6]. Cutaneous involvement in our case was subclinical, as demonstrated by immunohistochemistry of a few tiny lymphoid aggregates found by microscopic examination, which is also unusual in lymphomatous ATLL.
Despite substantial progress in recent years, the molecular pathogenesis of ATLL remains unclear. After monoclonal integration of HTLV-1 and expression of viral oncogenes, such as Tax and HBZ, dysregulation of signaling pathways related to T-cell proliferation/differentiation and immune surveillance leads to leukemogenesis. Interestingly, Tax is dispensable for transformation and inactivated in a high proportion of cases [9]. However, HBZ is the only viral protein that remains consistently expressed in ATLL cases. Activation of PI3K, JAK/STAT and TCR/NF-kB pathways by genetic and epigenetic mechanisms seem to be crucial for tumor progression, and specific genes are commonly mutated, including CARD22, CCR4, CCR7, CDKN2A (p16), CDK2B (p15), EP300, FAS, FYN, GATA3, IRF4, PLCG1, PRKCB, TP53, STAT3 and VAV1. Accordingly, we observed mutations in genes of the TCR/NF-κB pathway (CBL, CUX1 and FAS), implicated in unrestricted and persistent NF-κB activation leading to the development of autoimmune diseases and neoplasms [13]. Such disbalance between T-cell activation and excessive NF-κB stimulation may have initiated deleterious consequences of TCR signaling, which, without negative regulation of nuclear signaling, may contribute to tumor progression. Interestingly, genetic alterations in genes associated with WNT/beta-catenin (AXIN1, CTNNB1 and SMO) and the RAS/MAPK (NF1), which are less commonly associated with ATLL, were also detected, suggesting possible unique pathogenic associations. As expected, several mutated genes that play a role in genomic stability (BARD1, TP53 and STAG2) and/or transcriptional regulation (HIST1H2AM, HIST1H2BO, IRF4 and GATA3) were seen. Also, genes directly involved in cell cycle control (CDK6) and soluble growth factors (HCF) had mutations in this tumor. Furthermore, trophic pathways related to surface receptors seem to be involved in our case, as suggested by mutations in CD36 (a lipid scavenger receptor) [14], LRP1B (a member of the low-density lipoprotein receptor family) [15] and FGFR2 (fibroblast growth factor receptor 2/CD332) [12]. Furthermore, additional epigenetic regulation may be represented by mutations in DNMT3A, a methyltransferase that may modulate gene expression by altering histones [16]. Finally, we found alterations in genes that have an unclear oncogenic mechanism of action, such as SDHD (a well-known driver gene in Cowden/Cowden-like syndromes) [17] and PCLO (a scaffold protein of the presynaptic cytomatrix at the active zone) [18].
Mutations in some of these genes (CBL, CDK6, DNMT3A, FAS, FGFR2, GATA3, HGF, IRF4, TP53 and STAG2) are well known in association with ATLL [12], but the specific alterations found are novel (CBL H42_L43insH, DNMT3A S199R, FGFR2 S431L, GATA3 loss of exons 4–6 and STAG2 I771M). Other genes have been described [18,19,20] in association with different hematopoietic or solid tumors (AXIN1, BARD1, CUX1, NF1, PCLO, SDHD and SMO), but are reported here for the first time in association with ATLL. Of interest, eight mutations (AXIN1, R712Q, BARD1 R749K, CTNNB1 I315V, CUX1 P102T, DNMT3A S199R, FGFR2 S431L, LRP1B Y2560C and STAG2 I771M) have not been reported before to the best of our knowledge after extensive literature/database searches. Current molecular pathogenesis of ATLL postulates important processes related to HTLV-1-mediated proliferation and immune evasion based on unclear stochastic genetic alterations necessary for full-blown disease. Accordingly, mutations belonging to major well-characterized pathways were found in this study. Focusing on the novel point mutations in the TCR/NF-kB (CUX1 P102T), epigenetic/methylation regulatory (DNMT3A S199R) and genetic stability (BARD1 and STAG2) pathways, our findings suggest commonalities with prior reports [12]. Similarly, various novel mutations belonging to the category of trophic proliferative signaling (FGFR2 S431L and LRP1B Y2560C) were sequenced. However, we also found novel mutations in the WNT/beta-catenin pathway (AXIN1, R712Q and CTNNB1 I315V), which is underappreciated in ATLL. Overexpression of Wnt5a (an activator of beta-catenin/CTNNB1 not found in our case) has been proposed as a mediator of hypercalcemia [21] and suggests that the beta-catenin (CTNNB1 I315V) defect we observed may have abrogated this mechanism, since our patient remained normocalcemic. Likewise, AXIN1 inactivation may have contributed to such normocalcemic phenotype, since this tumor suppressor regulates G-protein coupled signaling upstream of beta-catenin [20].
In summary, we present a clinically unusual lethal case of ATLL with several novel mutations (AXIN1, R712Q, BARD1 R749K, CTNNB1 I315V, CUX1 P102T, DNMT3A S199R, FGFR2 S431L, LRP1B Y2560C and STAG2 I771M) and unexpected myocardial involvement, which probably contributed to the fatal outcome.
Author Contributions
Conceptualization, V.E.N.; methodology, R.A. and T.H.Z.; formal analysis R.A. and T.H.Z.; investigation, V.E.N., R.A., T.H.Z. and B.C.B.; data curation, R.A.; writing—original draft preparation, T.H.Z.; writing—review and editing, R.A., V.E.N. and B.C.B. All authors have read and agreed to the published version of the manuscript.
Funding
This research received no external funding.
Conflicts of Interest
The authors declare no conflict of interest.
Figure 1 Gross appearance of the heart. The left myocardium shows and focal thickening and white-brown discoloration (arrow) that corresponds to leukemic infiltration.
Figure 2 (A) Adult T-cell leukemia/lymphoma (ATLL) infiltration of endocardium and myocardium (H&E, 20×). (B) Higher magnification of infiltrating lymphoma showing pleomorphism, scant eosinophilic cytoplasm, irregular nuclear contours with coarse chromatin and variably prominent nucleoli (H&E, 200×). The lymphoma cells were strongly positive for CD4 (C) and CD25 (D) by immunohistochemistry (20×).
curroncol-28-00079-t001_Table 1 Table 1 Somatic mutations identified by next-generation sequencing (NGS).
Gene Somatic Mutation Allele Frequency (%)
AXIN1 R712Q 44.94
BARD1 R749K 24.75
CBL H42_L43insH 17.61
CTNNB1 I315V 76.45
CUX1 R44W 36.15
CUX1 P102T 26.84
DNMT3A S199R 39.04
FAS D228fs*2 45.37
FGFR2 S431L 26.61
LRP1B D1063N 68.28
LRP1B Y2560C 46.64
NF1 S665F 31.97
SDHD F34C 29.79
SMO G24A 48.98
STAG2 I771M 40.98
TP53 H193L 70.02
Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations. | Not recovered | ReactionOutcome | CC BY | 33562071 | 20,134,169 | 2021-02-06 |
Give an alphabetized list of all active substances of drugs taken by the patient who experienced 'Erythema'. | Methicillin-resistant Staphylococcus aureus (MRSA) panniculitis in a patient undergoing stem cell mobilisation.
Methicillin-resistant Staphylococcus aureus (MRSA) can cause a wide range of skin infections, however MRSA panniculitis without bacteremia is a rare manifestation. Here, we report a woman in her 20s with relapsed Hodgkin lymphoma undergoing stem cell mobilisation who presented with bilateral subcutaneous nodules over her shins. Ultrasound scan of one nodule showed non-specific inflammatory changes. Punch biopsy of a nodule showed lobular panniculitis with Gram-positive cocci. Blood cultures were negative but a culture from the biopsy grew MRSA. She was started on doxycycline with improvement in her symptoms. This case serves as a reminder to consider infections as a cause of panniculitis in immunocompromised patients.
Background
Panniculitis usually presents as painful erythematous nodules or plaques and is characterised by inflammation of subcutaneous adipose tissue. Recognition, diagnosis and evaluation is challenging because of its rarity and myriad causes, including infection, malignancy, drugs and inflammatory conditions. Infectious panniculitis can occur primarily after direct inoculation or secondarily from hematogenous spread.1 We report a case of methicillin-resistant Staphylococcus aureus (MRSA) panniculitis.
Case presentation
A female in her 20s with relapsed Hodgkin lymphoma (HL) was referred to our centre for autologous stem cell transplantation. She was diagnosed with stage 2 HL in 2016 and underwent chemoradiotherapy, attaining complete remission. She relapsed in 2019 with a recurrent mediastinal mass and widespread lymphadenopathy. She underwent salvage chemotherapy with bendamustine and brentuximab (BB), which was uneventful except for a grade 1 cutaneous adverse drug reaction (CADR) to BB affecting 5% of her body surface area. This resolved with topical steroids and antihistamines. She had no other significant medical or surgical history. Medication on admission for stem cell harvesting included chlorpheniramine 4 mg two times per day, mometasone 0.1% lotion two times per day for her previous CADR and acyclovir 400 mg two times per day for prophylaxis against herpes zoster.
The patient went on to receive mobilisation chemotherapy with ifosfamide, carboplatin and etoposide. Pegfilgrastim was administered on days 5 and 11. On day 11, she was admitted with a fever of 38.3°C and pain in her legs. Examination revealed bilateral scattered tender, indurated subcutaneous nodules over her shins with mild overlying erythema, approximately 3–5 cm in diameter (figure 1). There was a residual dry scaly excoriated hyperpigmented rash from the previous CADR.
Figure 1 Photo of subcutaneous nodule on the lower limb.
Investigations
Investigations on admission showed a white cell count of 0.79×109/L, with neutrophils 0.56×109/L. Following admission, she was started on daily filgrastim due to her neutropaenia and low CD34+ count, which precluded successful mobilisation. C-reactive protein (CRP) was elevated at 74, and procalcitonin was 0.18. Blood cultures and a blood fungal culture were negative. An ultrasound scan of the leg nodule showed vague increased echogenicity and increased vascularity in the subcutaneous tissue with no evidence of abscess formation. A punch biopsy of the nodule confirmed lobular panniculitis with an inflammatory cell infiltrate composed of numerous neutrophils, mixed with lymphocytes, eosinophils, histiocytes and occasional multinucleated giant cells (figure 2A). Granulomas were not observed. No features of vasculitis were identified. Gram-positive cocci were present in the dermis and subcutis (figure 2B). No fungal organisms or acid-fast bacilli were seen on Grocott’s methenamine silver or Ziehl-Neelsen stains. Culture from the punch biopsy grew MRSA. Her antinuclear antibody titre was negative at <1:80. A tuberculosis quantiferon test was negative, and a chest radiograph was normal.
Figure 2 (A) Histology slide showing lobular panniculitis with an inflammatory cell infiltrate composed of numerous neutrophils, mixed with lymphocytes, eosinophils, histiocytes and occasional multinucleated giant cells. (B) Histology slide showing Gram-positive cocci.
Treatment
A diagnosis of infective panniculitis secondary to MRSA was made. She was started on doxycycline with resolution of her fever and nodules. Her filgrastim injections were continued till neutrophil recovery.
Outcome and follow-up
The patient unfortunately failed to mobilise peripheral blood stem cells but went on to have a successful bone marrow harvest with no evidence of microbial contamination of her cyropreserved stem cells. Her lower limb subcutaneous nodules also resolved completely without scarring nor atrophy following treatment with doxycycline.
DISCUSSION
Panniculitis can be classified as septal or lobular, with or without vasculitis. Histologically, infectious panniculitis presents as a neutrophilic predominant mixed inflammatory infiltrate with a lobular pattern of inflammation.2 Infective panniculitis can be caused by bacterial, mycobacterial, fungal, protozoal or viral infections. S. aureus is a skin commensal commonly responsible for primary cutaneous lesions such as folliculitis, carbuncles or cellulitis. Deeper pathology such as abscesses or rarely, panniculitis may result from haematogenous spread in bacteraemic patients,3 or following inoculation from primary superficial lesions. In our patient, repeated blood cultures were negative for S. aureus. Given this, we hypothesise that her prior CADR to BB chemotherapy resulted in weakened skin integrity, superficial inoculation and subsequent deep tissue infection which flared opportunistically when she was neutropaenic. To our knowledge, MRSA-induced panniculitis without bacteremia is rare. However, there have been a few reports of this phenomenon with Pseudomonas aeruginosa.4 5
We initially considered filgrastim-induced panniculitis as a differential. Filgrastim has been associated with several cutaneous reactions such as Sweet’s syndrome, pyoderma gangrenosum and vasculitis. A few cases have been reported in association with pegfilgrastim.6 Possible hypotheses include secondary cytokine production after filgrastim administration and neutrophil activation.7 In our patient, the temporal relationship between administration of pegfilgastrim and her symptoms initially led us to suspect pegfilgrastim as the cause of her panniculitis. However given her positive biopsy culture for MRSA, the presence of Gram-positive cocci in her dermis and subdermal layer, and clinical response to doxycycline despite being continued on filgrastim, we deemed this unlikely.
The site of the lesions, clinical context of HL and neutrophil-rich inflammatory infiltrate also raise the possibility of erythema nodosum. Erythema nodosum is usually idiopathic, but has also been associated with infection, drug, inflammatory condition or malignancy.8 Although this is classically a septal panniculitis,9 there can be histological overlap in some cases.10 Our patient's biopsy was in keeping with that of a lobular panniculitis. Her culture was positive for MRSA which is not a typical infection associated with erythema nodosum. In view of this and her quick response to doxycycline, we concluded erythema nodosum to be less probable.
The possibility of bacterial contamination during the biopsy procedure was also considered. MRSA is endemic in healthcare facilities,11 and patients who are colonised with MRSA may contaminate surrounding environmental surfaces.12 Our institution carries out active surveillance to identify MRSA-colonised patients. Our patient’s MRSA swabs (nasal, axilla and groin) were persistently negative. In addition, the procedure was done under aseptic technique, MRSA was cultured and demonstrated in histology specimens, and she improved following the institution of antimicrobial therapy. In light of this, bacterial contamination was considered unlikely.
Learning points
Infectious panniculitis due to Staphylococcus aureus in the absence of bacteraemia is extremely rare.
Careful workup including biopsy and culture is important to allow correct identification of aetiology and appropriate management.
Appropriate diagnosis allowed continued filgrastim injections so that her time-sensitive stem cell harvest could proceed.
Contributors: APYN drafted the manuscript. Y-LC and W-YJ reviewed and revised the manuscript. SBJW analysed the histology specimen.
Funding: The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests: None declared.
Patient consent for publication: Obtained.
Provenance and peer review: Not commissioned; externally peer reviewed. | ACYCLOVIR, BENDAMUSTINE, BRENTUXIMAB VEDOTIN, CARBOPLATIN, CHLORPHENIRAMINE, ETOPOSIDE, IFOSFAMIDE, MOMETASONE, PEGFILGRASTIM | DrugsGivenReaction | CC BY-NC | 33563686 | 19,224,532 | 2021-02-09 |
Give an alphabetized list of all active substances of drugs taken by the patient who experienced 'Pain in extremity'. | Methicillin-resistant Staphylococcus aureus (MRSA) panniculitis in a patient undergoing stem cell mobilisation.
Methicillin-resistant Staphylococcus aureus (MRSA) can cause a wide range of skin infections, however MRSA panniculitis without bacteremia is a rare manifestation. Here, we report a woman in her 20s with relapsed Hodgkin lymphoma undergoing stem cell mobilisation who presented with bilateral subcutaneous nodules over her shins. Ultrasound scan of one nodule showed non-specific inflammatory changes. Punch biopsy of a nodule showed lobular panniculitis with Gram-positive cocci. Blood cultures were negative but a culture from the biopsy grew MRSA. She was started on doxycycline with improvement in her symptoms. This case serves as a reminder to consider infections as a cause of panniculitis in immunocompromised patients.
Background
Panniculitis usually presents as painful erythematous nodules or plaques and is characterised by inflammation of subcutaneous adipose tissue. Recognition, diagnosis and evaluation is challenging because of its rarity and myriad causes, including infection, malignancy, drugs and inflammatory conditions. Infectious panniculitis can occur primarily after direct inoculation or secondarily from hematogenous spread.1 We report a case of methicillin-resistant Staphylococcus aureus (MRSA) panniculitis.
Case presentation
A female in her 20s with relapsed Hodgkin lymphoma (HL) was referred to our centre for autologous stem cell transplantation. She was diagnosed with stage 2 HL in 2016 and underwent chemoradiotherapy, attaining complete remission. She relapsed in 2019 with a recurrent mediastinal mass and widespread lymphadenopathy. She underwent salvage chemotherapy with bendamustine and brentuximab (BB), which was uneventful except for a grade 1 cutaneous adverse drug reaction (CADR) to BB affecting 5% of her body surface area. This resolved with topical steroids and antihistamines. She had no other significant medical or surgical history. Medication on admission for stem cell harvesting included chlorpheniramine 4 mg two times per day, mometasone 0.1% lotion two times per day for her previous CADR and acyclovir 400 mg two times per day for prophylaxis against herpes zoster.
The patient went on to receive mobilisation chemotherapy with ifosfamide, carboplatin and etoposide. Pegfilgrastim was administered on days 5 and 11. On day 11, she was admitted with a fever of 38.3°C and pain in her legs. Examination revealed bilateral scattered tender, indurated subcutaneous nodules over her shins with mild overlying erythema, approximately 3–5 cm in diameter (figure 1). There was a residual dry scaly excoriated hyperpigmented rash from the previous CADR.
Figure 1 Photo of subcutaneous nodule on the lower limb.
Investigations
Investigations on admission showed a white cell count of 0.79×109/L, with neutrophils 0.56×109/L. Following admission, she was started on daily filgrastim due to her neutropaenia and low CD34+ count, which precluded successful mobilisation. C-reactive protein (CRP) was elevated at 74, and procalcitonin was 0.18. Blood cultures and a blood fungal culture were negative. An ultrasound scan of the leg nodule showed vague increased echogenicity and increased vascularity in the subcutaneous tissue with no evidence of abscess formation. A punch biopsy of the nodule confirmed lobular panniculitis with an inflammatory cell infiltrate composed of numerous neutrophils, mixed with lymphocytes, eosinophils, histiocytes and occasional multinucleated giant cells (figure 2A). Granulomas were not observed. No features of vasculitis were identified. Gram-positive cocci were present in the dermis and subcutis (figure 2B). No fungal organisms or acid-fast bacilli were seen on Grocott’s methenamine silver or Ziehl-Neelsen stains. Culture from the punch biopsy grew MRSA. Her antinuclear antibody titre was negative at <1:80. A tuberculosis quantiferon test was negative, and a chest radiograph was normal.
Figure 2 (A) Histology slide showing lobular panniculitis with an inflammatory cell infiltrate composed of numerous neutrophils, mixed with lymphocytes, eosinophils, histiocytes and occasional multinucleated giant cells. (B) Histology slide showing Gram-positive cocci.
Treatment
A diagnosis of infective panniculitis secondary to MRSA was made. She was started on doxycycline with resolution of her fever and nodules. Her filgrastim injections were continued till neutrophil recovery.
Outcome and follow-up
The patient unfortunately failed to mobilise peripheral blood stem cells but went on to have a successful bone marrow harvest with no evidence of microbial contamination of her cyropreserved stem cells. Her lower limb subcutaneous nodules also resolved completely without scarring nor atrophy following treatment with doxycycline.
DISCUSSION
Panniculitis can be classified as septal or lobular, with or without vasculitis. Histologically, infectious panniculitis presents as a neutrophilic predominant mixed inflammatory infiltrate with a lobular pattern of inflammation.2 Infective panniculitis can be caused by bacterial, mycobacterial, fungal, protozoal or viral infections. S. aureus is a skin commensal commonly responsible for primary cutaneous lesions such as folliculitis, carbuncles or cellulitis. Deeper pathology such as abscesses or rarely, panniculitis may result from haematogenous spread in bacteraemic patients,3 or following inoculation from primary superficial lesions. In our patient, repeated blood cultures were negative for S. aureus. Given this, we hypothesise that her prior CADR to BB chemotherapy resulted in weakened skin integrity, superficial inoculation and subsequent deep tissue infection which flared opportunistically when she was neutropaenic. To our knowledge, MRSA-induced panniculitis without bacteremia is rare. However, there have been a few reports of this phenomenon with Pseudomonas aeruginosa.4 5
We initially considered filgrastim-induced panniculitis as a differential. Filgrastim has been associated with several cutaneous reactions such as Sweet’s syndrome, pyoderma gangrenosum and vasculitis. A few cases have been reported in association with pegfilgrastim.6 Possible hypotheses include secondary cytokine production after filgrastim administration and neutrophil activation.7 In our patient, the temporal relationship between administration of pegfilgastrim and her symptoms initially led us to suspect pegfilgrastim as the cause of her panniculitis. However given her positive biopsy culture for MRSA, the presence of Gram-positive cocci in her dermis and subdermal layer, and clinical response to doxycycline despite being continued on filgrastim, we deemed this unlikely.
The site of the lesions, clinical context of HL and neutrophil-rich inflammatory infiltrate also raise the possibility of erythema nodosum. Erythema nodosum is usually idiopathic, but has also been associated with infection, drug, inflammatory condition or malignancy.8 Although this is classically a septal panniculitis,9 there can be histological overlap in some cases.10 Our patient's biopsy was in keeping with that of a lobular panniculitis. Her culture was positive for MRSA which is not a typical infection associated with erythema nodosum. In view of this and her quick response to doxycycline, we concluded erythema nodosum to be less probable.
The possibility of bacterial contamination during the biopsy procedure was also considered. MRSA is endemic in healthcare facilities,11 and patients who are colonised with MRSA may contaminate surrounding environmental surfaces.12 Our institution carries out active surveillance to identify MRSA-colonised patients. Our patient’s MRSA swabs (nasal, axilla and groin) were persistently negative. In addition, the procedure was done under aseptic technique, MRSA was cultured and demonstrated in histology specimens, and she improved following the institution of antimicrobial therapy. In light of this, bacterial contamination was considered unlikely.
Learning points
Infectious panniculitis due to Staphylococcus aureus in the absence of bacteraemia is extremely rare.
Careful workup including biopsy and culture is important to allow correct identification of aetiology and appropriate management.
Appropriate diagnosis allowed continued filgrastim injections so that her time-sensitive stem cell harvest could proceed.
Contributors: APYN drafted the manuscript. Y-LC and W-YJ reviewed and revised the manuscript. SBJW analysed the histology specimen.
Funding: The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests: None declared.
Patient consent for publication: Obtained.
Provenance and peer review: Not commissioned; externally peer reviewed. | ACYCLOVIR, BENDAMUSTINE, BRENTUXIMAB VEDOTIN, CARBOPLATIN, CHLORPHENIRAMINE, ETOPOSIDE, IFOSFAMIDE, MOMETASONE, PEGFILGRASTIM | DrugsGivenReaction | CC BY-NC | 33563686 | 19,224,532 | 2021-02-09 |
Give an alphabetized list of all active substances of drugs taken by the patient who experienced 'Panniculitis'. | Methicillin-resistant Staphylococcus aureus (MRSA) panniculitis in a patient undergoing stem cell mobilisation.
Methicillin-resistant Staphylococcus aureus (MRSA) can cause a wide range of skin infections, however MRSA panniculitis without bacteremia is a rare manifestation. Here, we report a woman in her 20s with relapsed Hodgkin lymphoma undergoing stem cell mobilisation who presented with bilateral subcutaneous nodules over her shins. Ultrasound scan of one nodule showed non-specific inflammatory changes. Punch biopsy of a nodule showed lobular panniculitis with Gram-positive cocci. Blood cultures were negative but a culture from the biopsy grew MRSA. She was started on doxycycline with improvement in her symptoms. This case serves as a reminder to consider infections as a cause of panniculitis in immunocompromised patients.
Background
Panniculitis usually presents as painful erythematous nodules or plaques and is characterised by inflammation of subcutaneous adipose tissue. Recognition, diagnosis and evaluation is challenging because of its rarity and myriad causes, including infection, malignancy, drugs and inflammatory conditions. Infectious panniculitis can occur primarily after direct inoculation or secondarily from hematogenous spread.1 We report a case of methicillin-resistant Staphylococcus aureus (MRSA) panniculitis.
Case presentation
A female in her 20s with relapsed Hodgkin lymphoma (HL) was referred to our centre for autologous stem cell transplantation. She was diagnosed with stage 2 HL in 2016 and underwent chemoradiotherapy, attaining complete remission. She relapsed in 2019 with a recurrent mediastinal mass and widespread lymphadenopathy. She underwent salvage chemotherapy with bendamustine and brentuximab (BB), which was uneventful except for a grade 1 cutaneous adverse drug reaction (CADR) to BB affecting 5% of her body surface area. This resolved with topical steroids and antihistamines. She had no other significant medical or surgical history. Medication on admission for stem cell harvesting included chlorpheniramine 4 mg two times per day, mometasone 0.1% lotion two times per day for her previous CADR and acyclovir 400 mg two times per day for prophylaxis against herpes zoster.
The patient went on to receive mobilisation chemotherapy with ifosfamide, carboplatin and etoposide. Pegfilgrastim was administered on days 5 and 11. On day 11, she was admitted with a fever of 38.3°C and pain in her legs. Examination revealed bilateral scattered tender, indurated subcutaneous nodules over her shins with mild overlying erythema, approximately 3–5 cm in diameter (figure 1). There was a residual dry scaly excoriated hyperpigmented rash from the previous CADR.
Figure 1 Photo of subcutaneous nodule on the lower limb.
Investigations
Investigations on admission showed a white cell count of 0.79×109/L, with neutrophils 0.56×109/L. Following admission, she was started on daily filgrastim due to her neutropaenia and low CD34+ count, which precluded successful mobilisation. C-reactive protein (CRP) was elevated at 74, and procalcitonin was 0.18. Blood cultures and a blood fungal culture were negative. An ultrasound scan of the leg nodule showed vague increased echogenicity and increased vascularity in the subcutaneous tissue with no evidence of abscess formation. A punch biopsy of the nodule confirmed lobular panniculitis with an inflammatory cell infiltrate composed of numerous neutrophils, mixed with lymphocytes, eosinophils, histiocytes and occasional multinucleated giant cells (figure 2A). Granulomas were not observed. No features of vasculitis were identified. Gram-positive cocci were present in the dermis and subcutis (figure 2B). No fungal organisms or acid-fast bacilli were seen on Grocott’s methenamine silver or Ziehl-Neelsen stains. Culture from the punch biopsy grew MRSA. Her antinuclear antibody titre was negative at <1:80. A tuberculosis quantiferon test was negative, and a chest radiograph was normal.
Figure 2 (A) Histology slide showing lobular panniculitis with an inflammatory cell infiltrate composed of numerous neutrophils, mixed with lymphocytes, eosinophils, histiocytes and occasional multinucleated giant cells. (B) Histology slide showing Gram-positive cocci.
Treatment
A diagnosis of infective panniculitis secondary to MRSA was made. She was started on doxycycline with resolution of her fever and nodules. Her filgrastim injections were continued till neutrophil recovery.
Outcome and follow-up
The patient unfortunately failed to mobilise peripheral blood stem cells but went on to have a successful bone marrow harvest with no evidence of microbial contamination of her cyropreserved stem cells. Her lower limb subcutaneous nodules also resolved completely without scarring nor atrophy following treatment with doxycycline.
DISCUSSION
Panniculitis can be classified as septal or lobular, with or without vasculitis. Histologically, infectious panniculitis presents as a neutrophilic predominant mixed inflammatory infiltrate with a lobular pattern of inflammation.2 Infective panniculitis can be caused by bacterial, mycobacterial, fungal, protozoal or viral infections. S. aureus is a skin commensal commonly responsible for primary cutaneous lesions such as folliculitis, carbuncles or cellulitis. Deeper pathology such as abscesses or rarely, panniculitis may result from haematogenous spread in bacteraemic patients,3 or following inoculation from primary superficial lesions. In our patient, repeated blood cultures were negative for S. aureus. Given this, we hypothesise that her prior CADR to BB chemotherapy resulted in weakened skin integrity, superficial inoculation and subsequent deep tissue infection which flared opportunistically when she was neutropaenic. To our knowledge, MRSA-induced panniculitis without bacteremia is rare. However, there have been a few reports of this phenomenon with Pseudomonas aeruginosa.4 5
We initially considered filgrastim-induced panniculitis as a differential. Filgrastim has been associated with several cutaneous reactions such as Sweet’s syndrome, pyoderma gangrenosum and vasculitis. A few cases have been reported in association with pegfilgrastim.6 Possible hypotheses include secondary cytokine production after filgrastim administration and neutrophil activation.7 In our patient, the temporal relationship between administration of pegfilgastrim and her symptoms initially led us to suspect pegfilgrastim as the cause of her panniculitis. However given her positive biopsy culture for MRSA, the presence of Gram-positive cocci in her dermis and subdermal layer, and clinical response to doxycycline despite being continued on filgrastim, we deemed this unlikely.
The site of the lesions, clinical context of HL and neutrophil-rich inflammatory infiltrate also raise the possibility of erythema nodosum. Erythema nodosum is usually idiopathic, but has also been associated with infection, drug, inflammatory condition or malignancy.8 Although this is classically a septal panniculitis,9 there can be histological overlap in some cases.10 Our patient's biopsy was in keeping with that of a lobular panniculitis. Her culture was positive for MRSA which is not a typical infection associated with erythema nodosum. In view of this and her quick response to doxycycline, we concluded erythema nodosum to be less probable.
The possibility of bacterial contamination during the biopsy procedure was also considered. MRSA is endemic in healthcare facilities,11 and patients who are colonised with MRSA may contaminate surrounding environmental surfaces.12 Our institution carries out active surveillance to identify MRSA-colonised patients. Our patient’s MRSA swabs (nasal, axilla and groin) were persistently negative. In addition, the procedure was done under aseptic technique, MRSA was cultured and demonstrated in histology specimens, and she improved following the institution of antimicrobial therapy. In light of this, bacterial contamination was considered unlikely.
Learning points
Infectious panniculitis due to Staphylococcus aureus in the absence of bacteraemia is extremely rare.
Careful workup including biopsy and culture is important to allow correct identification of aetiology and appropriate management.
Appropriate diagnosis allowed continued filgrastim injections so that her time-sensitive stem cell harvest could proceed.
Contributors: APYN drafted the manuscript. Y-LC and W-YJ reviewed and revised the manuscript. SBJW analysed the histology specimen.
Funding: The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests: None declared.
Patient consent for publication: Obtained.
Provenance and peer review: Not commissioned; externally peer reviewed. | ACYCLOVIR, CARBOPLATIN, CHLORPHENIRAMINE, ETOPOSIDE, FILGRASTIM, IFOSFAMIDE, MOMETASONE, PEGFILGRASTIM | DrugsGivenReaction | CC BY-NC | 33563686 | 19,019,075 | 2021-02-09 |
Give an alphabetized list of all active substances of drugs taken by the patient who experienced 'Pyrexia'. | Methicillin-resistant Staphylococcus aureus (MRSA) panniculitis in a patient undergoing stem cell mobilisation.
Methicillin-resistant Staphylococcus aureus (MRSA) can cause a wide range of skin infections, however MRSA panniculitis without bacteremia is a rare manifestation. Here, we report a woman in her 20s with relapsed Hodgkin lymphoma undergoing stem cell mobilisation who presented with bilateral subcutaneous nodules over her shins. Ultrasound scan of one nodule showed non-specific inflammatory changes. Punch biopsy of a nodule showed lobular panniculitis with Gram-positive cocci. Blood cultures were negative but a culture from the biopsy grew MRSA. She was started on doxycycline with improvement in her symptoms. This case serves as a reminder to consider infections as a cause of panniculitis in immunocompromised patients.
Background
Panniculitis usually presents as painful erythematous nodules or plaques and is characterised by inflammation of subcutaneous adipose tissue. Recognition, diagnosis and evaluation is challenging because of its rarity and myriad causes, including infection, malignancy, drugs and inflammatory conditions. Infectious panniculitis can occur primarily after direct inoculation or secondarily from hematogenous spread.1 We report a case of methicillin-resistant Staphylococcus aureus (MRSA) panniculitis.
Case presentation
A female in her 20s with relapsed Hodgkin lymphoma (HL) was referred to our centre for autologous stem cell transplantation. She was diagnosed with stage 2 HL in 2016 and underwent chemoradiotherapy, attaining complete remission. She relapsed in 2019 with a recurrent mediastinal mass and widespread lymphadenopathy. She underwent salvage chemotherapy with bendamustine and brentuximab (BB), which was uneventful except for a grade 1 cutaneous adverse drug reaction (CADR) to BB affecting 5% of her body surface area. This resolved with topical steroids and antihistamines. She had no other significant medical or surgical history. Medication on admission for stem cell harvesting included chlorpheniramine 4 mg two times per day, mometasone 0.1% lotion two times per day for her previous CADR and acyclovir 400 mg two times per day for prophylaxis against herpes zoster.
The patient went on to receive mobilisation chemotherapy with ifosfamide, carboplatin and etoposide. Pegfilgrastim was administered on days 5 and 11. On day 11, she was admitted with a fever of 38.3°C and pain in her legs. Examination revealed bilateral scattered tender, indurated subcutaneous nodules over her shins with mild overlying erythema, approximately 3–5 cm in diameter (figure 1). There was a residual dry scaly excoriated hyperpigmented rash from the previous CADR.
Figure 1 Photo of subcutaneous nodule on the lower limb.
Investigations
Investigations on admission showed a white cell count of 0.79×109/L, with neutrophils 0.56×109/L. Following admission, she was started on daily filgrastim due to her neutropaenia and low CD34+ count, which precluded successful mobilisation. C-reactive protein (CRP) was elevated at 74, and procalcitonin was 0.18. Blood cultures and a blood fungal culture were negative. An ultrasound scan of the leg nodule showed vague increased echogenicity and increased vascularity in the subcutaneous tissue with no evidence of abscess formation. A punch biopsy of the nodule confirmed lobular panniculitis with an inflammatory cell infiltrate composed of numerous neutrophils, mixed with lymphocytes, eosinophils, histiocytes and occasional multinucleated giant cells (figure 2A). Granulomas were not observed. No features of vasculitis were identified. Gram-positive cocci were present in the dermis and subcutis (figure 2B). No fungal organisms or acid-fast bacilli were seen on Grocott’s methenamine silver or Ziehl-Neelsen stains. Culture from the punch biopsy grew MRSA. Her antinuclear antibody titre was negative at <1:80. A tuberculosis quantiferon test was negative, and a chest radiograph was normal.
Figure 2 (A) Histology slide showing lobular panniculitis with an inflammatory cell infiltrate composed of numerous neutrophils, mixed with lymphocytes, eosinophils, histiocytes and occasional multinucleated giant cells. (B) Histology slide showing Gram-positive cocci.
Treatment
A diagnosis of infective panniculitis secondary to MRSA was made. She was started on doxycycline with resolution of her fever and nodules. Her filgrastim injections were continued till neutrophil recovery.
Outcome and follow-up
The patient unfortunately failed to mobilise peripheral blood stem cells but went on to have a successful bone marrow harvest with no evidence of microbial contamination of her cyropreserved stem cells. Her lower limb subcutaneous nodules also resolved completely without scarring nor atrophy following treatment with doxycycline.
DISCUSSION
Panniculitis can be classified as septal or lobular, with or without vasculitis. Histologically, infectious panniculitis presents as a neutrophilic predominant mixed inflammatory infiltrate with a lobular pattern of inflammation.2 Infective panniculitis can be caused by bacterial, mycobacterial, fungal, protozoal or viral infections. S. aureus is a skin commensal commonly responsible for primary cutaneous lesions such as folliculitis, carbuncles or cellulitis. Deeper pathology such as abscesses or rarely, panniculitis may result from haematogenous spread in bacteraemic patients,3 or following inoculation from primary superficial lesions. In our patient, repeated blood cultures were negative for S. aureus. Given this, we hypothesise that her prior CADR to BB chemotherapy resulted in weakened skin integrity, superficial inoculation and subsequent deep tissue infection which flared opportunistically when she was neutropaenic. To our knowledge, MRSA-induced panniculitis without bacteremia is rare. However, there have been a few reports of this phenomenon with Pseudomonas aeruginosa.4 5
We initially considered filgrastim-induced panniculitis as a differential. Filgrastim has been associated with several cutaneous reactions such as Sweet’s syndrome, pyoderma gangrenosum and vasculitis. A few cases have been reported in association with pegfilgrastim.6 Possible hypotheses include secondary cytokine production after filgrastim administration and neutrophil activation.7 In our patient, the temporal relationship between administration of pegfilgastrim and her symptoms initially led us to suspect pegfilgrastim as the cause of her panniculitis. However given her positive biopsy culture for MRSA, the presence of Gram-positive cocci in her dermis and subdermal layer, and clinical response to doxycycline despite being continued on filgrastim, we deemed this unlikely.
The site of the lesions, clinical context of HL and neutrophil-rich inflammatory infiltrate also raise the possibility of erythema nodosum. Erythema nodosum is usually idiopathic, but has also been associated with infection, drug, inflammatory condition or malignancy.8 Although this is classically a septal panniculitis,9 there can be histological overlap in some cases.10 Our patient's biopsy was in keeping with that of a lobular panniculitis. Her culture was positive for MRSA which is not a typical infection associated with erythema nodosum. In view of this and her quick response to doxycycline, we concluded erythema nodosum to be less probable.
The possibility of bacterial contamination during the biopsy procedure was also considered. MRSA is endemic in healthcare facilities,11 and patients who are colonised with MRSA may contaminate surrounding environmental surfaces.12 Our institution carries out active surveillance to identify MRSA-colonised patients. Our patient’s MRSA swabs (nasal, axilla and groin) were persistently negative. In addition, the procedure was done under aseptic technique, MRSA was cultured and demonstrated in histology specimens, and she improved following the institution of antimicrobial therapy. In light of this, bacterial contamination was considered unlikely.
Learning points
Infectious panniculitis due to Staphylococcus aureus in the absence of bacteraemia is extremely rare.
Careful workup including biopsy and culture is important to allow correct identification of aetiology and appropriate management.
Appropriate diagnosis allowed continued filgrastim injections so that her time-sensitive stem cell harvest could proceed.
Contributors: APYN drafted the manuscript. Y-LC and W-YJ reviewed and revised the manuscript. SBJW analysed the histology specimen.
Funding: The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests: None declared.
Patient consent for publication: Obtained.
Provenance and peer review: Not commissioned; externally peer reviewed. | ACYCLOVIR, BENDAMUSTINE, BRENTUXIMAB VEDOTIN, CARBOPLATIN, CHLORPHENIRAMINE, ETOPOSIDE, IFOSFAMIDE, MOMETASONE, PEGFILGRASTIM | DrugsGivenReaction | CC BY-NC | 33563686 | 19,224,532 | 2021-02-09 |
Give an alphabetized list of all active substances of drugs taken by the patient who experienced 'Skin mass'. | Methicillin-resistant Staphylococcus aureus (MRSA) panniculitis in a patient undergoing stem cell mobilisation.
Methicillin-resistant Staphylococcus aureus (MRSA) can cause a wide range of skin infections, however MRSA panniculitis without bacteremia is a rare manifestation. Here, we report a woman in her 20s with relapsed Hodgkin lymphoma undergoing stem cell mobilisation who presented with bilateral subcutaneous nodules over her shins. Ultrasound scan of one nodule showed non-specific inflammatory changes. Punch biopsy of a nodule showed lobular panniculitis with Gram-positive cocci. Blood cultures were negative but a culture from the biopsy grew MRSA. She was started on doxycycline with improvement in her symptoms. This case serves as a reminder to consider infections as a cause of panniculitis in immunocompromised patients.
Background
Panniculitis usually presents as painful erythematous nodules or plaques and is characterised by inflammation of subcutaneous adipose tissue. Recognition, diagnosis and evaluation is challenging because of its rarity and myriad causes, including infection, malignancy, drugs and inflammatory conditions. Infectious panniculitis can occur primarily after direct inoculation or secondarily from hematogenous spread.1 We report a case of methicillin-resistant Staphylococcus aureus (MRSA) panniculitis.
Case presentation
A female in her 20s with relapsed Hodgkin lymphoma (HL) was referred to our centre for autologous stem cell transplantation. She was diagnosed with stage 2 HL in 2016 and underwent chemoradiotherapy, attaining complete remission. She relapsed in 2019 with a recurrent mediastinal mass and widespread lymphadenopathy. She underwent salvage chemotherapy with bendamustine and brentuximab (BB), which was uneventful except for a grade 1 cutaneous adverse drug reaction (CADR) to BB affecting 5% of her body surface area. This resolved with topical steroids and antihistamines. She had no other significant medical or surgical history. Medication on admission for stem cell harvesting included chlorpheniramine 4 mg two times per day, mometasone 0.1% lotion two times per day for her previous CADR and acyclovir 400 mg two times per day for prophylaxis against herpes zoster.
The patient went on to receive mobilisation chemotherapy with ifosfamide, carboplatin and etoposide. Pegfilgrastim was administered on days 5 and 11. On day 11, she was admitted with a fever of 38.3°C and pain in her legs. Examination revealed bilateral scattered tender, indurated subcutaneous nodules over her shins with mild overlying erythema, approximately 3–5 cm in diameter (figure 1). There was a residual dry scaly excoriated hyperpigmented rash from the previous CADR.
Figure 1 Photo of subcutaneous nodule on the lower limb.
Investigations
Investigations on admission showed a white cell count of 0.79×109/L, with neutrophils 0.56×109/L. Following admission, she was started on daily filgrastim due to her neutropaenia and low CD34+ count, which precluded successful mobilisation. C-reactive protein (CRP) was elevated at 74, and procalcitonin was 0.18. Blood cultures and a blood fungal culture were negative. An ultrasound scan of the leg nodule showed vague increased echogenicity and increased vascularity in the subcutaneous tissue with no evidence of abscess formation. A punch biopsy of the nodule confirmed lobular panniculitis with an inflammatory cell infiltrate composed of numerous neutrophils, mixed with lymphocytes, eosinophils, histiocytes and occasional multinucleated giant cells (figure 2A). Granulomas were not observed. No features of vasculitis were identified. Gram-positive cocci were present in the dermis and subcutis (figure 2B). No fungal organisms or acid-fast bacilli were seen on Grocott’s methenamine silver or Ziehl-Neelsen stains. Culture from the punch biopsy grew MRSA. Her antinuclear antibody titre was negative at <1:80. A tuberculosis quantiferon test was negative, and a chest radiograph was normal.
Figure 2 (A) Histology slide showing lobular panniculitis with an inflammatory cell infiltrate composed of numerous neutrophils, mixed with lymphocytes, eosinophils, histiocytes and occasional multinucleated giant cells. (B) Histology slide showing Gram-positive cocci.
Treatment
A diagnosis of infective panniculitis secondary to MRSA was made. She was started on doxycycline with resolution of her fever and nodules. Her filgrastim injections were continued till neutrophil recovery.
Outcome and follow-up
The patient unfortunately failed to mobilise peripheral blood stem cells but went on to have a successful bone marrow harvest with no evidence of microbial contamination of her cyropreserved stem cells. Her lower limb subcutaneous nodules also resolved completely without scarring nor atrophy following treatment with doxycycline.
DISCUSSION
Panniculitis can be classified as septal or lobular, with or without vasculitis. Histologically, infectious panniculitis presents as a neutrophilic predominant mixed inflammatory infiltrate with a lobular pattern of inflammation.2 Infective panniculitis can be caused by bacterial, mycobacterial, fungal, protozoal or viral infections. S. aureus is a skin commensal commonly responsible for primary cutaneous lesions such as folliculitis, carbuncles or cellulitis. Deeper pathology such as abscesses or rarely, panniculitis may result from haematogenous spread in bacteraemic patients,3 or following inoculation from primary superficial lesions. In our patient, repeated blood cultures were negative for S. aureus. Given this, we hypothesise that her prior CADR to BB chemotherapy resulted in weakened skin integrity, superficial inoculation and subsequent deep tissue infection which flared opportunistically when she was neutropaenic. To our knowledge, MRSA-induced panniculitis without bacteremia is rare. However, there have been a few reports of this phenomenon with Pseudomonas aeruginosa.4 5
We initially considered filgrastim-induced panniculitis as a differential. Filgrastim has been associated with several cutaneous reactions such as Sweet’s syndrome, pyoderma gangrenosum and vasculitis. A few cases have been reported in association with pegfilgrastim.6 Possible hypotheses include secondary cytokine production after filgrastim administration and neutrophil activation.7 In our patient, the temporal relationship between administration of pegfilgastrim and her symptoms initially led us to suspect pegfilgrastim as the cause of her panniculitis. However given her positive biopsy culture for MRSA, the presence of Gram-positive cocci in her dermis and subdermal layer, and clinical response to doxycycline despite being continued on filgrastim, we deemed this unlikely.
The site of the lesions, clinical context of HL and neutrophil-rich inflammatory infiltrate also raise the possibility of erythema nodosum. Erythema nodosum is usually idiopathic, but has also been associated with infection, drug, inflammatory condition or malignancy.8 Although this is classically a septal panniculitis,9 there can be histological overlap in some cases.10 Our patient's biopsy was in keeping with that of a lobular panniculitis. Her culture was positive for MRSA which is not a typical infection associated with erythema nodosum. In view of this and her quick response to doxycycline, we concluded erythema nodosum to be less probable.
The possibility of bacterial contamination during the biopsy procedure was also considered. MRSA is endemic in healthcare facilities,11 and patients who are colonised with MRSA may contaminate surrounding environmental surfaces.12 Our institution carries out active surveillance to identify MRSA-colonised patients. Our patient’s MRSA swabs (nasal, axilla and groin) were persistently negative. In addition, the procedure was done under aseptic technique, MRSA was cultured and demonstrated in histology specimens, and she improved following the institution of antimicrobial therapy. In light of this, bacterial contamination was considered unlikely.
Learning points
Infectious panniculitis due to Staphylococcus aureus in the absence of bacteraemia is extremely rare.
Careful workup including biopsy and culture is important to allow correct identification of aetiology and appropriate management.
Appropriate diagnosis allowed continued filgrastim injections so that her time-sensitive stem cell harvest could proceed.
Contributors: APYN drafted the manuscript. Y-LC and W-YJ reviewed and revised the manuscript. SBJW analysed the histology specimen.
Funding: The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests: None declared.
Patient consent for publication: Obtained.
Provenance and peer review: Not commissioned; externally peer reviewed. | ACYCLOVIR, BENDAMUSTINE, BRENTUXIMAB VEDOTIN, CARBOPLATIN, CHLORPHENIRAMINE, ETOPOSIDE, IFOSFAMIDE, MOMETASONE, PEGFILGRASTIM | DrugsGivenReaction | CC BY-NC | 33563686 | 19,224,532 | 2021-02-09 |
Give an alphabetized list of all active substances of drugs taken by the patient who experienced 'Skin reaction'. | Methicillin-resistant Staphylococcus aureus (MRSA) panniculitis in a patient undergoing stem cell mobilisation.
Methicillin-resistant Staphylococcus aureus (MRSA) can cause a wide range of skin infections, however MRSA panniculitis without bacteremia is a rare manifestation. Here, we report a woman in her 20s with relapsed Hodgkin lymphoma undergoing stem cell mobilisation who presented with bilateral subcutaneous nodules over her shins. Ultrasound scan of one nodule showed non-specific inflammatory changes. Punch biopsy of a nodule showed lobular panniculitis with Gram-positive cocci. Blood cultures were negative but a culture from the biopsy grew MRSA. She was started on doxycycline with improvement in her symptoms. This case serves as a reminder to consider infections as a cause of panniculitis in immunocompromised patients.
Background
Panniculitis usually presents as painful erythematous nodules or plaques and is characterised by inflammation of subcutaneous adipose tissue. Recognition, diagnosis and evaluation is challenging because of its rarity and myriad causes, including infection, malignancy, drugs and inflammatory conditions. Infectious panniculitis can occur primarily after direct inoculation or secondarily from hematogenous spread.1 We report a case of methicillin-resistant Staphylococcus aureus (MRSA) panniculitis.
Case presentation
A female in her 20s with relapsed Hodgkin lymphoma (HL) was referred to our centre for autologous stem cell transplantation. She was diagnosed with stage 2 HL in 2016 and underwent chemoradiotherapy, attaining complete remission. She relapsed in 2019 with a recurrent mediastinal mass and widespread lymphadenopathy. She underwent salvage chemotherapy with bendamustine and brentuximab (BB), which was uneventful except for a grade 1 cutaneous adverse drug reaction (CADR) to BB affecting 5% of her body surface area. This resolved with topical steroids and antihistamines. She had no other significant medical or surgical history. Medication on admission for stem cell harvesting included chlorpheniramine 4 mg two times per day, mometasone 0.1% lotion two times per day for her previous CADR and acyclovir 400 mg two times per day for prophylaxis against herpes zoster.
The patient went on to receive mobilisation chemotherapy with ifosfamide, carboplatin and etoposide. Pegfilgrastim was administered on days 5 and 11. On day 11, she was admitted with a fever of 38.3°C and pain in her legs. Examination revealed bilateral scattered tender, indurated subcutaneous nodules over her shins with mild overlying erythema, approximately 3–5 cm in diameter (figure 1). There was a residual dry scaly excoriated hyperpigmented rash from the previous CADR.
Figure 1 Photo of subcutaneous nodule on the lower limb.
Investigations
Investigations on admission showed a white cell count of 0.79×109/L, with neutrophils 0.56×109/L. Following admission, she was started on daily filgrastim due to her neutropaenia and low CD34+ count, which precluded successful mobilisation. C-reactive protein (CRP) was elevated at 74, and procalcitonin was 0.18. Blood cultures and a blood fungal culture were negative. An ultrasound scan of the leg nodule showed vague increased echogenicity and increased vascularity in the subcutaneous tissue with no evidence of abscess formation. A punch biopsy of the nodule confirmed lobular panniculitis with an inflammatory cell infiltrate composed of numerous neutrophils, mixed with lymphocytes, eosinophils, histiocytes and occasional multinucleated giant cells (figure 2A). Granulomas were not observed. No features of vasculitis were identified. Gram-positive cocci were present in the dermis and subcutis (figure 2B). No fungal organisms or acid-fast bacilli were seen on Grocott’s methenamine silver or Ziehl-Neelsen stains. Culture from the punch biopsy grew MRSA. Her antinuclear antibody titre was negative at <1:80. A tuberculosis quantiferon test was negative, and a chest radiograph was normal.
Figure 2 (A) Histology slide showing lobular panniculitis with an inflammatory cell infiltrate composed of numerous neutrophils, mixed with lymphocytes, eosinophils, histiocytes and occasional multinucleated giant cells. (B) Histology slide showing Gram-positive cocci.
Treatment
A diagnosis of infective panniculitis secondary to MRSA was made. She was started on doxycycline with resolution of her fever and nodules. Her filgrastim injections were continued till neutrophil recovery.
Outcome and follow-up
The patient unfortunately failed to mobilise peripheral blood stem cells but went on to have a successful bone marrow harvest with no evidence of microbial contamination of her cyropreserved stem cells. Her lower limb subcutaneous nodules also resolved completely without scarring nor atrophy following treatment with doxycycline.
DISCUSSION
Panniculitis can be classified as septal or lobular, with or without vasculitis. Histologically, infectious panniculitis presents as a neutrophilic predominant mixed inflammatory infiltrate with a lobular pattern of inflammation.2 Infective panniculitis can be caused by bacterial, mycobacterial, fungal, protozoal or viral infections. S. aureus is a skin commensal commonly responsible for primary cutaneous lesions such as folliculitis, carbuncles or cellulitis. Deeper pathology such as abscesses or rarely, panniculitis may result from haematogenous spread in bacteraemic patients,3 or following inoculation from primary superficial lesions. In our patient, repeated blood cultures were negative for S. aureus. Given this, we hypothesise that her prior CADR to BB chemotherapy resulted in weakened skin integrity, superficial inoculation and subsequent deep tissue infection which flared opportunistically when she was neutropaenic. To our knowledge, MRSA-induced panniculitis without bacteremia is rare. However, there have been a few reports of this phenomenon with Pseudomonas aeruginosa.4 5
We initially considered filgrastim-induced panniculitis as a differential. Filgrastim has been associated with several cutaneous reactions such as Sweet’s syndrome, pyoderma gangrenosum and vasculitis. A few cases have been reported in association with pegfilgrastim.6 Possible hypotheses include secondary cytokine production after filgrastim administration and neutrophil activation.7 In our patient, the temporal relationship between administration of pegfilgastrim and her symptoms initially led us to suspect pegfilgrastim as the cause of her panniculitis. However given her positive biopsy culture for MRSA, the presence of Gram-positive cocci in her dermis and subdermal layer, and clinical response to doxycycline despite being continued on filgrastim, we deemed this unlikely.
The site of the lesions, clinical context of HL and neutrophil-rich inflammatory infiltrate also raise the possibility of erythema nodosum. Erythema nodosum is usually idiopathic, but has also been associated with infection, drug, inflammatory condition or malignancy.8 Although this is classically a septal panniculitis,9 there can be histological overlap in some cases.10 Our patient's biopsy was in keeping with that of a lobular panniculitis. Her culture was positive for MRSA which is not a typical infection associated with erythema nodosum. In view of this and her quick response to doxycycline, we concluded erythema nodosum to be less probable.
The possibility of bacterial contamination during the biopsy procedure was also considered. MRSA is endemic in healthcare facilities,11 and patients who are colonised with MRSA may contaminate surrounding environmental surfaces.12 Our institution carries out active surveillance to identify MRSA-colonised patients. Our patient’s MRSA swabs (nasal, axilla and groin) were persistently negative. In addition, the procedure was done under aseptic technique, MRSA was cultured and demonstrated in histology specimens, and she improved following the institution of antimicrobial therapy. In light of this, bacterial contamination was considered unlikely.
Learning points
Infectious panniculitis due to Staphylococcus aureus in the absence of bacteraemia is extremely rare.
Careful workup including biopsy and culture is important to allow correct identification of aetiology and appropriate management.
Appropriate diagnosis allowed continued filgrastim injections so that her time-sensitive stem cell harvest could proceed.
Contributors: APYN drafted the manuscript. Y-LC and W-YJ reviewed and revised the manuscript. SBJW analysed the histology specimen.
Funding: The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests: None declared.
Patient consent for publication: Obtained.
Provenance and peer review: Not commissioned; externally peer reviewed. | ACYCLOVIR, BENDAMUSTINE, BRENTUXIMAB VEDOTIN, CARBOPLATIN, CHLORPHENIRAMINE, ETOPOSIDE, IFOSFAMIDE, MOMETASONE, PEGFILGRASTIM | DrugsGivenReaction | CC BY-NC | 33563686 | 19,224,532 | 2021-02-09 |
Give an alphabetized list of all active substances of drugs taken by the patient who experienced 'Staphylococcal infection'. | Methicillin-resistant Staphylococcus aureus (MRSA) panniculitis in a patient undergoing stem cell mobilisation.
Methicillin-resistant Staphylococcus aureus (MRSA) can cause a wide range of skin infections, however MRSA panniculitis without bacteremia is a rare manifestation. Here, we report a woman in her 20s with relapsed Hodgkin lymphoma undergoing stem cell mobilisation who presented with bilateral subcutaneous nodules over her shins. Ultrasound scan of one nodule showed non-specific inflammatory changes. Punch biopsy of a nodule showed lobular panniculitis with Gram-positive cocci. Blood cultures were negative but a culture from the biopsy grew MRSA. She was started on doxycycline with improvement in her symptoms. This case serves as a reminder to consider infections as a cause of panniculitis in immunocompromised patients.
Background
Panniculitis usually presents as painful erythematous nodules or plaques and is characterised by inflammation of subcutaneous adipose tissue. Recognition, diagnosis and evaluation is challenging because of its rarity and myriad causes, including infection, malignancy, drugs and inflammatory conditions. Infectious panniculitis can occur primarily after direct inoculation or secondarily from hematogenous spread.1 We report a case of methicillin-resistant Staphylococcus aureus (MRSA) panniculitis.
Case presentation
A female in her 20s with relapsed Hodgkin lymphoma (HL) was referred to our centre for autologous stem cell transplantation. She was diagnosed with stage 2 HL in 2016 and underwent chemoradiotherapy, attaining complete remission. She relapsed in 2019 with a recurrent mediastinal mass and widespread lymphadenopathy. She underwent salvage chemotherapy with bendamustine and brentuximab (BB), which was uneventful except for a grade 1 cutaneous adverse drug reaction (CADR) to BB affecting 5% of her body surface area. This resolved with topical steroids and antihistamines. She had no other significant medical or surgical history. Medication on admission for stem cell harvesting included chlorpheniramine 4 mg two times per day, mometasone 0.1% lotion two times per day for her previous CADR and acyclovir 400 mg two times per day for prophylaxis against herpes zoster.
The patient went on to receive mobilisation chemotherapy with ifosfamide, carboplatin and etoposide. Pegfilgrastim was administered on days 5 and 11. On day 11, she was admitted with a fever of 38.3°C and pain in her legs. Examination revealed bilateral scattered tender, indurated subcutaneous nodules over her shins with mild overlying erythema, approximately 3–5 cm in diameter (figure 1). There was a residual dry scaly excoriated hyperpigmented rash from the previous CADR.
Figure 1 Photo of subcutaneous nodule on the lower limb.
Investigations
Investigations on admission showed a white cell count of 0.79×109/L, with neutrophils 0.56×109/L. Following admission, she was started on daily filgrastim due to her neutropaenia and low CD34+ count, which precluded successful mobilisation. C-reactive protein (CRP) was elevated at 74, and procalcitonin was 0.18. Blood cultures and a blood fungal culture were negative. An ultrasound scan of the leg nodule showed vague increased echogenicity and increased vascularity in the subcutaneous tissue with no evidence of abscess formation. A punch biopsy of the nodule confirmed lobular panniculitis with an inflammatory cell infiltrate composed of numerous neutrophils, mixed with lymphocytes, eosinophils, histiocytes and occasional multinucleated giant cells (figure 2A). Granulomas were not observed. No features of vasculitis were identified. Gram-positive cocci were present in the dermis and subcutis (figure 2B). No fungal organisms or acid-fast bacilli were seen on Grocott’s methenamine silver or Ziehl-Neelsen stains. Culture from the punch biopsy grew MRSA. Her antinuclear antibody titre was negative at <1:80. A tuberculosis quantiferon test was negative, and a chest radiograph was normal.
Figure 2 (A) Histology slide showing lobular panniculitis with an inflammatory cell infiltrate composed of numerous neutrophils, mixed with lymphocytes, eosinophils, histiocytes and occasional multinucleated giant cells. (B) Histology slide showing Gram-positive cocci.
Treatment
A diagnosis of infective panniculitis secondary to MRSA was made. She was started on doxycycline with resolution of her fever and nodules. Her filgrastim injections were continued till neutrophil recovery.
Outcome and follow-up
The patient unfortunately failed to mobilise peripheral blood stem cells but went on to have a successful bone marrow harvest with no evidence of microbial contamination of her cyropreserved stem cells. Her lower limb subcutaneous nodules also resolved completely without scarring nor atrophy following treatment with doxycycline.
DISCUSSION
Panniculitis can be classified as septal or lobular, with or without vasculitis. Histologically, infectious panniculitis presents as a neutrophilic predominant mixed inflammatory infiltrate with a lobular pattern of inflammation.2 Infective panniculitis can be caused by bacterial, mycobacterial, fungal, protozoal or viral infections. S. aureus is a skin commensal commonly responsible for primary cutaneous lesions such as folliculitis, carbuncles or cellulitis. Deeper pathology such as abscesses or rarely, panniculitis may result from haematogenous spread in bacteraemic patients,3 or following inoculation from primary superficial lesions. In our patient, repeated blood cultures were negative for S. aureus. Given this, we hypothesise that her prior CADR to BB chemotherapy resulted in weakened skin integrity, superficial inoculation and subsequent deep tissue infection which flared opportunistically when she was neutropaenic. To our knowledge, MRSA-induced panniculitis without bacteremia is rare. However, there have been a few reports of this phenomenon with Pseudomonas aeruginosa.4 5
We initially considered filgrastim-induced panniculitis as a differential. Filgrastim has been associated with several cutaneous reactions such as Sweet’s syndrome, pyoderma gangrenosum and vasculitis. A few cases have been reported in association with pegfilgrastim.6 Possible hypotheses include secondary cytokine production after filgrastim administration and neutrophil activation.7 In our patient, the temporal relationship between administration of pegfilgastrim and her symptoms initially led us to suspect pegfilgrastim as the cause of her panniculitis. However given her positive biopsy culture for MRSA, the presence of Gram-positive cocci in her dermis and subdermal layer, and clinical response to doxycycline despite being continued on filgrastim, we deemed this unlikely.
The site of the lesions, clinical context of HL and neutrophil-rich inflammatory infiltrate also raise the possibility of erythema nodosum. Erythema nodosum is usually idiopathic, but has also been associated with infection, drug, inflammatory condition or malignancy.8 Although this is classically a septal panniculitis,9 there can be histological overlap in some cases.10 Our patient's biopsy was in keeping with that of a lobular panniculitis. Her culture was positive for MRSA which is not a typical infection associated with erythema nodosum. In view of this and her quick response to doxycycline, we concluded erythema nodosum to be less probable.
The possibility of bacterial contamination during the biopsy procedure was also considered. MRSA is endemic in healthcare facilities,11 and patients who are colonised with MRSA may contaminate surrounding environmental surfaces.12 Our institution carries out active surveillance to identify MRSA-colonised patients. Our patient’s MRSA swabs (nasal, axilla and groin) were persistently negative. In addition, the procedure was done under aseptic technique, MRSA was cultured and demonstrated in histology specimens, and she improved following the institution of antimicrobial therapy. In light of this, bacterial contamination was considered unlikely.
Learning points
Infectious panniculitis due to Staphylococcus aureus in the absence of bacteraemia is extremely rare.
Careful workup including biopsy and culture is important to allow correct identification of aetiology and appropriate management.
Appropriate diagnosis allowed continued filgrastim injections so that her time-sensitive stem cell harvest could proceed.
Contributors: APYN drafted the manuscript. Y-LC and W-YJ reviewed and revised the manuscript. SBJW analysed the histology specimen.
Funding: The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests: None declared.
Patient consent for publication: Obtained.
Provenance and peer review: Not commissioned; externally peer reviewed. | ACYCLOVIR, CARBOPLATIN, CHLORPHENIRAMINE, ETOPOSIDE, FILGRASTIM, IFOSFAMIDE, MOMETASONE, PEGFILGRASTIM | DrugsGivenReaction | CC BY-NC | 33563686 | 19,019,075 | 2021-02-09 |
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