Intravenous Immunoglobulin-Associated Elevation of Liver Enzymes in Neurological Autoimmune Disorder: A Case Series

Behera, Anupama; Guru, Satyabrata

doi:10.7759/cureus.10020

Cited by 7 publications

(9 citation statements)

References 6 publications

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“…Elevated LFTs, hyperbilirubinemia, and subsequent biopsy consistent with drug-induced hepatitis were attributed to the increased dose of IVIG that may cause transaminitis ( 17 ); consequently, the subsequent dose of IVIG was reduced. This observation emphasizes the importance of a multidisciplinary team approach for such a unique presentation, which was a strength of our case.…”

Section: Discussionmentioning

confidence: 99%

Case Report: Initial Treatment Adjustments and Complications in Ovarian Cancer Patient With Inborn Error of Immunity

Mammadova¹,

Redden²,

Cruz³

et al. 2022

Front. Oncol.

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BackgroundPatients with inborn errors of immunity (IEI) have increased risk of developing cancers secondary to impaired anti-tumor immunity. Treatment of patients with IEI and cancer is challenging as chemotherapy can exacerbate infectious susceptibility. However, the literature on optimal cancer treatment in the setting of IEI is sparse.ObjectivesWe present a patient with specific antibody deficiency with normal immunoglobins (SADNI), immune dysregulation (ID), and stage III ovarian carcinoma as an example of the need to modify conventional treatment in the context of malignancy, IEI, and ongoing infections.MethodsThis is a retrospective chart review of the patient’s clinical manifestations, laboratory evaluation and treatment course.ResultsOur patient is a female with SADNI and ID diagnosed with stage III ovarian carcinoma at 60 years of age. Her ID accounted for antinuclear antibody positive (ANA+) mixed connective tissue diseases, polyarthralgia, autoimmune neutropenia, asthma, autoimmune thyroiditis, and Celiac disease. Due to the lack of precedent in the literature, her treatment was modified with continuous input from infectious disease, allergy/immunology and oncology specialist using a multidisciplinary approach.The patient completed debulking surgery and 6 cycles of chemotherapy. The dosing for immunoglobulin replacement therapy was increased for prophylaxis. Chemotherapy doses were lowered for all cycles preemptively for IEI. The therapy included carboplatin, paclitaxel, bevacizumab, and pegfilgrastim. The patient completed six-months of maintenance medication involving bevacizumab.Her treatment course was complicated by Mycobacterium avium-complex (MAC) infection, elevated bilirubin and liver enzymes attributed to excessive immunoglobulin replacement therapy, and urinary tract infection (UTI) and incontinence.Cancer genetic analysis revealed no targetable markers and primary immunodeficiency gene panel of 407 genes by Invitae was unrevealing. Lab tests revealed no evidence of Epstein-Barr Virus (EBV) infection. Post-chemotherapy imaging revealed no evidence of cancer for 1 year and 4 months, but the disease relapsed subsequently. The patient’s lung scarring requires vigilance.ConclusionsOur patient with ovarian cancer and IEI required modified treatment and prevention of complications. In cases of IEI, optimal chemotherapy should be titrated to minimize immunosuppression yet treat cancer aggressively while decreasing the risk of infection with prophylactic antibiotics and prolonged post-treatment surveillance, including pulmonary evaluation.

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Section: Discussionmentioning

confidence: 99%

Case Report: Initial Treatment Adjustments and Complications in Ovarian Cancer Patient With Inborn Error of Immunity

Mammadova¹,

Redden²,

Cruz³

et al. 2022

Front. Oncol.

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“…Gammagard liquid, which was the IVIG formulation used in our patient, contains glycine and is not known to cause elevated liver enzymes. 4,5 In our case, it was important to rule out other causes of liver injury.…”

Section: Discussionmentioning

confidence: 90%

Elevated Liver Enzymes With Positive Hepatitis B Serology After Intravenous Immunoglobulin Treatment of Guillain-Barré Syndrome

Patel,

Le,

Puskoor

et al. 2023

ACG Case Rep J

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Intravenous immunoglobulin (IVIG) is used to treat multiple conditions, one of which is Guillain-Barré syndrome. Despite its multiple benefits, IVIG can cause a wide variety of side effects, most of which resolve with supportive care. We present a case in which a patient with new-onset Guillain-Barré syndrome was treated with IVIG and subsequently developed an acute elevation in liver enzymes with positive hepatitis B serology.

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“…A recent retrospective cohort study ( n = 104) found that high serum total protein levels in paediatric neurological patients were significantly associated with the occurrence of IVIg-ARs (OR, 14.8; 95% confidence interval, 2.4–90.5; p < 0.01) [17]. A reversible, asymptomatic rise in liver enzymes, particularly transaminase levels is also common with IVIg administration [20, 23, 26, 39, 44, 69].…”

Section: Abnormalities Of Laboratory Parametersmentioning

confidence: 99%

“…Sugar-stabilised IVIg formula may be associated with eczematous skin reactions – this AR was the main reason for discontinuation (58%) of this product in the study [18]. A prospective case series suggested that maltose-containing stabilising agents in IVIg preparations may cause a self-limited, asymptomatic transaminitis [69]. One prospective cohort study also found the occurrence of transaminitis to be associated with sucrose and PEG/sorbitol-containing IVIg preparations as opposed to glycine-containing preparations; the underlying mechanism was unclear [26].…”

Section: Treatment-specific Risk Factorsmentioning

confidence: 99%

“…Several studies support the use of a routine full blood count (FBC), electrolytes-urea-creatinine (EUC), and liver function test (LFT) before commencing treatment [26, 69]. Obtaining a baseline FBC (focussing on haemoglobin, white cell count, platelet count, and absolute neutrophil count) and EUC (particularly creatinine) is advised to assist in identifying patients at greater risk of complications [56, 57].…”

Section: Preventative Measures and Management Of Arsmentioning

confidence: 99%

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Adverse Reactions Associated with Intravenous Immunoglobulin Administration in the Treatment of Neurological Disorders: A Systematic Review

Jiang¹,

Kimber²,

Gupta³

et al. 2023

Int Arch Allergy Immunol

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Intravenous immunoglobulin (IVIg), which is used to treat multiple neurological conditions, may be associated with serious adverse reactions. The individual neurological disease characteristics associated with adverse reactions, along with strategies to prevent and treat adverse reactions, are uncertain. A systematic review was conducted of the databases PubMed, Embase, and Cochrane Library to summarise studies that report adverse reactions of IVIg therapy in patients with neurological disease. There were 65 studies included in the review. The reported rates of adverse reactions vary widely, but the best evidence suggests rates between 25 and 34% per patient. Common adverse reactions include headache and laboratory abnormalities. Less common but serious adverse reactions included thromboembolic complications and anaphylaxis. Overall, there is a lack of high-quality comparative data to definitively determine if any specific neurological indications are associated with a higher risk of adverse reactions. However, individual neurological disease characteristics possibly associated with an increased likelihood of adverse reactions include limited mobility (as in certain neuromuscular conditions), paraproteinaemia (as in certain peripheral neuropathies), and cardiomyopathy (as in certain myopathies). There is limited evidence to support the effectiveness of prevention and treatment strategies, which may include modification to dose, reduced infusion rate, and premedication. Further studies regarding methods to prevent and treat IVIg-ARs in neurology patients are required.

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Intravenous Immunoglobulin-Associated Elevation of Liver Enzymes in Neurological Autoimmune Disorder: A Case Series

Cited by 7 publications

References 6 publications

Case Report: Initial Treatment Adjustments and Complications in Ovarian Cancer Patient With Inborn Error of Immunity

Case Report: Initial Treatment Adjustments and Complications in Ovarian Cancer Patient With Inborn Error of Immunity

Elevated Liver Enzymes With Positive Hepatitis B Serology After Intravenous Immunoglobulin Treatment of Guillain-Barré Syndrome

Adverse Reactions Associated with Intravenous Immunoglobulin Administration in the Treatment of Neurological Disorders: A Systematic Review

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