In-vivo and human evidence for potential efficacy of therapeutic polyclonal RSV neutralizing antibodies for palivizumab-resistant RSV infections.

BACKGROUND: Monoclonal antibody (palivizumab), intravenous immune globulin (IGIV), or respiratory syncytial virus (RSV)-polyclonal-hyperimmune-globulin (RSV-IG as Respigam®, RI-001, RI-002) are used with ribavirin in RSV-infected immunocompromised patients, with debated efficacy. Palivizumab-resistance (PR) can arise during treatment of persistent infections in this population. RSV-IG may confer benefit in PR-RSV infection. METHODS: RSV-IG [RI-001] was provided for an immunocompromised infant with RSV-pneumonitis refractory to ribavirin and palivizumab. RSV-neutralizing antibody, respiratory RSV load (qPCR), and F-gene-sequence-detection of PR was determined. Prophylactic RSV-IG [RI-002] or palivizumab was administered in a cotton-rat model infected with wild-type and PR-RSV. Lung RSV load and neutralizing antibody were measured. RESULTS: As protective RI-001-neutralizing antibody titers waned in the infant, a subpopulation of PR-escape mutants were detected with a fatal RSV-burden in the lungs. In PR-RSV-infected cotton rats, prophylactic RI-002 reduced RSV-load in the lungs (2.45 vs 0.28 log10 PFU/g lung-tissue reduction, respectively, p < 0.05) and provided protective RSV-neutralizing antibody. CONCLUSIONS: RSV-IG and ribavirin use in immunocompromised patients requires further study.

Assessing the impact of hepatitis B immune globulin (HBIG) on responses to hepatitis B vaccine during co-administration.

INTRODUCTION: A hepatitis B vaccination (HepB) series with an initial dose of hepatitis B immune globulin (HBIG) is the recommended prophylaxis for infants born to mothers with chronic hepatitis B virus (HBV) infection and for HBV-exposed persons without known protection. The HepB and HBIG are administered at different sites (limbs). Instances of HepB and HBIG administered at the same site are documented but the impact on immune responses to HepB remains unanswered. METHODS: Newborn and adult BALB/c mice received one dose of HepB at time zero alone or with HBIG in the same or different sites, followed by 2 additional doses of HepB at 3 and 10 weeks (newborn mice) or 4 and 16 weeks (adult mice). To study memory responses mice were given a 4th, booster, dose of HepB at 26 weeks and B cells analyzed. RESULTS: Administration of HepB with HBIG resulted in reduced responses to HepB following the first 2 doses, regardless of site, compared to mice that received HepB only. Lower levels of antibody to HBV surface antigen (anti-HBs) were observed at the end of the 3-dose series (p < 0.0001) in all groups of newborn mice that received HepB and HBIG. In adult mice, this difference was only seen when HepB and HBIG were delivered at the same site. However, following a HepB booster at 26 weeks, HBsAg-specific B-cell expansion and memory phenotype were not impacted by initial HBIG administration CONCLUSION: Administration of HBIG with HepB can delay and reduce responses to HepB in mice. Our findings suggest that the initial circulating levels of HBIG could prevent infection despite an impaired response to vaccine and support the current recommendation of assessing seroprotection after series completion for infants born to HBV carrier mothers, including in cases where vaccine and HBIG are administered incorrectly at the same site.

Prevalence of sensitization to Malassezia spp. in adults with atopic dermatitis and psoriasis and its correlation with disease severity / Prevalência da sensibilização a Malassezia spp. em pacientes adultos portadores de dermatite atópica e psoríase e sua correlação com a gravidade das doenças

Fundamentals: Atopic Dermatitis (AD) and Psoriasis (PS) share clinical and physiopathological similarities. Objective: Determine the prevalence of sensitization to Malassezia spp. in adults with AD and PS and its correlation with disease severity. Methods: A cross-sectional study was carried out from January 2016 to August 2017 with adults. Malassezia spp.-specific IgE dosages were measured, and skin scrapings for fungal culture performed. Parametric or nonparametric tests were used for analysis. Results: Median age of the 20 participants with AD was 29 years old, and the mean SCO-RAD was 45.35 ± 18.32. Malassezia spp.- specific IgE median dosage was 0.63 kU/l. M. furfur and M. sympodialis were isolated. Spearman's nonparametric correlation analysis showed no correlation between sensitization to Malassezia spp. and disease severity. The median age of the 36 participants with PS was 61 years old, the median body surface area affected was 22%, and Malassezia spp.-specific IgE median dosage was 0.00 kU/l. M. furfur and Malassezia spp. were identified. Study limitations: Assessing the sensitization to Malasseziaspp. was difficult due to the reduced number of participants in the study. Furthermore, there was no uniformity in the location to collect skin scrapings. The use of topical medication was not suspended before collecting skin specimens for mycological examination, therefore interfer-ing with fungal isolation. Conclusion: Sensitization to Malassezia spp. was only detected in the AD sample. Malassezia spp.-specific IgE test did not prove to be a marker for disease severity in our AD sample (AU)

Fundamentos: Dermatite atópica (DA) e psoríase apresentam similaridades clínicas e fisiopatológicas. Objetivos: Avaliar a frequência da sensibilização a Malasseziaspp. em adultos portadores de DA e psoríase e correlacionar à gra-vidade dos quadros clínicos. Métodos: De janeiro de 2016 a agosto de 2017, conduziu-se um estudo observacional em indivíduos adultos onde foram realizadas dosagem de IgE específica anti-Malassezia spp. e raspados das lesões para cultura micológica. Testes paramétricos ou não paramétricos foram utilizados para análise. Resultados: Nos 20 portadores de DA, a mediana da idade foi 29 anos. O valor médio do Scoring Atopic Dermatitis foi 45,35 ± 18,32. A mediana de IgE específica anti-Malasseziaspp. foi 0,63 kU/l. M. furfur e M. sympodialis foram isolados. A análise de correlação não-paramétrica de Spearman não mostrou correlação entre a sensibilização à Malassezia spp. e a gra-vidade. Nos 36 pacientes com psoríase, foram obtidas as seguintes medianas: idade 61 anos, comprometimento de superfície corpórea 22% e IgE específica anti-Malassezia spp. 0,00 kU/l. Houve identificação de M. furfur e Malasse-zia spp. Limitações do estudo: O número reduzido de participantes dificultou a avaliação da sensibilização por IgE a Malasseziaspp. Não houve uniformidade nos locais de coleta dos raspados cutâneos. Medicamentos tópicos não foram suspensos anteriormente ao exame micológico, prejudicando o isolamento dos fungos. Conclusões: Sensibili-zação a Malassezia spp. apenas ocorreu nos portadores de DA. O teste de IgE específica anti-Malassezia spp. não se mostrou um marcador de gravidade para a DA neste grupo (AU)

Severe recalcitrant hidradenitis suppurativa in a 2-year-old boy with partial trisomy 13.

We report the case of a 2-year-old boy with mosaic trisomy 13 and immunodeficiency who developed severe hidradenitis suppurativa beginning at the age of 18 months. Unresponsive to standard therapies, he exhibited a partial response to immunoglobulin replacement therapy.

Tratamiento con inmunoglobulina intravenosa y esteroides sistémicos en pacientes con necrólisis epidérmica tóxica: Experiencia en un hospital en Ciudad de México / Use of Intravenous Immunoglobulins and Systemic Corticosteroids in Patients with Toxic Epidermal Necrolysis: Experience of a Hospital in Mexico City

La necrólisis epidérmica tóxica es la reacción secundaria a medicamentos más grave dentro del espectro de las reacciones mucocutáneas. El tratamiento multidisciplinario es clave para disminuir la mortalidad de los pacientes, además de la suspensión del fármaco causal. Existen pocos estudios de tratamientos farmacológicos en pacientes con necrólisis epidérmica tóxica en Latinoamérica que combinen el uso de esteroides sistémicos e inmunoglobulina intravenosa (IgIV). Describimos 6 casos de pacientes con necrólisis epidérmica tóxica tratados con esteroides sistémicos e IgIV en un hospital de referencia dermatológica en Ciudad de México. Ningún paciente falleció ni presentó complicaciones a corto y mediano plazo de seguimiento. En la mayoría de los casos se empleó una dosis de IgIV de 1g/kg por 3-5 días y 1g de metilprednisolona por 3-5 días. El tiempo de ingreso hospitalario fue de 14,8 días. La combinación de esteroides sistémicos e IgIv parece ser una opción segura en pacientes con necrólisis epidérmica tóxica (AU)

Toxic epidermal necrolysis is the most serious mucocutaneous adverse drug reaction. Multidisciplinary treatment and withdrawal of the causative drug are key to reducing mortality. Few studies have analyzed the use of systemic corticosteroids and intravenous immunoglobulins (IVIG) in patients with toxic epidermal necrolysis in Latin America. We describe our experience with 6 cases treated at a dermatology referral hospital in Mexico City. None of the patients died or developed complications in the short or medium term. The most widely used regimen was a combination of IVIG 1 g/kg for 3 to 5 days and methylprednisolone 1 g for 3 to 5 days. Mean hospital stay was 14.8 days. The combined use of systemic corticosteroids and IVIG seems to be a safe treatment option for patients with toxic epidermal necrolysis (AU)

[Translated article] Use of Intravenous Immunoglobulins and Systemic Corticosteroids in Patients With Toxic Epidermal Necrolysis: Experience of a Hospital in Mexico City / Tratamiento con inmunoglobulina intravenosa y esteroides sistémicos en pacientes con necrólisis epidérmica tóxica: experiencia en un hospital en Ciudad de México

Toxic epidermal necrolysis is the most serious mucocutaneous adverse drug reaction. Multidisciplinary treatment and withdrawal of the causative drug are key to reducing mortality. Few studies have analyzed the use of systemic corticosteroids and intravenous immunoglobulins (IVIG) in patients with toxic epidermal necrolysis in Latin America. We describe our experience with 6 cases treated at a dermatology referral hospital in Mexico City. None of the patients died or developed complications in the short or medium term. The most widely used regimen was a combination of IVIG 1g/kg for 3–5 days and methylprednisolone 1g for 3–5 days. Mean hospital stay was 14.8 days. The combined use of systemic corticosteroids and IVIG seems to be a safe treatment option for patients with toxic epidermal necrolysis (AU)

La necrólisis epidérmica tóxica es la reacción secundaria a medicamentos más grave dentro del espectro de las reacciones mucocutáneas. El tratamiento multidisciplinario es clave para disminuir la mortalidad de los pacientes, además de la suspensión del fármaco causal. Existen pocos estudios de tratamientos farmacológicos en pacientes con necrólisis epidérmica tóxica en Latinoamérica que combinen el uso de esteroides sistémicos e inmunoglobulina intravenosa (IgIV). Describimos 6 casos de pacientes con necrólisis epidérmica tóxica tratados con esteroides sistémicos e IgIV en un hospital de referencia dermatológica en Ciudad de México. Ningún paciente falleció ni presentó complicaciones a corto y mediano plazo de seguimiento. En la mayoría de los casos se empleó una dosis de IgIV de 1g/kg por 3-5 días y 1g de metilprednisolona por 3-5 días. El tiempo de ingreso hospitalario fue de 14,8 días. La combinación de esteroides sistémicos e IgIv parece ser una opción segura en pacientes con necrólisis epidérmica tóxica (AU)

Profilaxia pós-exposição antirrábica: evidências sobre pré-medicação, administração de soro e esquema vacinal / Anti-rabies post-exposure prophylaxis: evidence on premedication, serum administration and vaccination scheme

A raiva é uma zoonose transmitida ao homem pela inoculação do vírus rábico contido na saliva do animal infectado. A infecção por este vírus causa encefalite aguda com índice de letalidade próximo a 100%.Embora não haja cura para a raiva clínica, a doença é facilmente evitável pelo fornecimento oportuno de profilaxia adequada. A profiaxia antirrábica humana pode ser realizada pré (PrEP) ou pós (PEP) exposição potencial ao virus da raiva. As tecnologias utilizadas para esta profilaxia são as vacinas e os soros. Há diversos esquemas de profilaxia PrEP e PEP utilizados no mundo. No Brasil, há ainda indicação de administração de medicações prévias à infiltração de soro heterólogo, a fim de mitigar potenciais reações anafiláticas. A administração concomitante de vacinas, imunoglobulinas e pré-medicação para hipersensibilidade (anti-histamínicos e corticoides) através da via intramuscular é uma prática instituída no contexto municipal de Campo Grande - MS, ocasionando problemas recorrentes de falta de sítios para administração completa da profilaxia, especialmente em crianças. Quais os cuidados necessários durante a realização de Profilaxia Pós Exposição Antirrábica em situações de limitação de vias de administração e risco de hipersensibilidade? Após análise do conteúdo, a fim de concluir a revisão em tempo oportuno para a tomada de decisão da gestão, a equipe de pesquisa deliberou pela extração de dados somente dos estudos secundários. Os principais achados estão sumarizados em infográfico no APÊNDICE A. É indicada a modernização do Procedimento Operacional Padrão vigente na prefeitura de Campo Grande. A substituição das práticas relacionadas à pré-medicação IM, vacinação IM e administração de soro IM é cientificamente embasada e elimina o problema que originou a questão de pesquisa desta revisão, apresentando benefícios para gestão, profissionais e usuários do SUS.

Infection rates and tolerability of three different immunoglobulin administration modalities in patients with primary immunodeficiency diseases.

Aim: This post hoc analysis evaluated the efficacy and overall tolerability of immunoglobulin (Ig) treatment modalities (intravenous Ig [iv.Ig], subcutaneous Ig [sc.Ig] and facilitated sc.Ig [fsc.Ig]). Materials & methods: A total of 30 participants with primary immunodeficiency diseases aged ≥2 years sequentially received iv.Ig, sc.Ig and fsc.Ig during consecutive clinical studies. Results: For iv.Ig, sc.Ig and fsc.Ig, rates of validated acute serious bacterial infections/participant-year (0, 0.09 and 0.04, respectively) and all infections/participant year (4.17, 3.68 and 2.42, respectively) were similarly low; rates of systemic and local causally related adverse events/participant-year were 5.60, 1.93 and 0.88, respectively and 0.13, 0.92 and 1.57, respectively. Conclusion: fsc.Ig provided similar efficacy to iv.Ig and sc.Ig. Clinical Trial registration: NCT00546871, NCT00814320, NCT01175213 (ClinicalTrials.gov).

Review: Improving the performance of neonatal piglets.

Newborn piglets have a high incidence of preweaning mortality that is not only associated with low birth weights but also with the presence of intra-uterine growth-restricted (IUGR) piglets. Such IUGR piglets are commonly seen in litters from hyperprolific sows as a result of insufficient placental transfer of nutrients. Nutritional strategies can be used prior to and during gestation to enhance foetal development and can also be implemented in the transition period to reduce the duration of farrowing and increase colostrum yield. Recent findings showed that the energy status of sows at the onset of farrowing is crucial to diminish stillbirth rate. Newborn piglets often fail to consume enough colostrum to promote thermostability and subsequent growth, and this is particularly problematic in very large litters when there are fewer available teats than the number of suckling piglets. One injection of 75 IU of oxytocin approximately 14 h after farrowing can prolong the colostral phase, hence increasing the supply of immunoglobulins to piglets. Nevertheless, assistance must be provided to piglets after birth in order to increase their chance of survival. Various approaches can be used, such as: (1) optimising the farrowing environment, (2) supervising farrowing and assisting newborn piglets, (3) using cross-fostering techniques, (4) providing nurse sows, and 5) providing artificial milk. Although research advances have been made in developing feeding and management strategies for sows that increase performance of their newborn piglets, much work still remains to be done to ensure that maximal outcomes are achieved.

Síndrome inflamatorio multisistémico post COVID-19 con afectación miocárdica: reporte de caso / Clinical case: post-COVID multisystem inflammatory syndrome with myocardial involvement / Síndrome inflamatória multissistêmica pós-COVID com acometimento do miocárdio (SIMC): relato de caso

En abril de 2020, durante el pico de la pandemia COVID-19 producida por el coronavirus emergente SARS-CoV-2, en el Reino Unido se comunicaron casos de shock hiperinflamatorio de características similares a la enfermedad de Kawasaki y el síndrome de shock tóxico en un grupo de ocho niños. El Royal College of Pediatrics and Child Health lo denominó síndrome inflamatorio multisistémico pediátrico temporalmente asociado con COVID-19 (SIM-C). Actualmente, el SIM-C es una enfermedad infrecuente, solapada con otras entidades, que requiere una alta sospecha clínica para identificarlo oportunamente. El síndrome inflamatorio multisistémico temporal asociado con SARS-CoV-2 pediátrico (PIMST) es una nueva entidad clínica con un amplio espectro de presentación postexposición al virus, inmunomediado con hiperinflamación y activación de una tormenta de citoquinas. Ocurre típicamente entre la segunda y cuarta semana de evolución. Se describen marcadores de inflamación característicamente elevados, como son la ferritina, proteína C reactiva (PCR), velocidad de eritrosedimentación (VES), lactato deshidrogenasa y dímero-D, asociados a neutropenia, linfopenia y anemia. La Organización Mundial de la Salud (OMS) define: caso a menores de 19 años con fiebre ≥3 días, marcadores inflamatorios elevados, evidencia de infección por SARS-CoV-2 y ninguna otra etiología microbiana; con afectación de al menos dos sistemas: dermatológico (rash, conjuntivitis no exudativa, inflamación mucocutánea), hemodinámico (hipotensión, shock), cardíaco (disfunción de miocardio, pericardio, valvular o coronario), hematológico (coagulopatía), digestivo (vómitos, diarrea, dolor abdominal). Considerando la gravedad de esta nueva entidad, es necesario el reconocimiento oportuno y referencia temprana para atención especiaizada y tratamiento oportuno.

Summary: In April 2020, during the peak of the COVID-19 pandemic caused by the emerging coronavirus SARS-CoV-2, 8 children reported cases of hyperinflammatory toxic shock with characteristics similar to Kawasaki disease and syndrome in the United Kingdom. The Royal College of Pediatrics and Child Health has called it pediatric Multisystem Inflammatory Syndrome (MIS) temporally associated with COVID-19. Currently, MIS-C is a rare disease, overlapping with other conditions, which requires a high clinical suspicion for its timely identification. Pediatric SARS-CoV-2-associated temporary multisystem inflammatory syndrome (TMIS-C) is a new clinical entity with a broad spectrum of presentation after exposure to the virus, immune-mediated with hyperinflammation and activation of a cytokine storm. It typically occurs between the 2nd to 4th week of evolution. Characteristically elevated markers of inflammation are described, such as ferritin, C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), lactate dehydrogenase and D-dimer, associated with neutropenia, lymphopenia and anemia. The World Health Organization (WHO) defines it as: a case under 19 years of age with fever ≥ 3 days, elevated inflammatory markers, evidence of SARS-CoV-2 infection and no other microbial etiology; with involvement of at least 2 systems: dermatological (rash, non-exudative conjunctivitis, mucocutaneous inflammation), hemodynamic (hypotension, shock), cardiac (myocardial, pericardial, valvular, or coronary dysfunction), hematologic (coagulopathy), digestive (vomiting, diarrhea, abdominal pain) Considering the seriousness of this new entity, timely recognition and early referral for specialized care and timely treatment are key.

No mês de abril de 2020, durante o pico da pandemia de COVID-19 causada pelo emergente coronavírus SARS-CoV-2, 8 casos de crianças com choque hiperinflamatório com características semelhantes à doença e síndrome de Kawasaki foram relatados no Reino Unido. O Royal College of Pediatrics and Child Health nomeou-o como síndrome inflamatória multissistêmica pediátrica (MIS) temporariamente associada ao COVID-19. Atualmente, o SIM-C é uma doença rara, sobrepondo-se a outras entidades, o que requer alta suspeição clínica para sua identificação oportuna. A síndrome inflamatória multissistêmica temporária associada ao SARS-CoV-2 pediátrico (SIMT) é uma nova entidade clínica com amplo espectro de apresentação após exposição ao vírus, imunomediada com hiperinflamação e ativação de uma tempestade de citocinas. Geralmente ocorre entre a 2ª a 4ª semana de evolução. São descritos marcadores de inflamação caracteristicamente elevados, como ferritina, proteína C reativa (PCR), velocidade de hemossedimentação (VHS), lactato desidrogenase e D-dímero, associados a neutropenia, linfopenia e anemia. A Organização Mundial da Saúde (OMS) a define como: caso de menor de 19 anos com febre ≥ 3 dias, marcadores inflamatórios elevados, evidência de infecção por SARS-CoV-2 e nenhuma outra etiologia microbiana; com envolvimento de pelo menos 2 sistemas: dermatológico (erupção cutânea, conjuntivite não exsudativa, inflamação mucocutânea), hemodinâmica (hipotensão, choque), cardíaca (disfunção miocárdica, pericárdica, valvar ou coronariana), hematológica (coagulopatia), digestiva (vômitos, diarreia, dor abdominal) Considerando a gravidade dessa nova entidade, é necessário o reconhecimento oportuno e encaminhamento precoce para atendimento especializado e tratamento oportuno.

The clinical course and short-term health outcomes of multisystem inflammatory syndrome in children in the single pediatric rheumatology center.

OBJECTIVES: Multisystem inflammatory syndrome in children (MIS-C) is a rare but severe condition resulting in excessive response of the immune system after SARS-CoV-2 infection. We report a single-center cohort of children with MIS-C, describing the spectrum of presentation, therapies, clinical course, and short-term outcomes. METHODS: This is a prospective observational study from to a tertiary pediatric rheumatology center including patients (aged 1 month to 21 years) diagnosed with MIS-C between April 2020-April 2021. Demographic, clinical, laboratory results and follow-up data were collected through the electronic patient record system and analyzed. RESULTS: A total of 67 patients with MIS-C were included in the study. Fever was detected in all patients; gastrointestinal system symptoms were found in 67.2% of the patients, rash in 38.8%, conjunctivitis in 31.3%, hypotension in 26.9% myocarditis, and/or pericarditis in 22.4%, respectively. Respiratory symptoms were only in five patients (7.5%). Kawasaki Disease like presentation was found 37.3% of the patients. The mean duration of hospitalization was 11.8 7.07 days. Fifty-seven patients (85%) received intravenous immunoglobulin (IVIG), 45 (67%) received corticosteroids, 17 (25.3%) received anakinra, and one (1.5%) received tocilizumab. Seven of the patients (10.4%) underwent therapeutic plasma exchange (TPE). In 21 (31.3%) patients, a pediatric intensive care unit (PICU) was required in a median of 2 days. The first finding to improve was fever, while the first parameter to decrease was ferritin (median 6.5 days (IQR, 4-11.2 days)). Sixty-five patients were discharged home with a median duration of hospital stay of 10 days (IQR, 7-15 days). CONCLUSION: Patients with MIS-C may have severe cardiac findings and intensive care requirements in admission and hospital follow-up. The vast majority of these findings improve with effective treatment without any sequelae until discharge and in a short time in follow-up. Although the pathogenesis and treatment plan of the disease are partially elucidated, follow-up studies are needed in terms of long-term prognosis and relapse probabilities.

Recommendations for Hepatitis B Immunoglobulin and Antiviral Prophylaxis Against Hepatitis B Recurrence After Liver Transplantation.

The combination of hepatitis B immunoglobulin and potent nucleos(t)ide analogs after liver transplantation is considered as the standard of care for prophylaxis against hepatitis B virus recurrence. However, the recommended doses, route of administration, and duration of HBIG administration remain unclear. Moreover, hepatitis B immunoglobulin-free prophylaxis with potent nucleos(t)ide analogs has shown promising disease outcomes in preventing hepatitis B virus recurrence. The current recommendations, produced by the Turkish Association for the Study of the Liver, Acute Liver Failure and Liver Transplantation Special Interest Group, suggest a reduced need for hepatitis B immunoglobulin administration with effective long-term suppression of hepatitis B virus replication using potent nucleos(t) ide analogs after liver transplantation.

Prevalence of hypogammaglobulinemia and its management with subcutaneous immunoglobulin supplementation in patients after allogeneic hematopoietic stem cell transplantation-a single-center analysis.

Secondary immunodeficiencies are frequently observed after allo-HSCT. The efficacy of subcutaneous IgG preparations in this population is unknown. A retrospective single-institution study involved 126 adult patients transplanted in 2012-2019 for hematological malignancies. Patients were tested every 2-3 weeks for plasma IgG concentration during the 1st year after transplantation and supplemented with facilitated subcutaneous immunoglobulin when they either had IgG concentration < 500 mg/dl or between 500 and 700 mg/dl and recurrent infection. The IgG concentration < 500 mg/dL was diagnosed in 41 patients, while 500-700 mg/dL in 25 and altogether 53 patients received IgG supplementation. The median number of IgG administrations was 2. The median time to the first IgG administration after allo-HSCT was 4.1 months, while to the next administration (if more than one was required) 53 days (prophylactic group) and 32 days (group with infections). We did not observe any significant toxicity. Two situations were associated with increased probability of meeting criteria for IgG supplementation: diagnosis of either acute lymphoblastic leukemia (ALL) or chronic lymphocytic leukemia (CLL) (83.8% versus 39.3% for other diagnosis, p = 0.000) and the systemic use of corticosteroids (64.2% versus 31.5% for patients without systemic corticosteroids, p = 0.005). Over 40% of the adult recipients may require at least incidental immunoglobulin supplementation during the first year after allo-HSCT. Low IgG concentrations are associated with inferior outcomes. The subcutaneous route of IgG administration appeared to be safe and may allow for long persistence.

Severe autoimmune hemolytic anemia following receipt of SARS-CoV-2 mRNA vaccine.

BACKGROUND: Large clinical trials have demonstrated the overall safety of vaccines for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). However, reports have emerged of autoimmune phenomena, including vaccine-associated myocarditis, immune thrombocytopenia, and immune thrombotic thrombocytopenia. CASE PRESENTATION: Here we present a novel case of a young woman who developed life-threatening autoimmune hemolytic anemia (AIHA) after her first dose of a SARS-CoV-2 mRNA vaccine. Notably, initial direct antiglobulin testing was negative using standard anti-IgG reagents, which are "blind" to certain immunoglobulin (IgG) isotypes. Further testing using an antiglobulin reagent that detects all IgG isotypes was strongly positive and confirmed the diagnosis of AIHA. The patient required transfusion with 13 units of red blood cells, as well as treatment with corticosteroids, rituximab, mycophenolate mofetil, and immune globulin. CONCLUSION: As efforts to administer SARS-CoV-2 vaccines continue globally, clinicians must be aware of potential autoimmune sequelae of these therapies.