Letter to the Editor
Vaccination of patients with non-Hodgkin lymphoma under rituximab or other immunosuppressive drugs
Vacunación en el paciente con linfoma no hodgkiniano en tratamiento con rituximab u otros fármacos inmunodepresores
a Servicio de Medicina Preventiva, Calidad y Seguridad del paciente, Gerencia de Atención Especializada Áreas III y IV, Hospital de Sierrallana, Torrelavega, Cantabria, Spain
b Servicio de Medicina Preventiva, Hospital Obispo Polanco, Teruel, Spain
c Servicio de Hematología y Hemoterapia, Hospital San Jorge, Huesca, Spain
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"cabecera" => "<span class="elsevierStyleTextfn">Letter to the Editor</span>" "titulo" => "Vaccination of patients with non-Hodgkin lymphoma under rituximab or other immunosuppressive drugs" "tieneTextoCompleto" => true "saludo" => "Dear Editor," "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "43" "paginaFinal" => "44" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Juan Rodríguez-García, Rafael Fernández-Santos, José Antonio García-Erce" "autores" => array:3 [ 0 => array:4 [ "nombre" => "Juan" "apellidos" => "Rodríguez-García" "email" => array:1 [ 0 => "juan.rodriguez@scsalud.es" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Rafael" "apellidos" => "Fernández-Santos" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "José Antonio" "apellidos" => "García-Erce" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Servicio de Medicina Preventiva, Calidad y Seguridad del paciente, Gerencia de Atención Especializada Áreas III y IV, Hospital de Sierrallana, Torrelavega, Cantabria, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Medicina Preventiva, Hospital Obispo Polanco, Teruel, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Servicio de Hematología y Hemoterapia, Hospital San Jorge, Huesca, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Vacunación en el paciente con linfoma no hodgkiniano en tratamiento con rituximab u otros fármacos inmunodepresores" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Although pneumococcal vaccination is strongly recommended for patients who are immunosuppressed or patients with other high-risk medical conditions, this important procedure is not commonly used in daily clinical practice.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> In addition, since 2013, all adult immunosuppressed patients in our country should receive the pneumococcal conjugate vaccine, among others.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> We report the case of a patient diagnosed with non-Hodgkin's lymphoma (NHL) with other associated risk factors for invasive pneumococcal disease (IPD) who received several cycles of combination chemotherapy.</p><p id="par0010" class="elsevierStylePara elsevierViewall">52-year-old male patient diagnosed with nasopharyngeal BALT NHL in 1999. He also had severe chronic obstructive pulmonary disease, rheumatoid arthritis, diabetes mellitus type 2 and moderate chronic renal failure. He received 3 cycles of rituximab, cyclophosphamide, doxorubicin, vincristine and prednisone (R-CHOP) every 2 months, achieving the complete metabolic remission in 2004. In 2006 he was diagnosed with gastric MALT NHL, so 6 cycles of R-CHOP were scheduled. In 2010 he showed haematological relapse, which was subjected to another dosage schedule of 6 cycles of R-CHOP. 7 days after completing the last cycle, he developed pneumonia, requiring hospitalization. At 24 days of discharge, he was readmitted due to a pneumonic process relapse. Maintenance treatment with rituximab 375<span class="elsevierStyleHsp" style=""></span>mg/m<span class="elsevierStyleSup">2</span> every 2 months was started, for a 2-year period. Again, in July 2011, the patient developed pneumonia, finding <span class="elsevierStyleItalic">Haemophilus influenzae</span> type b (Hib) in sputum during admission. In August 2011, an anti-pneumococcal polysaccharide 23-valent vaccine was administered, but in October, 48 days after receiving the vaccine, a new pneumonic condition required hospitalization. <span class="elsevierStyleItalic">Streptococcus pneumoniae</span> was isolated in blood cultures. Conjugate vaccines against Hib and meningococcal C were administered in November. At 34 days of discharge, he was readmitted with a diagnosis of pneumonia, developing nephrotic syndrome during hospitalization, which was considered secondary to pneumococcal infection. In March 2013 he received a dose of Prevenar-13. The patient was given an appointment for November 2014, for a comprehensive examination. His consent was requested and it became clear that there were no more infectious or pneumonic conditions, neither moderate nor severe, during the 3 years after the last admission.</p><p id="par0015" class="elsevierStylePara elsevierViewall">In reviewing the case, some key elements in the patient's treatment regarding prevention through vaccination called our attention. These relate to at least 2 of the episodes of severe pneumonia requiring hospitalization. The patient was not vaccinated against pneumococcus or other encapsulated bacteria after initial diagnosis of hematologic malignancy despite its comorbidity, neither was he when the need to use immunosuppressive therapy arose or after it was completed, nor after the first episodes of severe pneumonia which required hospitalization.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Adults with one or more IPD risk conditions are 7.4 times more likely to develop the disease than healthy subjects, and those with 2 or more, the risk is multiplied by 9.6.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> In this case, the risk of infection in patients treated with anti-CD20 is added to the increased risk associated with the patient diagnosis and comorbidity, which is related to the number and time interval between cycles, favouring a defect in humoral and cell immunity.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a> The effect of treatment with rituximab alone or in combination chemotherapy has been studied in patients with NHL and other haematological malignancies, observing an increased risk of leukopenia, hypogammaglobulinemia and serious infections, frequently including pneumonia and flu conditions.<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">4–6</span></a> However, coverage against preventable diseases through more frequent vaccination in these patients, such as influenza and pneumococcal disease, remain low in patients under 65 years of age, with 32% and 19.1%, respectively.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> One of the main reasons given for non-vaccination of immunosuppressed patients is the lack of response, however, some studies have shown a response to the unconjugated polysaccharide vaccine of up to 45.4% in patients with NHL who had been splenectomized.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> In addition, the new 13-valent conjugate vaccine is more immunogenic than the polysaccharide and is highly effective in preventing IPD caused by the 13 serotypes,<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a> in fact, its administration has shown good immunogenicity in patients with NHL, multiple myeloma or amyloidosis undergoing bone marrow transplant, reaching protective titres in 78% of patients compared with 61% when the unconjugated polysaccharide vaccine was used.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a> Despite this, vaccine failures are possible, especially when the preparation is administered during the period in which the patient's immune system remains impaired, therefore, in these cases, revaccination is recommended at 3–6 months after the completion of the immunosuppressive therapy.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Although the risk of invasive disease and its complications is lower, in addition to updating the patient's immunization schedule, we must not forget influenza vaccination at the start of the season and vaccination against other bacteria capped as Hib and meningococcus -covering at least the type C and B in our environment-, preferably at diagnosis or at least 15 days before the start of the cycles of treatment with immunosuppressive drugs, whenever possible.<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">8,10</span></a></p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Rodríguez-García J, Fernández-Santos R, García-Erce JA. Vacunación en el paciente con linfoma no hodgkiniano en tratamiento con rituximab u otros fármacos inmunodepresores. Med Clin (Barc). 2016;146:43–44.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0055" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Improving influenza, pneumococcal polysaccharide, and hepatitis B vaccination coverage among adults aged <65 years at high risk: a report on recommendations of the Task Force on Community Preventive Services" "autores" => array:1 [ 0 => array:3 [ "colaboracion" => "Task Force on Community Preventive Services" "etal" => false "autores" => array:4 [ 0 => "B.C. Willis" 1 => "S.M. Ndiaye" 2 => "D.P. Hopkins" 3 => "A. 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