IVIG: an ally against fever in ALL?

#Leukemia  #ALL  #cancer  #oncology  #pediatrics  #prophylaxis  #immunoglobulin  #fever


Acute lymphoblastic laukemia (ALL) is the most common pediatric cancer. Despite therapeutic advances, infections remain a major cause of complications and mortality. Approximately 20% of deaths related to pediatric hematologic cancer treatment are due to infections, accounting for more than half of non-disease-related deaths.

Intensive treatments, such as chemotherapy, weaken the immune system, leading to a decrease in immunoglobulins (IgG) and B lymphocytes, both essential for infection defense. This immune deficiency exposes children to frequent infections, often accompanied by fever requiring hospitalization. These repeated hospitalizations can interrupt chemotherapy, increasing the risk of relapse.

Prophylaxis with intravenous immunoglobulins (IVIG), successfully used in patients with primary immunodeficiencies, could be a solution to reduce the risk of infections in children with ALL. However, the efficacy and relevance of such an approach in this population remain uncertain, particularly due to the potential risk of side effects.

This study evaluates the impact of IVIG prophylaxis on reducing hospitalizations for fever, antibiotic use, and treatment interruptions in children with intermediate-risk ALL.

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IVIG: An Effective Shield Against Infections?

A total of 177 children with intermediate-risk ALL were included and randomly assigned to two groups:

• One group receiving IVIG prophylaxis (0.7 g/kg every 3 weeks, starting on day 22 after diagnosis);
• A control group receiving standard care.

The impact of this prophylaxis was measured by analyzing the following outcomes: the number of hospitalizations for fever, antibiotic use, and chemotherapy adjustments due to infections.

Children who received IVIG had fewer hospitalizations for fever (206 vs. 271, p = 0.011), with a particularly marked reduction during the maintenance phase (100 vs. 166, p < 0.001). Admissions for fever with negative blood cultures, often associated with viral infections, were also less frequent (113 vs. 200, p < 0.001). These patients required fewer antibiotic treatments (78 vs. 137, p < 0.001) and fewer chemotherapy adjustments (72 vs. 134, p < 0.001).

However, IVIG prophylaxis had no significant impact on relapse rates, disease-free survival, or overall survival. Its main benefit lies in reducing infections and improving treatment tolerance.

Fewer Hospitalizations, but a Limited Overall Benefit?

Acute lymphoblastic leukemia is the most common pediatric cancer. Its treatment, based on intensive chemotherapy, weakens the immune system and increases the risk of infections, which account for a significant share of complications and hospitalizations.

Infections, besides being potentially severe, can disrupt the chemotherapy protocol, increasing the risk of relapse. Currently, strategies to reduce these infections remain limited. IVIG prophylaxis could be a promising therapeutic avenue.

This study aimed to assess whether prophylactic IVIG administration could reduce the number of hospitalizations for fever, limit antibiotic use, and prevent chemotherapy interruptions in children with intermediate-risk ALL.

The results show that IVIG significantly reduces hospitalizations for fever, particularly during the maintenance phase. Antibiotic use and treatment interruptions are also reduced. However, IVIG did not improve survival rates or reduce the risk of relapse.

Further research will help identify which patients could benefit most from IVIG. The increased risk of thrombosis observed must be evaluated before considering widespread prophylaxis. Future studies should focus on children most vulnerable to infections, particularly those with immune deficiencies, to optimize IVIG use and tailor it to high-risk profiles.

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