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Rituximab with a TBD

Discussion in 'Rituximab: News and Research' started by duncan, Apr 11, 2016.

  1. duncan

    duncan Senior Member

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    A new study (in Diagnostic Microbiology & Infectious Disease) by mainstream Lyme clinician/researcher Gary Wormser on Rituximab prescribed for RA, when the patient contracts Babesia. I thought it might be relevant as I recall a couple discussions on what might happen if ME/CFS patients were treated with Rituximab and had a TBD like Lyme.

    Persistence of babesiosis for >2 years in a patient on rituximab for rheumatoid arthritis

    John Raffalli, Gary P. Wormser
    [​IMG]
    DOI: http://dx.doi.org/10.1016/j.diagmicrobio.2016.02.016



    Highlights
    • •A patient with rheumatoid arthritis on rituximab developed Babesia microti infection.
    • •Babesiosis persisted for 26 months despite prolonged anti-babesia drug therapy.
    • •The case illustrates the detrimental effects of rituximab on clearance of babesiosis.
    • •The immunosuppressive effects of rituximab may last for ~18 months post-treatment.
    • •Patients on rituximab in babesia endemic areas should avoid deer tick bites.
    Abstract
    We report a patient who was being treated with rituximab for rheumatoid arthritis who developed Babesia microti infection that persisted for 26 months despite prolonged anti-babesia drug therapy. The explanation for the persistence was likely to have been the long-term immunocompromising effects of rituximab, as evidenced by seronegativity for B. microti antibodies that lasted for more than 1 year after onset of infection.


     
    Last edited: Apr 11, 2016
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  2. Antares in NYC

    Antares in NYC Senior Member

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    This may tell us that very specific subsets of CFS folks will not benefit from Rituximab, particularly those with an active infection, specially those TBD infections that cause immune suppression in the first place.

    For once I don't feel like throwing something at my computer screen at the mere mention of Wormser. Progress?
    :rolleyes:
     
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  3. deleder2k

    deleder2k Senior Member

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    The study says:

    I don't think can tell us anything about Rituximab response rates in persons with ME.
     
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  4. duncan

    duncan Senior Member

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    Nods.

    What it might suggest is that Rituximab used for an autoimmune disorder (RA), might be problematic if an infection is also at play.

    In this case, the infection was babesiosis, a tick-borne disease. Since some ME/CFS patients may bring a TBD to the party, embracing Rituximab may bring with it some added risks. Some forum members had wondered about that risk.
     
    Last edited: Apr 12, 2016
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  5. Gingergrrl

    Gingergrrl Senior Member

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    @duncan or anyone smarter than me... What would this mean if someone tried RTX for an autoimmune disease but had IgM+ antibodies for things like EBV, VZV, etc, but completely negative on all TBD. Am still trying to figure this one out!
     
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  6. duncan

    duncan Senior Member

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    The short answer is I don't know, @Gingergrrl. Hopefully, another member will offer some insight.

    But if it were me, I'd be concerned about any potential active infection since my understanding is rituximab depletes one's B cells, and I would be concerned about the implications to my body's ability to defend itself appropriately. If ANY infection is at a stage where IgM's are involved, my rudimentary handle on immune basics would suggest to me this is possibly an active infection since it hasn't even progressed to IgG's yet. Of course, could be false positives.

    Maybe I have all that wrong.
     
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  7. Gingergrrl

    Gingergrrl Senior Member

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    If the IgM+ are 2-3 years after the infection has passed (or in my case with VZV, it is more like 30 years!), then I assume they are false positives or immune system in chaos vs. an active infection?
     
  8. duncan

    duncan Senior Member

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    I don't know what the IgM thresholds are for VZV. I also don't know how reliable those stated thresholds are. I would want a doctor I trusted assuring me I was infection free.

    I will use Lyme as an example. The rule of thumb for a Lyme infection is first 60 or so days of being infected with Bb, you would show IgM's (after the first couple of weeks when you literally might not show anything since it's too soon). When infected, the CDC says you will test positive for two of three IgM bands. So if you only have, say, one IgM band positive, you don't have Lyme - or at least this is the general guideline. Two or three IgM's: Jackpot.

    If left untreated, or treated inadequately, you would move to IgG's. At this point, doctors when testing you - if they know anything about Lyme "rules" - will be looking for elevated IgG's, i.e. five or more published bands to determine whether you are positive for Lyme. Anything under five bands, no Lyme; five or more bands, you've Lyme.

    Only, the reality is some people test positive for IgM's month after month after month. Year after year. Some people test four bands IgG positive one year, seven bands IgG bands positive the next. Who has active Lyme? Depends on who you talk to.

    So, I cannot say whether you should chalk up your results to immune issues, or to an echo of an old infection, or a false positive, or to an active infection. I'd want to know, though, if I were considering Rituximab.
     
  9. Gingergrrl

    Gingergrrl Senior Member

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    My experience so far is that absolutely no two doctors agree on this issue. All non-ME/CFS doctors say that it all indicates prior infection or that my immune system is in hyper-drive cranking out antibodies to all kinds of viruses that are no longer there (like things from childhood like VZV and coxsackie, etc.) Whereas ME/CFS doctors will say it is a current or re-activation yet I took Famvir for eight months with no change in the IgM+ titers for EBV or VZV, etc, and the enteroviruses (one is 1:80 and other is 1:160) are below the threshold of active infection which is 1:320. It is just guesswork since literally no two doctors agree on the planet.

    The chances that I will do RTX are slim to none but was just curious what you thought and how these viruses related to the rules for RTX for Lyme and TBD's.
     
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  10. duncan

    duncan Senior Member

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    I have high sister titers, too. EBV, HHV-6, a bunch of both Coxsackie A and B, etc. It really does seem like our immune systems are on hyper-warp drive. It is in part because of this tendency that I keep a judicious and semi-skeptical eye on my Lyme and other TBD values.

    Just curious: Did you test for NK cell function, @Gingergrrl ? I am out-of-range low, and I understand many (but far from all) of us are.
     
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  11. Gingergrrl

    Gingergrrl Senior Member

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    Yes I have very low NK cell functioning. It was "5" in mid 2014 and then went up to "6" by end of 2014 and I have not tested it since but suspect it would still be around the same.
     
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  12. duncan

    duncan Senior Member

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    Yep. I was 5 in 2013. I also am low in a couple IgG subclasses.

    It gets too convoluted for me some days.
     
  13. Gingergrrl

    Gingergrrl Senior Member

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    So we are about the same NK function. I was normal in IgG subclasses in 2014 but in 2015, I was low in IgG subclass 3. It is very convoluted for me as well. Am willing to try treatments anyway if they are offered to me and I wish I knew which was the best one to fight for given my specific situation. It appears to be IVIG but am so unclear and don't want to make the wrong choice!
     
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  14. msf

    msf Senior Member

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    This is interesting, but it would be more interesting if it was the other way round, i.e. they were given Rituximab some time after getting babesiosis. All we can say from this is that it might not be a good idea to get bitten by a tick if you have been on Rituximab for several years.
     
    Last edited: Apr 19, 2016
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  15. duncan

    duncan Senior Member

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    I wonder how they knew when she contracted it since often people test negative for babesia antibodies even after having been infected. Perhaps she had an acute case.
     
    Last edited: Apr 19, 2016
  16. msf

    msf Senior Member

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    Well, the bit Delender quoted sounded fairly acute, but then I don´t know much about Babesiosis.
     
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