Infliximab does not activate replication of lymphotropic herpesviruses in patients with refractory rheumatoid arthritis
J. Torre-Cisneros,
M. del Castillo2,
J. J. Castón,
M. C. Castro1,
V. Pérez1 and
E. Collantes1
Section of Infectious Diseases and 1 Service of Rheumatology, Reina Sofía University Hospital, Córdoba and 2 Service of Hematology, Punta Europa Hospital, Algeciras (Cádiz), Spain.
Correspondence to: J. Torre-Cisneros, Sección de Enfermedades Infecciosas, Hospital Universitario Reina Sofía, Avda. Menéndez Pidal s/n, Córdoba E-14004, Spain. E-mail: julian.torre.sspa{at}juntadeandalucia.es
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Abstract
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Objective. The reactivation of human lymphotropic herpesviruses can be related to the intensity of immunosuppression. We analysed the risk of reactivation of lymphotropic herpesviruses in patients with refractory rheumatoid arthritis treated with an anti-tumour necrosis factor-
(TNF-
) agent (infliximab).
Methods. Fifteen patients were treated with infliximab (3 mg/kg) at weeks 0, 2 and 6. Samples of both plasma and peripheral blood mononuclear cells (PBMC) were obtained before treatment (week 0) and before each infusion at weeks 2 and 6. Samples were analysed using a multiplex qualitative polymerase chain reaction (PCR) for lymphotropic herpesviruses. Quantification of cytomegalovirus (CMV) viral load (copies/ml) was performed using quantitative PCR. Reactivation was defined as the presence of viral DNA in plasma. Latent infection was defined as the presence of viral DNA in PBMC samples but not in plasma.
Results. On baseline, latent CMV infection was detected in eight patients (53.3%), human herpesviruses-6 (HHV-6) in two (13.3%), EpsteinBarr virus (EBV) in seven (46.6%), CMV + HHV-6 in one (6.6%), CMV + EBV in two (13.3%) and HHV-6 + EBV in one (6.6%). Viral reactivation related to infliximab treatment was not observed. There was only one patient who had HHV-6 reactivation, but this was already detected in the baseline sample.
Conclusions. Infliximab treatment does not induce replication of human lymphotropic herpesviruses in patients with rheumatoid arthritis. Thus, herpesviruses prophylaxis would not be indicated in these patients.
KEY WORDS: Rheumatoid arthritis, Herpesviruses, Latent infection, CMV, Infliximab
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Introduction
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Infliximab is an immunosuppressive agent that targets tumour necrosis factor-
(TNF-
), a potent pro-inflammatory cytokine implicated in different inflammatory diseases, such as rheumatoid arthritis (RA) and Crohn's disease. Infliximab can reduce the cellular immune response, impairing the release of other pro-inflammatory cytokines [interleukin (IL)-1, IL-6 and IL-8] and the induction of programmed cell death (apoptosis) [14].
The efficacy of anti-TNF-
agents in the treatment of RA has been demonstrated in large-scale trials and represents an important tool in refractory cases [1, 2]. However, the efficacy can be limited by the appearance of infections related to the deterioration of cellular immunity, particularly tuberculosis [5, 6]. In addition, other opportunistic infections such as coccidiomycosis, histoplasmosis, listeriosis and Pneumocystis carinii pneumonia have been reported in patients treated with infliximab [1, 7, 8].
The risk of reactivation of lymphotropic herpesviruses [ß-herpesvirus: cytomegalovirus (CMV), human herpesvirus (HHV)-6 and HHV-7;
-herpesvirus: EpsteinBarr virus (EBV), HHV-8] in different conditions of immunosuppression has been clearly shown [911]. For this reason, our primary aim was to investigate the risk of reactivation of herpesviruses in patients with RA treated with infliximab to establish the need for prophylaxis when it is possible.
Informed consent was obtained from all patients. The institutional policy in biomedical research was applied in this study.
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Material and methods
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Patient population
We analysed a cohort of 15 patients with refractory forms of RA under treatment with infliximab (3 mg/kg body weight) at weeks 0, 2 and 6. Previously, they had received treatment with methotrexate (MTX) or leflunomide (except for contraindication and/or intolerance) and more than two disease-modifying anti-rheumatic drugs (DMARDs) without obtaining a response. In the month prior to the onset of the treatment with infliximab, no changes in medication took place. For this reason, 10 and 5 patients, respectively, received MTX and leflunomide therapy jointly with infliximab. Demographic data and the activity parameters of the disease were recorded in each control.
Clinical specimens
Samples of both plasma and peripheral blood mononuclear cells (PBMC) were obtained before the onset of the treatment with infliximab (baseline) and before each infusion at weeks 2 and 6.
Serology
IgG anti-CMV was measured by enzyme-linked immunosorbent assay (ELISA, DiaSorin P002033). The IgG anti-VCA of EBV was detected by enzyme-linked immunosorbent assay (ELISA, DiaSorin P001606). The IgG anti-HHV-6 and the IgG anti-HHV-8 were determined by an indirect immunofluorescent assay (Biotrin International Ltd, Ireland).
Qualitative multiplex PCR analysis of lymphotropic herpesvirus (CMV, HHV-6, HHV-7, HHV-8, EBV)
A multiplex nested PCR assay was used for the simultaneous detection of lymphotropic human herpesviruses in serum as previously described [12].
Definitions
Viral reactivation was defined as the presence of viral DNA in plasma. Latent infection was defined as the presence of viral DNA in PBMC but not in plasma.
Statistics
The quantitative variables were expressed as mean ± standard deviation. The variables which followed a normal distribution were analysed by analysis of the variance (ANOVA). For variables which did not follow a normal distribution, the Friedman test for overall comparisons was used. Finally, the Wilcoxon test was applied to compare the results for each week with regard to the baseline. P values of <0.05 were considered statistically significant.
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Results
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The main characteristics of the 15 patients as well as their treatments are summarized in Table 1. Thirteen patients (86.6%) were female, with a mean age of 52 yr (range 3171 yr). The mean duration of RA was 12 yr (range 527 yr), 66.7% having seropositive forms. After 6 weeks of infliximab therapy, a significant improvement in C reactive protein (43.1±35.6 mg/l vs 15.8±14.7 mg/l; P<0.001) and in DAS28 score (5.9±1 vs 3.7±1; P<0.001) was observed.
The viral studies are summarized in Table 2. In the initial evaluation, latent CMV infection was detected in eight patients (53.3%), latent HHV-6 infection in two (13.3%), latent EBV infection in seven (46.6%), latent CMV + HHV-6 co-infection in one (6.6%), latent CMV + EBV co-infection in two (13.3%) and latent HHV-6 + EBV co-infection in one (6.6%). Although latent infection was detected at baseline in some patients, none of them developed viral reactivation after the onset of infliximab. At week 6, there was only one case of viral reactivation which corresponded to HHV-6. This reactivation was already present in the baseline sample.
None of patients developed viral disease during the 6 months after therapy with infliximab.
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Discussion
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Infliximab therapy can be considered as a new model of immunosuppression, similar to solid organ transplantation, bone marrow transplantation and human immunodeficiency virus (HIV) infection. It is well known that in all those situations the intense immunosuppression may induce viral reactivation [9, 13, 14]. Reactivation of ß-herpesviruses, especially CMV, has been shown in all these models of immunosuppression. Moreover, the reactivation of CMV could activate the replication of latent EBV, HHV-6, HHV-7 and HHV-8 infections, leading to the development of post-transplant lymphoproliferative disease and Kaposi's sarcoma [15].
Thus, the main goal of our study was to evaluate the risk of viral reactivation related to the use of infliximab. Our results show that none of the patients developed reactivation of herpesviruses after infliximab therapy, even when they had latent infection before treatment. Only one case of reactivation of HHV-6 was detected, which already appeared at baseline. Symptoms due to HHV-6 disease were not developed after 6 months of follow-up.
The high incidence of latent infection by herpesviruses (86.7%) could be explained by a high state of net immunosuppression related to the rheumatoid arthritis together with previous treatments (such as steroids or methotrexate). The absence of viral reactivation in this study can be explained by a relative preservation of the immune response against herpesvirus compared with other models such as organ transplantation or advanced HIV infection.
A limitation of the study is the relatively short period of treatment and follow-up. However, the immune deterioration induced by immunosuppressive drugs is rapid after treatment. In some cases, such as with OKT3 treatment, viral reactivation can be documented a few hours after the first dose. The longer periods of follow-up are only needed in other models of immunosuppression, such as HIV infection, in which the cellular immune response progressively deteriorates.
In conclusion, we consider that prophylaxis of latent infection by lymphotropic herpesviruses such as CMV does not appear to be necessary before infliximab therapy in patients with RA. This recommendation is based on the absence of viral reactivation after infliximab therapy. Further studies with larger numbers of patients and longer follow-up will be needed to confirm these results.
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Acknowledgments
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The authors would like to thank Ester Sanchez for her assistance in preparation of this manuscript.
The authors have declared no conflicts of interest.
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Submitted 6 January 2005;
revised version accepted 29 April 2005.