Improvement of hemoglobin levels after a switch from intravenous to subcutaneous administration of immunoglobulin in chronic inflammatory demyelinating polyneuropathy and multifocal motor neuropathy.

BACKGROUND: Intravenous immunoglobulin (IVIG) is recommended treatment for chronic inflammatory demyelinating polyneuropathy (CIDP) and multifocal motor neuropathy (MMN). Recent studies have demonstrated that subcutaneous immunoglobulin (SCIG) is feasible, safe, and effective in both disorders. IVIG leads to transient hemolysis and, consequently, we hypothesized that frequent small doses of SCIG exerts less hemolytic activity than a few larger doses of IVIG. STUDY DESIGN AND METHODS: In an open-label study, 23 three patients treated with IVIG for CIDP or MMN were switched to SCIG at an equal dosage. IVIG was administered two to three times for 6 weeks. Two weeks after the last IVIG infusion at Week 8, SCIG was initiated with injections twice or thrice weekly until Week 20. Blood samples were drawn 2 weeks after IVIG at Weeks 2 and 8 and during SCIG at Weeks 14 and 20 determining hemoglobin (Hb) and hemolytic variables. RESULTS: Seventeen patients completed the study. At enrollment, the Hb level was 138 ± 12 g/L, haptoglobin level was 1.4 ± 0.5 g/L, reticulocyte count was 58.7 × 109  ± 21.3 × 109 /L, and bilirubin level was 6.6 ± 2.3 µmol/L. The average of the two blood samples drawn at comparable intervals during IVIG and SCIG showed that Hb increased from 135 ± 15 to 138 ± 15 g/L (p = 0.03). During IVIG the hemolytic variables showed signs of mild hemolysis that improved during SCIG, haptoglobin increasing from 1.2 ± 0.5 to 1.5 ± 0.6 g/L (p = 0.002), reticulocytes decreasing from 71.9 × 109  ± 35.8 × 109 to 54.5 × 109  ± 16.3 × 109 /L (p = 0.02), and bilirubin decreasing from 7.3 ± 2.8 to 5.8 ± 1.8 µmol/L (p = 0.001). CONCLUSION: A switch from IVIG to SCIG was associated with a slight increase of Hb levels and an improvement of laboratory variables related to hemolytic activity.

[Acute kidney injury secondary to the first intravenous administration of acyclovir].

Acute kidney injury secondary to precipitation of acyclovir crystals in the kidneys is well known and mainly observed in the setting of dehydration or pre-existing renal impairment. We describe a case of acute kidney injury secondary to intravenous administration of acyclovir in a 64-year-old female with trans-versal myelitis and no prior medical history. She developed a rapid rise in the plasma creatinine level only seven hours after the primary drug administration. Acyclovir was discontinued and a urinary flow rate was maintained at 100-200 ml/h with IV fluids. The kidney function returned to normal within five days.

[Exfoliative dermatitis as a side effect of intravenous immunoglobulin treatment]. / Eksfoliativ dermatitis som bivirkning til behandling med intravenøs højdosisimmunglobulin.

Three patients with immune-mediated polyneuropathies developed rash, eczema, whole body scaling, vesicles in hands and loss of hair a few days after infusion of large doses of intravenous immunoglobulin (IVIG). The condition was diagnosed as exfoliative dermatitis. Two out of three patients were afterwards treated with low doses of IVIG slowly increased over a year given under the protection of oral steroids. Our findings indicate that exfoliative dermatitis can be provoked by IVIG treatment, and that the treatment can be reinstalled by slowly increasing the IVIG dose under steroid cover.

[Haemolytic anaemia as a complication to intravenous infusion of human immunoglobulin]. / Hæmolytisk anæmi som komplikation til intravenøs indgift af humant immunglobulin.

A 85-year-old female treated for chronic inflammatory demyelinating polyradiculoneuropathy had three episodes of anaemia one week following treatment with large doses (2g/kg body weight) of immunoglobulin (Ig). At the final episode, she presented with haemolytic anaemia with fatigue, jaundice and loss of appetite. During the next two months anaemia was recognized in two additional cases. Subsequently, a series of twelve conseuntively studied IVIg treated patients showed a significant decrease of haemoglobin of 0.80 mmol/l 8-15 days after infusion. Haemolytic anaemia is a severe side effect that seems to be more frequent than previously recognized. It may possibly be prevented by the use of lyophilized Ig-preparations with low isohaemagglutinin titers or by slower Ig infusion rates.