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\begin{document}

\title{T CELL-MEDIATED HYPERSENSITIVITY TO LUMACAFTOR AND IVACAFTOR IN CYSTIC
FIBROSIS}



\author[1]{Aida Semic-Jusufagic}%
\author[2]{Monday Ogese}%
\author[1]{Christopher Edwards}%
\author[1]{Mark Wilkinson}%
\author[1]{Claire Nissenbaum}%
\author[1]{Tim Lee}%
\author[2]{Pirmohamed Munir}%
\author[2]{Dean Naisbitt}%
\affil[1]{Leeds Teaching Hospitals NHS Trust}%
\affil[2]{University of Liverpool}%


\vspace{-1em}



  
  \date{June 18, 2024}


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\selectlanguage{english}
\begin{abstract}
We describe a case of Drug Reaction with Eosinophilia and Systemic
Symptoms (DRESS) to multiple CFTR modulators and piperacillin in an 8
year old female with CF. To our knowledge this is the first reported
case of delayed type, T-cell mediated hypersensitivity to multiple CFTR
modulators described in literature. Our findings suggest possible
cross-reactivity between CFTR modulators or multiple sensitisations,
which should be taken into account in similar cases.%
\end{abstract}%



\sloppy


\textbf{T CELL-MEDIATED HYPERSENSITIVITY TO LUMACAFTOR AND IVACAFTOR IN
CYSTIC FIBROSIS}

Clinical Letter

Word Count: 1097

\emph{To the Editor,}

Cystic fibrosis (CF) is a serious genetic condition affecting the
respiratory and digestive systems impacting life
expectancy\textsuperscript{1}. Patients with CF often require frequent
high dose antibiotics associated with cutaneous hypersensitivity in
30-50\% of patients \textsuperscript{2}. The discovery of CFTR
modulators has transformed CF treatment. These drugs tackle the
underlying cause of the disease and prevent misfolding and proteasomal
degradation of the CFTR protein \textsuperscript{3}. Hypersensitivity to
these novel drugs is a concern because it can prevent access to these
transformative medications. We have recently reported a case of
delayed-type T cell-mediated hypersensitivity to lumacaftor two weeks
after a patient was treated with the combination of ivacaftor and
lumacaftor\textsuperscript{4}.

Herein, we describe a case of Drug Reaction with Eosinophilia and
Systemic Symptoms (DRESS) to multiple CFTR modulators and piperacillin
in an 8 year old female with CF. The patient was started on the daily
fixed dose combination of ivacaftor/lumacaftor (Orkambi) midway through
a two-week course of home intravenous (IV) antibiotics
(piperacillin/tazobactam and tobramycin). She was also taking
prophylactic flucloxacillin and a 4 week course of ciprofloxacin. Three
days after the IV antibiotics were completed, and 9 days after the
ivacaftor/lumacaftor had been commenced, the patient presented to
hospital with a temperature up to 41\selectlanguage{ngerman}°C and rapidly evolving mildly
pruritic, polymorphic rash (initially maculopapular then more purpuric)
starting from upper chest and spreading to face, trunk and limbs (figure
1A). She had prominent facial erythema, non-purulent conjunctivitis and
complained of sore throat, malaise and vomiting. Following transfer to
the CF centre, she had two further doses of piperacillin/tazobactam.
Each time piperacillin/tazobactam was administered, her parents noted
that patient's rash became more prominent. On the second day she
developed prominent midfacial oedema. All the drugs were discontinued
and she was started on IV meropenem and clindamycin. The blood tests
revealed raised C-reactive protein (277 mg/L), lymphopenia (0.45
x10\textsuperscript{9}/L), leukopenia, eosinophilia (0.77 x
10\textsuperscript{9}/L), thrombocytopenia (110
x10\textsuperscript{9}/L) and deranged liver function tests (ALT: 99
iu/L and albumin: 19 g/L). The patient also had a significant drop in
phosphate and magnesium levels which required replacement. The tests
conducted to exclude infectious causes (throat swab, blood cultures,
Streptolysin O antibody titre, PCR for meningococcal, pneumococcal,
enterovirus, paraechovirus, EBV, CMV and adenovirus, IgM to EBV and CMV)
were all negative. Symptoms started resolving after 6 days with
generalised desquamation of skin prominent on her face, palms and feet
(figure 1B) which resolved on day 8. A year before the index reaction,
she had suffered from anaphylaxis after administration of ceftazidime.
At the time of assessment, patient was on prophylactic daily dose of
flucloxacillin, which ruled it out as potential culprit. Further
allergological work up included skin prick testing (SPT) with
standardised dilutions of piperacillin/tazobactam (4.5mg/ml),
ciprofloxacin (2mg/ml), ceftazidime (2mg/ml), cefuroxime (2mg/ml),
ceftriaxone (2mg/ml) and cefotaxime (2mg/ml) and non-standardised
dilution of ivacaftor/lumacaftor (crushed and diluted in 5ml of water
for injection), all of which revealed negative results. Further
intradermal testing (IDT) with standardised dilutions of ceftazidime
(1/10) and piperacillin/tazobactam (1/10) was negative on immediate
reading after 20 minutes. However, the patient experienced delayed weal
and flare reaction to SPT with ivacaftor/lumacaftor 24 hours later with
a further increase at 72 hours (figure 1C) and positive IDT test to
piperacillin/tazobactam after 24 hours (figure 1D). Patch testing with
ivacaftor/lumacaftor was 1+ positive on days 2 and 4 and negative in
control subjects. The results were negative to piperacillin/tazobactam
and ciprofloxacin.

We further assessed patient's \emph{in vitro} drug specific T cell
responses using LTT and IFN-\selectlanguage{greek}γ \selectlanguage{english}ELIspot. PBMC were isolated from patient's
blood by density centrifugation using Lymphoprep (Alere Technologies AS,
Oslo, Norway) from a sample provided 9 months after the index reaction.
In the \emph{in vitro} assays, PBMC proliferated in the presence of
lumacaftor and secreted high levels of IFN-\selectlanguage{greek}γ \selectlanguage{english}(figure 1E and G).
Ivacaftor did not activate the patient's T-cells. Lower levels of PBMC
proliferation and IFN-\selectlanguage{greek}γ \selectlanguage{english}secretion were also detected with piperacillin
(figure 1F and H). The chemical structure of lumacaftor differs from
piperacillin (figure 1 I and K), hence it is plausible that the observed
T-cell responses is not due to cross-reactivity but is a result of a
primary T-cell response to the individual drugs.

A year after the original reaction to lumacaftor, the patient was
admitted for observed administration of tezacaftor/ivacaftor (Symkevi).
Unfortunately, 7 hours after her first dose she started developing
erythroderma spreading from chest to face and limbs, temperature up to
40\selectlanguage{ngerman}°C, headache, sore throat, malaise, abdominal pain and cough. She was
treated with IV hydrocortisone, followed by daily 1mg/kg oral
prednisolone and was started on IVs meropenem. Her temperature dropped
after 48 hours and the rash started resolving after 72 hours without
desquamation. Laboratory investigations confirmed raised CRP (97 mg/L),
eosinophilia (1.40 x10\textsuperscript{9}/L), lymphopenia (0.32
x10\textsuperscript{9}/L) and deranged liver function tests (ALT 513
iu/L, total bilirubin 34 \selectlanguage{greek}µ\selectlanguage{english}mol/L, albumin 26 g/L). Further patch testing
to tezacaftor/ivacaftor and ivacaftor (Kalydeco) separately using 30\%
dilution in soft paraffin was positive to both at day 2 and day 4
(figure 1E) suggesting reactivity to ivacaftor, showing the value of
patch testing in diagnosis of CFTR induced T-cell mediated cutaneous
adverse drug reactions. Assessment of T cell responses using LTT and
IFN-\selectlanguage{greek}γ \selectlanguage{english}ELIspot to tezacaftor and ivacaftor failed to demonstrate
significant PBMC proliferation. This has demonstrated that the patient
developed hypersensitivity to lumacaftor first and subsequently to
ivacaftor. The discrepancy between lumacaftor and ivacaftor \emph{in
vitro} T-cell responses is somewhat confusing, but may relate to the
known extensive metabolism of ivacaftor. It is possible that T-cell
stimulatory ivacaftor metabolites are not formed in immune cell culture.
Thus, further experiments are ongoing to incorporate a CYP3A4
metabolising system into the LTT.

To our knowledge this is the first reported case of delayed type, T-cell
mediated hypersensitivity to multiple CFTR modulators described in
literature. Our findings suggest possible cross-reactivity between CFTR
modulators or multiple sensitisations, which should be taken into
account in similar cases.

Given the significant improvement in CF symptoms experienced by patients
receiving the CFTR modulators, it is important to continuously monitor
the safety profile of these novel drugs. Hypersensitivity to any or all
of the components of CFTR modulator combinations will restrict the use
of these life-transforming disease-modifying treatments. Although
desensitisation treatment was considered, given the severity and the
nature of the reaction this was not deemed suitable due to the risk of
triggering potentially life threatening severe cutaneous adverse
reaction.

A careful assessment of the patients' medication history\emph{, in
vivo}tests and \emph{in vitro} T-cell diagnostic assays is important for
identifying the particular culprit drug(s). Accurate identification of
the culprit will ensure personalised patient therapy without withholding
effective treatment.

Aida Semic-Jusufagic, MD, Ph.D\textsuperscript{1, \#}

Monday O Ogese, Ph.D\textsuperscript{2\#}

Christopher Edwards, MD\textsuperscript{3}

Mark Wilkinson, MD\textsuperscript{4}

Claire Nissenbaum, MD\textsuperscript{3}

Tim Lee, MD, Ph.D\textsuperscript{3}

Munir Pirmohamed, MD, Ph.D\textsuperscript{2}

Dean J Naisbitt. PhD\textsuperscript{2}

\textsuperscript{1} Paediatric Allergy, Leeds Children's Hospital, Leeds
Teaching Hospitals NHS Trust, Leeds, UK.

\textsuperscript{2}MRC Centre for Drug Safety Science, Department of
Pharmacology and Therapeutics, Institute of Systems, Molecular and
Integrative Biology, University of Liverpool, Liverpool, UK.

\textsuperscript{3} Cystic Fibrosis Centre, Leeds Children's Hospital,
Leeds Teaching Hospitals NHS Trust, Leeds, UK.

\textsuperscript{4} Dermatology Department, Chapel Allerton Hospital,
Leeds Teaching Hospitals NHS Trust, Leeds, UK.

\textsuperscript{\#}ASJ and MOO contributed equally to this work.

\textbf{Correspondence:} Dr Aida Semic-Jusufagic

Paediatric Allergy, E floor, Martin Wing, Leeds General Infirmary,
Leeds, UK, LS1 3EX.

\textbf{Telephone:} +44113 392 2441\textbf{; Email: aida.semic@nhs.net}

\textbf{Funding information:} The work was conducted with funding from a
BBSRC/GSK Industrial Partnership award (Grant Number BB/R008108/1). The
project also received core funding from the MRC Centre for Drug Safety
Science (Grant Number G0700654).

\textbf{Conflict of interest statement:} the authors have no conflict to
declare.

\textbf{Acknowledgements:} The authors would like to thank the patient
and her parents for their consent to publish these important findings.

\textbf{Keywords:} Cystic fibrosis transmembrane regulator (CFTR);
cystic fibrosis (CF), lymphocyte transformation test, interferon-gamma
ELIspot, Drug related eosinophilia with systemic symptoms (DRESS).



\textbf{Reference}

1. Boucher RC. New concepts of the pathogenesis of cystic fibrosis lung
disease. The European respiratory journal. 2004; \textbf{23} (1):
146-58.

2. Parmar JS, Nasser S. Antibiotic allergy in cystic fibrosis. Thorax.
2005; \textbf{60} (6): 517-20.

3. Molinski S, Eckford PD, Pasyk S, Ahmadi S, Chin S, Bear CE.
Functional Rescue of F508del-CFTR Using Small Molecule Correctors.
Frontiers in pharmacology. 2012; \textbf{3} : 160.

4. Roehmel JF, Ogese MO, Rohrbach A, Mall MA, Naisbitt DJ. Drug allergy
to CFTR modulator therapy associated with lumacaftor-specific CD4(+) T
lymphocytes. The Journal of allergy and clinical immunology.
2021;\textbf{147} (2): 753-6.

\textbf{Figure legend}

\textbf{Figure 1} . \textbf{A.} Targetoid eruption suggestive of
erythema multiforme (day 1). \textbf{B.} Toxic desquamation (day 6).
\textbf{C.}SPT-delayed reaction to ivacaftor/lumacaftor (72 hours).
\textbf{D.}IDT-delayed reaction to piperacillin/tazobactam (Tazocin)
after 24 hours. \textbf{E.} Positive patch test at 48 hours to
tezacaftor/ivacaftor (top) and ivacaftor (bottom) \textbf{F \&G.} LTT.
PBMC were cultured with drugs for 7 days. T-cell proliferation assessed
using thymidine incorporation and beta-counter.
\textbf{H\&I.}Interferon-\selectlanguage{greek}γ \selectlanguage{english}secretion assessed by ELISpot. \textbf{J-M.}
Chemical structures of drugs.



\textbf{Figure 1.}

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