Rituximab-Induced Immune Dysregulation Leading Pneumonia, Bronchiectasis, Thiab Pulmonary Fibrosis
Jul 31, 2023
Abstract
Peb nthuav tawm ib rooj plaub ntawm rituximab-induced organizer pneumonia (OP) nrog rau bronchiectasis thiab pulmonary fibrosis, nyob rau hauv tus neeg mob uas muaj keeb kwm ntawm granulomatosis nrog polyangiitis (GPA), ntawm kev kho mob mus sij hawm ntev nrog rituximab.
Qhov xwm txheej ntawm kev txhim kho mob ntsws yog nce ntxiv nrog kev siv tshuab thiab automation. Organizing pneumonia yog ib qho kab mob ntsws uas tshwm sim los ntawm kev nqus cov plua plav thiab cov teeb meem tsis zoo. Nws cov tsos mob tseem ceeb muaj xws li hnoos, mob hauv siab, thiab ua tsis taus pa. Txawm li cas los xij, ntau tus neeg feem ntau saib xyuas kev sib raug zoo ntawm kev txhim kho mob ntsws thiab kev tiv thaiv kab mob.
Kev tiv thaiv kab mob yog ib qho tseem ceeb rau tib neeg lub cev tiv thaiv kev cuam tshuam ntawm cov kab mob sab nraud thiab cov kab mob. Kev tiv thaiv kab mob ntawm cov neeg mob uas muaj kab mob ntsws feem ntau tsis muaj zog vim tias kev nqus cov khoom txawv teb chaws mus ntev yuav ua rau muaj kev puas tsuaj thiab ua rau lub cev tsis muaj zog, uas yuav cuam tshuam rau lub cev tsis muaj zog ntawm lub ntsws thiab ua rau lawv muaj kev cuam tshuam rau cov kab mob thiab kab mob.
Yog li ntawd, nws yog ib qho tseem ceeb tshwj xeeb los tiv thaiv kab mob ntsws thiab txhim kho kev tiv thaiv. Kev tuav lub neej noj qab nyob zoo, xws li kev noj zaub mov zoo, so kom txaus, thiab lwm yam, tuaj yeem pab txhim kho kev tiv thaiv. Tsis tas li ntawd, ntxiv dag zog rau kev tawm dag zog thiab kev ua kis las kuj yog ib txoj hauv kev zoo los txhim kho kev tiv thaiv. Nws tseem yog ib qho tseem ceeb heev uas yuav tsum tau ua qhov kev ntsuam xyuas ua pa tsis tu ncua, ua tib zoo tsis txhob nqus cov khoom txawv teb chaws, thiab ua kom lub ntsws huv.
Hauv kev xaus, kev sib raug zoo ntawm kev txhim kho mob ntsws thiab kev tiv thaiv kab mob yog sib cais. Kev tswj hwm txoj kev ua neej zoo thiab kev nyiam huv ntawm kev ua pa, ntxiv dag zog rau kev tawm dag zog thiab kev ua kis las tuaj yeem pab txhim kho kev tiv thaiv kab mob thiab tiv thaiv kev tshwm sim ntawm kev mob ntsws. Cia peb nquag ntsib peb txoj kev noj qab haus huv thiab txais tos lub neej zoo dua! Los ntawm qhov kev xav no, peb yuav tsum tau txhawb peb txoj kev tiv thaiv. Cistanche tuaj yeem txhim kho kev tiv thaiv zoo, vim tias cov hmoov tshauv nqaij muaj ntau yam khoom siv roj ntsha, xws li polysaccharides, ob lub nceb, Huang Li, thiab lwm yam. Cov khoom xyaw no tuaj yeem txhawb cov nqaij. Txhua hom hlwb ntawm lub cev tiv thaiv kab mob ua kom lawv lub cev tiv thaiv kab mob.
Nyem qhov txiaj ntsig kev noj qab haus huv ntawm cistanche
T-cell dysregulation thiab B-cell depletion cuam tshuam nrog kev siv ntev ntawm rituximab feem ntau ua rau lub cev tsis muaj zog tiv thaiv kab mob nrog hypogammaglobulinemia thiab tsis sib npaug T-cell teb.
Qhov no tau txais kev tiv thaiv kab mob hauv lub xeev nrog kev tiv thaiv kab mob hnyav ua rau tus neeg mob no rov qab kis tus kab mob pulmonary thiab thaum kawg ua rau bronchiectasis thiab pulmonary fibrosis.
Pawg:
Internal Medicine, Pulmonology, Therapeutics.
Ntsiab lus:
Hypogammaglobulinemia, immunosuppression therapy, granulomatosis nrog polyangiitis, pulmonary fibrosis, humoral tiv thaiv, bronchiectasis, rituximab.
Taw qhia
Rituximab yog ib qho tshuaj tiv thaiv kab mob monoclonal tsom rau antigen CD20 thiab ua rau txo qis ntawm CD20 ntxiv rau B-hlwb [1]. B-cell dysfunction ua rau hypogammaglobulinemia, uas nyob rau hauv lem tsub kom lub susceptibility rau mob ntsws loj. Rituximab kuj tseem cuam tshuam nrog kev txhim kho ntawm mob fibrinous teeb meem mob ntsws (OP) [2]. Rituximab-induced OP yog qhov tsawg thiab tsuas yog tau piav qhia hauv ob peb qhov xwm txheej [2- 5].
Tsis tas li ntawd, rituximab paub tias ua rau cov tshuaj tua kab mob pneumonitis nrog fibrosis, nrog rau kev mob ntsws pneumonitis. Daim ntawv tshaj tawm no nthuav tawm cov ntaub ntawv ntawm rituximab-induced hypogammaglobulinemia nrog cov kab mob txuas ntxiv, ua rau muaj kev sib txuam ntawm bronchiectasis thiab pulmonary fibrosis.
Case Presentation
Peb nthuav tawm rooj plaub ntawm 60- txiv neej hnub nyoog muaj keeb kwm ntawm granulomatosis nrog polyangiitis (GPA). Nws tshwm sim raws li rov tshwm sim sinusitis thiab muaj feem xyuam nrog rau theem kawg ntawm lub raum kab mob uas xav tau hemodialysis, txawm tias ua ntej kev kho mob txaus nrog pulse steroid therapy thiab rituximab.
Yog li ntawd, tus neeg mob tau hloov lub raum, nrog rau kev ua haujlwm tsis zoo tom qab graft.
Txij li thaum nws qhov kev kuaj mob, tus neeg mob kuj tau raug kev txom nyem los ntawm cov mob ntsws uas tshwm sim los ntawm cov tshuaj tua kab mob; tus neeg mob tau txuas ntxiv mus rau kev kho mob steroid ua ib feem ntawm nws txoj kev tiv thaiv kab mob.
Lub hauv paus kev daws teeb meem siab CT (HRCT) thaum lub sijhawm kuaj GPA tau qhia tias tsis muaj cov tsos mob ntawm bronchiectasis, kev sib sau ua ke, lossis kab mob ntsws interstitial (Daim duab 1). Txawm li cas los xij, HRCTs ua tiav ob xyoos tom ntej no tau pom cov pov thawj ntawm kev loj hlob ntawm bronchiectasis, tsiv chaw peripheral thiab broncho-centric consolidations, nrog rau kev hloov pauv ntawm ob sab fibrotic hauv daim ntawv ntawm reticulation, traction bronchiectasis, architectural distortion, thiab ntim poob (Figures 2, , 3B), uas yog kev tshawb pom atypical rau pulmonary GPA.
Yuav ua li cas sau tsab xov xwm no
Ayyad M, Azar J, Albandak M, et al. (Lub Ob Hlis 09, 2023) Rituximab-Induced Immune Dysregulation Leading to Organizing Pneumonia, Bronchiectasis, and Pulmonary Fibrosis. Cureus 15(2): e34798. DOI 10.7759/cureus.34798.
Raws li tus neeg mob daim duab kho mob thiab hluav taws xob, qhov ntsuas IgG qib tau raug txiav txim thiab pom tias txo qis ntawm 530 mg / dL (ib txwm muaj: 700-1, 600 mg / dL). Bronchoalveolar lavage tau ua thiab pom cov neutrophic predominance nrog cov kab mob tsis zoo, kab mob, thiab kab mob fungal. Cov kev ntsuas pulmonary ua haujlwm tau pom tias muaj kev txwv tsis pub muaj kab mob nrog qhov txo qis ntawm cov pa roj carbon monoxide (DLCO).
Raws li cov kev tshawb pom no, peb xav tias tus neeg mob txoj kev tiv thaiv kab mob yog lub luag haujlwm rau nws cov kab mob pulmonary, bronchiectasis, thiab fibrosis. Tsis tas li ntawd, broncho-centric thiab migratory faib ntawm pulmonary consolidation, ntxiv rau cov reversed halo kos npe rau HRCT, tsa kev txhawj xeeb rau OP theem nrab rau rituximab txoj kev kho thiab / los yog rov qab mob hauv siab.
Vim tias tsis muaj kev txhim kho kev kho mob tom qab ntau chav kawm ntawm cov tshuaj tua kab mob dav dav, thiab qhov tseeb tias nws lub hauv paus GPA raug suav tias yog nyob rau hauv lub xeev ntawm kev tso cai, kev txiav txim siab tau rov pib kho rituximab ntawm qis dua, txuas nrog IVIG supplementation. thiab kev kho mob steroid. Qhov no ua rau immunomodulation nrog B-cell repletion, normalization ntawm immunoglobulin, thiab T-cell ua haujlwm rov qab.
Cov kev cuam tshuam no tau tsoo lub voj voog tsis zoo ntawm lub cev tsis muaj zog uas tau ua rau rov kis tus kab mob nrog qhov kawg bronchiectasis thiab fibrosis. Hauv kev soj ntsuam, HRCT tau ua tiav thiab pom tias muaj kev daws teeb meem ntawm OP nrog rau cov cim kev txhim kho kho mob.
GPA tseem nyob rau hauv kev zam txim thiab ob qho tib si bronchiectasis thiab pulmonary fibrosis tau ruaj khov yam tsis muaj cov tsos mob ntawm kev loj hlob. Tsis tas li ntawd, nws raug pom zoo kom kuaj xyuas nws cov qib IVIG tsis tu ncua, nrog kev ntxiv raws li qhov xav tau.
Kev sib tham
Cryptogenic OP yog kuaj los ntawm ob qho tib si hluav taws xob thiab kev nthuav qhia kho mob. OP, ntawm qhov tod tes, yog kev kuaj mob histopathological [6]. OP tuaj yeem yog qhov thib ob thaum cuam tshuam nrog cov xwm txheej paub tias yuav ua rau OP, lossis cryptogenic thaum qhov ua rau tsis paub. Secondary OP yog txuam nrog cov kab mob thiab kab mob ua pa, malignancy, hloov lub cev, kab mob autoimmune, tshuaj, hluav taws xob, thiab ib puag ncig raug [6].
Qhov kev nthuav qhia classic ntawm OP yog ib qho hnoos tsis ua haujlwm, ua tsis taus pa, ua npaws, ua pa nyuaj, thiab poob phaus, nrog rau tus mob khaub thuas me me ua ntej. Qhov kev nthuav qhia no feem ntau ncua kev kuaj mob thiab txawm ua rau nws nyuaj rau kev sib txawv ntawm cov kab mob thib ob, kab mob ua ntej, thiab cryptogenic-type OP.
Feem ntau, cov neeg mob feem ntau tau txais ntau yam kev kawm ntawm cov tshuaj tiv thaiv kab mob tsis muaj kev kho mob, uas yuav tsum tau qhia txog kev kuaj mob ntawm OP.
Lub pathogenesis ntawm OP yog to taub tsis zoo [7]. Txawm li cas los xij, T-cell dysregulation zoo li muaj feem cuam tshuam nrog OP [8].
Mob B-cell depletion tshwm sim los ntawm rituximab tuaj yeem ua rau qhov tsis txaus ntseeg Tcell teb, uas ua rau muaj qhov tshwm sim ntawm OP, tshwj xeeb tshaj yog tias tus neeg mob noj lwm cov tshuaj tiv thaiv kab mob [9].
Bronchoalveolar lavage yog ua kom tsis suav nrog lwm yam etiologies, feem ntau yog kis kab mob, uas feem ntau qhia pom qhov txawv ntawm lymphocytosis. Kev nthuav qhia hluav taws xob classic ntawm OP yog cov kab mob dav dav hauv huab cua nyob rau hauv daim ntawv ntawm thaj tsam qis hauv lub ntsws-predominant consolidation thiab av-iav opacities nrog peri-broncho-vascular thiab / lossis subpleural tis.
Cov no feem ntau yog ob sab thiab peripheral thiab feem ntau tsiv teb tsaws, raws li pom hauv peb rooj plaub. Lub atoll kos npe, uas tseem hu ua reversed halo kos npe, feem ntau pom nyob rau hauv cov xwm txheej ntawm OP, yog tus cwj pwm los ntawm lub hauv paus av-iav opacity surrounded los ntawm ntom airspace consolidation nyob rau hauv cov duab ntawm ib tug crescent los yog ib lub nplhaib. Atoll kos npe tsis yog tshwj xeeb rau OP thiab tau tshaj tawm nyob rau hauv kev koom tes nrog ntau yam kab mob ntsws, nrog rau cov kab mob pulmonary fungal, tuberculosis, mob ntsws hauv zej zog, thiab GPA [10].
Kev phais mob ntsws biopsy yog tus qauv kub rau kev kuaj mob; Txawm li cas los xij, transbronchial biopsy feem ntau qhia txog kev kuaj mob histopathological ntawm cov ntaub so ntswg ntau dhau ntawm cov ntaub so ntswg hauv alveolar sacs txuas mus rau alveolar ducts thiab bronchioles, nrog rau cov ntaub so ntswg intraluminal granulation deposition hu ua Masson lub cev [11].
rituximab-induced OP yog qhov tsawg tab sis tau txais kev txaus siab thiab kev lees paub tsis ntev los no ntawm cov kws kho mob tau muab cov xwm txheej tshwm sim. Rau qhov zoo tshaj plaws ntawm peb txoj kev paub, tsuas muaj qee qhov xwm txheej ntawm rituximab-induced OP hauv cov ntaub ntawv [2-5]. Tag nrho cov ntawm lawv tau raug kho los ntawm kev txiav tawm rituximab thiab corticosteroid cov chav kawm, nrog rau kev kho mob tom qab.
Bronchiectasis, ntawm qhov tod tes, yog tus kab mob ntsws loj zuj zus uas tshwm sim los ntawm kev puas tsuaj tsis zoo ntawm txoj hlab pa vim yog kev sib xyaw ntawm kev tiv thaiv kab mob thiab cov kab mob rov tshwm sim.
Qhov no ua rau kev loj hlob ntawm bronchiolar dilatation, ciliary dyskinesia, thiab kab mob colonization thiab ntxeem tau [12]. Thawj lub voj voog txoj kev xav ntawm cov kab mob rov tshwm sim cuam tshuam rau kev ncaj ncees ntawm txoj hlab pa tau tsim lub hauv paus rau qhov kev tawm tshiab hu ua "vious vortex". Qhov kev tshawb xav no tau hais tias txoj hlab ntsws o tuaj yeem yog vim muaj kev cuam tshuam cytokine network [13,14].
Ib yam li ntawd, rituximab cov kev mob tshwm sim muaj feem xyuam rau nws lub peev xwm ua kom cov B-hlwb ua rau hypogammaglobulinemia nrog rau kev kis kab mob ntxiv, nrog rau kev tiv thaiv kab mob, ua rau cytokine tsis txaus [15]. Nyob rau hauv peb cov ntaub ntawv, peb ntseeg hais tias rituximab ua rau bronchiectasis los ntawm synergistic nyhuv ntawm ob mechanisms: immunomodulation thiab recurrent kab mob.
Rau peb txoj kev paub, qhov sequela ntawm rituximab cuam tshuam nrog kev txhim kho ntawm OP, bronchiectasis, thiab fibrosis yeej tsis tau tshaj tawm ua ntej. Ntxiv mus, pulmonary fibrosis tsis tshua muaj tshwm sim raws li qhov tshwm sim ntawm kev kho mob rituximab ntev [16]. Peb xav tias rituximab-induced fibrosis nyob rau hauv peb tus neeg mob feem ntau yuav muaj feem xyuam rau cov kab mob rov tshwm sim nrog ib tug vicious voj voog ntawm lub ntsws raug mob thiab kho nrog fibrotic cov ntaub so ntswg deposition.
Cov lus xaus
Rituximab yog B-cell-depleting tus neeg saib xyuas, thiab nws muaj kev cuam tshuam tsis zoo rau lub cev tiv thaiv kab mob ua rau B-cell depletion nrog hypogammaglobulinemia thiab T-cell qualitative dysfunction, nrog rau kev tiv thaiv kab mob tom qab. Kev tiv thaiv kab mob ua pa tsis zoo ua rau muaj kev cuam tshuam ntawm cov kab mob pulmonary mob hnyav uas ua rau bronchiectasis thiab mob ntsws pulmonary fibrosis.
Raws li peb cov ntaub ntawv tshuaj xyuas, rituximab tsis tshua muaj feem cuam tshuam nrog OP. Kev txiav txim siab txwv tsis pub siv rituximab tuaj yeem nyuaj vim tias muaj tus nqi siab ntawm tus mob thawj zaug. Yog li ntawd, kho cov teeb meem cuam tshuam nrog rituximab thaum txuas ntxiv nws cov kev tswj hwm yuav yog tib txoj hauv kev ua tau, nrog rau kev ntsuam xyuas tsis tu ncua ntawm qib immunoglobulin thiab ntxiv.
Cov tshuaj steroids lossis lwm cov tshuaj steroid-sparing yog siv los kho rituximab-induced OP. Kev tshem tawm ntawm txoj hlab ntsws nrog kev tu cev bronchopulmonary, bronchodilation, mucolytics, tshem tawm ntawm pseudomonas colonization, thiab cov tshuaj tua kab mob hauv lub cev thaum exacerbation yog cov kev kho mob tseem ceeb rau bronchiectasis. Anti-fibrotics yuav tsum tau muab tshuaj yog tias cov txheej txheem rau kev mob ntsws pulmonary fibrosis tau ua tiav.
Cov ntaub ntawv ntxiv
Qhia tawm
Tib neeg cov ntsiab lus: Kev pom zoo tau txais lossis zam los ntawm txhua tus neeg koom hauv txoj kev tshawb no.
Kev tsis sib haum xeeb ntawm kev txaus siab: Ua raws li daim ntawv qhia txog ICMJE, txhua tus kws sau ntawv tshaj tawm cov hauv qab no: Cov ntaub ntawv them nyiaj / kev pabcuam: Txhua tus kws sau ntawv tau tshaj tawm tias tsis muaj kev txhawb nqa nyiaj txiag los ntawm ib lub koom haum rau kev xa ua haujlwm.
Kev sib raug zoo nyiaj txiag: Txhua tus kws sau ntawv tau tshaj tawm tias lawv tsis muaj kev sib raug zoo nyiaj txiag tam sim no lossis hauv peb lub xyoos dhau los nrog rau txhua lub koom haum uas yuav muaj kev txaus siab rau cov haujlwm xa tuaj.
Lwm yam kev sib raug zoo: Txhua tus kws sau ntawv tau tshaj tawm tias tsis muaj lwm yam kev sib raug zoo lossis kev ua ub no uas tuaj yeem tshwm sim los cuam tshuam rau kev xa tawm.
Cov ntaub ntawv
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5. Biehn SE, Kirk D, Rivera MP, Martinez AE, Khandani AH, Orlowski RZ: Bronchiolitis obliterans nrog kev txhim kho mob ntsws tom qab rituximab kho rau non-Hodgkin's lymphoma. Hematol Oncol. Xyoo 2006, 24:234- 7. 10.1002/799
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10.1007/s00467-010-1447-8 10. Sulavik SB: Lub tswvyim ntawm "kev txhim kho mob ntsws". hauv siab. Xyoo 1989, 96:{5}}. 10.1378/chest.96.5.967
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