Use of rituximab for refractory cytopenias associated with autoimmune lymphoproliferative syndrome (ALPS)

V. Koneti Rao, Susan Price, Katie Perkins, Patricia Aldridge, Jean Tretler, Joie Davis, Janet K. Dale, Fred Gill, Kip R. Hartman, Linda C. Stork, David J. Gnarra, Lakshmanan Krishnamurti, Peter E. Newburger, Jennifer Puck, Thomas Fleisher

Research output: Contribution to journalArticle

52 Citations (Scopus)

Abstract

Background. ALPS is a disorder of apoptosis resulting in accumulation of autoreactive lymphocytes, leading to marked lymphadenopathy, hepatosplenomegaly, and multilineage cytopenias due to splenic sequestration and/or autoimmune destruction often presenting in childhood. We summarize our experience of rituximab use during the last 8 years in 12 patients, 9 children, and 3 adults, out of 259 individuals with ALPS, belonging to 166 families currently enrolled in studies at the National Institutes of Health. Methods. Refractory immune thrombocytopenia (platelet count<20,000) in nine patients and autoimmune hemolytic anemia (AIHA) in three patients led to treatment with rituximab. Among them, seven patients had undergone prior surgical splenectomy; three had significant splenomegaly; and two had no palpable spleen. Results. In seven out of nine patients with ALPS and thrombocytopenia, rituximab therapy led to median response duration of 21 months (range 14-36 months). In contrast, none of the three children treated with rituximab for AIHA responded. Noted toxicities included profound and prolonged hypogammaglobulinemia in three patients requiring replacement IVIG, total absence of antibody response to polysaccharide vaccines lasting up to 4 years after rituximab infusions in one patient and prolonged neutropenia in one patient. Conclusion. Toxicities including hypogammaglobulinemia and neutropenia constitute an additional infection risk burden, especially in asplenic individuals, and may warrant avoidance of rituximab until other immunosuppressive medication options are exhausted. Long-termfollow-up of ALPS patients with cytopenias after any treatment is necessary to determine relative risks and benefits.

Original languageEnglish (US)
Pages (from-to)847-852
Number of pages6
JournalPediatric Blood and Cancer
Volume52
Issue number7
DOIs
StatePublished - Jul 1 2009

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Autoimmune Lymphoproliferative Syndrome
Autoimmune Hemolytic Anemia
Agammaglobulinemia
Neutropenia
Rituximab
Idiopathic Thrombocytopenic Purpura
Intravenous Immunoglobulins
Splenomegaly
National Institutes of Health (U.S.)
Splenectomy
Immunosuppressive Agents
Platelet Count
Thrombocytopenia
Antibody Formation
Polysaccharides
Therapeutics
Vaccines
Spleen

Keywords

  • ALPS
  • Cytopenias
  • Lymphadenopathy
  • Rituximab
  • Splenomegaly

ASJC Scopus subject areas

  • Pediatrics, Perinatology, and Child Health
  • Hematology
  • Oncology

Cite this

Rao, V. K., Price, S., Perkins, K., Aldridge, P., Tretler, J., Davis, J., ... Fleisher, T. (2009). Use of rituximab for refractory cytopenias associated with autoimmune lymphoproliferative syndrome (ALPS). Pediatric Blood and Cancer, 52(7), 847-852. https://doi.org/10.1002/pbc.21965

Use of rituximab for refractory cytopenias associated with autoimmune lymphoproliferative syndrome (ALPS). / Rao, V. Koneti; Price, Susan; Perkins, Katie; Aldridge, Patricia; Tretler, Jean; Davis, Joie; Dale, Janet K.; Gill, Fred; Hartman, Kip R.; Stork, Linda C.; Gnarra, David J.; Krishnamurti, Lakshmanan; Newburger, Peter E.; Puck, Jennifer; Fleisher, Thomas.

In: Pediatric Blood and Cancer, Vol. 52, No. 7, 01.07.2009, p. 847-852.

Research output: Contribution to journalArticle

Rao, VK, Price, S, Perkins, K, Aldridge, P, Tretler, J, Davis, J, Dale, JK, Gill, F, Hartman, KR, Stork, LC, Gnarra, DJ, Krishnamurti, L, Newburger, PE, Puck, J & Fleisher, T 2009, 'Use of rituximab for refractory cytopenias associated with autoimmune lymphoproliferative syndrome (ALPS)', Pediatric Blood and Cancer, vol. 52, no. 7, pp. 847-852. https://doi.org/10.1002/pbc.21965
Rao, V. Koneti ; Price, Susan ; Perkins, Katie ; Aldridge, Patricia ; Tretler, Jean ; Davis, Joie ; Dale, Janet K. ; Gill, Fred ; Hartman, Kip R. ; Stork, Linda C. ; Gnarra, David J. ; Krishnamurti, Lakshmanan ; Newburger, Peter E. ; Puck, Jennifer ; Fleisher, Thomas. / Use of rituximab for refractory cytopenias associated with autoimmune lymphoproliferative syndrome (ALPS). In: Pediatric Blood and Cancer. 2009 ; Vol. 52, No. 7. pp. 847-852.
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abstract = "Background. ALPS is a disorder of apoptosis resulting in accumulation of autoreactive lymphocytes, leading to marked lymphadenopathy, hepatosplenomegaly, and multilineage cytopenias due to splenic sequestration and/or autoimmune destruction often presenting in childhood. We summarize our experience of rituximab use during the last 8 years in 12 patients, 9 children, and 3 adults, out of 259 individuals with ALPS, belonging to 166 families currently enrolled in studies at the National Institutes of Health. Methods. Refractory immune thrombocytopenia (platelet count<20,000) in nine patients and autoimmune hemolytic anemia (AIHA) in three patients led to treatment with rituximab. Among them, seven patients had undergone prior surgical splenectomy; three had significant splenomegaly; and two had no palpable spleen. Results. In seven out of nine patients with ALPS and thrombocytopenia, rituximab therapy led to median response duration of 21 months (range 14-36 months). In contrast, none of the three children treated with rituximab for AIHA responded. Noted toxicities included profound and prolonged hypogammaglobulinemia in three patients requiring replacement IVIG, total absence of antibody response to polysaccharide vaccines lasting up to 4 years after rituximab infusions in one patient and prolonged neutropenia in one patient. Conclusion. Toxicities including hypogammaglobulinemia and neutropenia constitute an additional infection risk burden, especially in asplenic individuals, and may warrant avoidance of rituximab until other immunosuppressive medication options are exhausted. Long-termfollow-up of ALPS patients with cytopenias after any treatment is necessary to determine relative risks and benefits.",
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AU - Price, Susan

AU - Perkins, Katie

AU - Aldridge, Patricia

AU - Tretler, Jean

AU - Davis, Joie

AU - Dale, Janet K.

AU - Gill, Fred

AU - Hartman, Kip R.

AU - Stork, Linda C.

AU - Gnarra, David J.

AU - Krishnamurti, Lakshmanan

AU - Newburger, Peter E.

AU - Puck, Jennifer

AU - Fleisher, Thomas

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N2 - Background. ALPS is a disorder of apoptosis resulting in accumulation of autoreactive lymphocytes, leading to marked lymphadenopathy, hepatosplenomegaly, and multilineage cytopenias due to splenic sequestration and/or autoimmune destruction often presenting in childhood. We summarize our experience of rituximab use during the last 8 years in 12 patients, 9 children, and 3 adults, out of 259 individuals with ALPS, belonging to 166 families currently enrolled in studies at the National Institutes of Health. Methods. Refractory immune thrombocytopenia (platelet count<20,000) in nine patients and autoimmune hemolytic anemia (AIHA) in three patients led to treatment with rituximab. Among them, seven patients had undergone prior surgical splenectomy; three had significant splenomegaly; and two had no palpable spleen. Results. In seven out of nine patients with ALPS and thrombocytopenia, rituximab therapy led to median response duration of 21 months (range 14-36 months). In contrast, none of the three children treated with rituximab for AIHA responded. Noted toxicities included profound and prolonged hypogammaglobulinemia in three patients requiring replacement IVIG, total absence of antibody response to polysaccharide vaccines lasting up to 4 years after rituximab infusions in one patient and prolonged neutropenia in one patient. Conclusion. Toxicities including hypogammaglobulinemia and neutropenia constitute an additional infection risk burden, especially in asplenic individuals, and may warrant avoidance of rituximab until other immunosuppressive medication options are exhausted. Long-termfollow-up of ALPS patients with cytopenias after any treatment is necessary to determine relative risks and benefits.

AB - Background. ALPS is a disorder of apoptosis resulting in accumulation of autoreactive lymphocytes, leading to marked lymphadenopathy, hepatosplenomegaly, and multilineage cytopenias due to splenic sequestration and/or autoimmune destruction often presenting in childhood. We summarize our experience of rituximab use during the last 8 years in 12 patients, 9 children, and 3 adults, out of 259 individuals with ALPS, belonging to 166 families currently enrolled in studies at the National Institutes of Health. Methods. Refractory immune thrombocytopenia (platelet count<20,000) in nine patients and autoimmune hemolytic anemia (AIHA) in three patients led to treatment with rituximab. Among them, seven patients had undergone prior surgical splenectomy; three had significant splenomegaly; and two had no palpable spleen. Results. In seven out of nine patients with ALPS and thrombocytopenia, rituximab therapy led to median response duration of 21 months (range 14-36 months). In contrast, none of the three children treated with rituximab for AIHA responded. Noted toxicities included profound and prolonged hypogammaglobulinemia in three patients requiring replacement IVIG, total absence of antibody response to polysaccharide vaccines lasting up to 4 years after rituximab infusions in one patient and prolonged neutropenia in one patient. Conclusion. Toxicities including hypogammaglobulinemia and neutropenia constitute an additional infection risk burden, especially in asplenic individuals, and may warrant avoidance of rituximab until other immunosuppressive medication options are exhausted. Long-termfollow-up of ALPS patients with cytopenias after any treatment is necessary to determine relative risks and benefits.

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KW - Rituximab

KW - Splenomegaly

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