751
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Liang J, Alfano DN, Squires JE, Riley MM, Parks WT, Kofler J, El-Gharbawy A, Madan-Kheterpal S, Acquaro R, Picarsic J. Novel NLRC4 Mutation Causes a Syndrome of Perinatal Autoinflammation With Hemophagocytic Lymphohistiocytosis, Hepatosplenomegaly, Fetal Thrombotic Vasculopathy, and Congenital Anemia and Ascites. Pediatr Dev Pathol 2017; 20:498-505. [PMID: 28403691 DOI: 10.1177/1093526616686890] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Autoinflammatory diseases are caused by pathologic activation of the innate immune system. Primary hemophagocytic lymphohistiocytosis (HLH) is an aggressive syndrome of excessive immune activation caused by monogenic mutations resulting in cytotoxic cell defects and subsequent failure to eliminate activated macrophages. Secondary HLH is often diagnosed in cases without a known Mendelian inheritance. However, some cases of "secondary" HLH have been shown to harbor mutations with partial dysfunction of the cytotoxic system. Recently, macrophage intrinsic abnormalities caused by NLRC4 inflammasome mutations have been linked to autoinflammation and recurrent macrophage activation syndromes resembling a primary HLH. We report a case of a former 28-week preterm infant with congenital anemia, ascites, and a heavy edematous placenta with fetal thrombotic vasculopathy, who developed hepatosplenomegaly and unexplained systemic inflammation with laboratory features of HLH in the early postnatal course and died at 2 months of age. Postmortem examination confirmed the hepatosplenomegaly with marked sinusoidal hemophagocytosis, along with striking hemophagocytosis in the bone marrow and lymph nodes. There was extensive acute and chronic ischemic bowel disease with matted bowel loops, fibrous adhesions, and patchy necrotizing enterocolitis features. Whole exome sequencing analysis demonstrated a novel mosaic heterozygous NLRC4 512 C> T (p.Ser171Phe) de novo mutation predicated to cause a dominant, gain-of-function mutation resulting in a constitutively active protein. The assembly of NLRC4-containing inflammasomes via an induced self-propagation mechanism likely enables a perpetuating process of systemic macrophage activation, presumed to be initiated in utero in this patient.
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Affiliation(s)
- Jiancong Liang
- 1 Department of Pathology, Children's Hospital of Pittsburgh of UPMC, University of Pittsburgh School of Medicine, Pennsylvania.,2 Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Tennessee
| | - Danielle N Alfano
- 3 Department of Pediatrics, Children's Hospital of Pittsburgh of UPMC, Pennsylvania
| | - James E Squires
- 3 Department of Pediatrics, Children's Hospital of Pittsburgh of UPMC, Pennsylvania
| | - Melissa M Riley
- 3 Department of Pediatrics, Children's Hospital of Pittsburgh of UPMC, Pennsylvania
| | - W Tony Parks
- 4 Department of Pathology, Dartmouth-Hitchcock Medical Center, New Hampshire
| | - Julia Kofler
- 5 University of Pittsburgh School of Medicine, Pennsylvania
| | - Areeg El-Gharbawy
- 6 Department of Pediatrics-Medical Genetics, Children's Hospital of Pittsburgh of UPMC, University of Pittsburgh School of Medicine, Pennsylvania
| | - Suneeta Madan-Kheterpal
- 6 Department of Pediatrics-Medical Genetics, Children's Hospital of Pittsburgh of UPMC, University of Pittsburgh School of Medicine, Pennsylvania
| | - Roxanne Acquaro
- 6 Department of Pediatrics-Medical Genetics, Children's Hospital of Pittsburgh of UPMC, University of Pittsburgh School of Medicine, Pennsylvania
| | - Jennifer Picarsic
- 1 Department of Pathology, Children's Hospital of Pittsburgh of UPMC, University of Pittsburgh School of Medicine, Pennsylvania
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752
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He M, Jia J, Zhang J, Beejadhursing R, Mwamaka Sharifu L, Yu J, Wang S, Feng L. Pregnancy-associated hemophagocytic lymphohistiocytosis secondary to NK/T cells lymphoma: A case report and literature review. Medicine (Baltimore) 2017; 96:e8628. [PMID: 29381934 PMCID: PMC5708933 DOI: 10.1097/md.0000000000008628] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
RATIONALE Hemophagocytic lymphohistiocytosis (HLH) occurs primarily in pediatric population, or secondary to malignancy, infection, or autoimmune disease. This disease is rare and prognosis is generally poor. Only a small number of cases during pregnancy have been reported in literature. PATIENT CONCERNS We report a case of pregnancy-associated HLH secondary to natural killer (NK)/T cells lymphoma. She was admitted at 30 weeks and 3 days of pregnancy with complaints of abdominal pain and fever as high as 39.2°C. The patient was found to have splenomegaly, pancytopenia, and acute hepatic failure. DIAGNOSES A subsequent bone marrow biopsy revealed focal hemophagocytosis and atypical lymphoid cells. The splenic pulp also contained a large number of tissue cells proliferating and devouring mature red blood cells, lymphocytes, and cell debris. On the basis of these findings, we diagnosed the case as pregnancy-associated hemophagocytic lymphohistiocytosis secondary to NK/T cells lymphoma. INTERVENTIONS Treatment consisted with dexamethasone and etoposide in combination with rituximab. OUTCOMES Due to timely termination of pregnancy, the neonate was in good condition. However, the patient died on the 18th day postoperation due to multiorgan failure. LESSONS We recommend that HLH be considered as differential diagnosis in a pregnant patient complaining of persistent fever, cytopenia, or declining clinical condition despite delivery of the baby. Prompt diagnosis and treatment is essential and fetal outcomes should also be considered. The decision to terminate a pregnancy and initiate chemotherapy during pregnancy with malignancy-associated HLH (M-HLH) needs to be further investigated in a larger cohort.
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753
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Ruscitti P, Cipriani P, Di Benedetto P, Liakouli V, Berardicurti O, Carubbi F, Ciccia F, Guggino G, Triolo G, Giacomelli R. H-ferritin and proinflammatory cytokines are increased in the bone marrow of patients affected by macrophage activation syndrome. Clin Exp Immunol 2017; 191:220-228. [PMID: 28960260 DOI: 10.1111/cei.13057] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/21/2017] [Indexed: 12/12/2022] Open
Abstract
Macrophage activation syndrome (MAS) is hyperinflammatory life-threatening syndrome, associated typically with high levels of serum ferritin. This is an iron storage protein including heavy (H) and light (L) subunits, categorized on their molecular weight. The H-/L subunits ratio may be different in tissues, depending on the specific tissue and pathophysiological status. In this study, we analysed the bone marrow (BM) biopsies of adult MAS patients to assess the presence of: (i) H-ferritin and L-ferritin; (ii) CD68+ /H-ferritin+ and CD68+ /L-ferritin+ ; and (iii) interleukin (IL)-1β, tumour necrosis factor (TNF) and interferon (IFN)-γ. We also explored possible correlations of these results with clinical data. H-ferritin, IL-1β, TNF and IFN-γ were increased significantly in MAS. Furthermore, an increased number of CD68+ /H-ferritin+ cells and an infiltrate of cells co-expressing H-ferritin and IL-12, suggesting an infiltrate of M1 macrophages, were observed. H-ferritin levels and CD68+ /H-ferritin+ cells were correlated with haematological involvement of the disease, serum ferritin and C-reactive protein. L-ferritin and CD68+ /L-ferritin+ cells did not correlate with these parameters. In conclusion, during MAS, H-ferritin, CD68+ /H-ferritin+ cells and proinflammatory cytokines were increased significantly in the BM inflammatory infiltrate, pointing out a possible vicious pathogenic loop. To date, H-ferritin and CD68+ /H-ferritin+ were associated significantly with haematological involvement of the disease, suggesting biomarkers assessing severity of clinical picture.
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Affiliation(s)
- P Ruscitti
- Division of Rheumatology, Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - P Cipriani
- Division of Rheumatology, Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - P Di Benedetto
- Division of Rheumatology, Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - V Liakouli
- Division of Rheumatology, Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - O Berardicurti
- Division of Rheumatology, Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - F Carubbi
- Division of Rheumatology, Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - F Ciccia
- Division of Rheumatology, Department of Internal Medicine, University of Palermo, Palermo, Italy
| | - G Guggino
- Division of Rheumatology, Department of Internal Medicine, University of Palermo, Palermo, Italy
| | - G Triolo
- Division of Rheumatology, Department of Internal Medicine, University of Palermo, Palermo, Italy
| | - R Giacomelli
- Division of Rheumatology, Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
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754
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Confirmed efficacy of etoposide and dexamethasone in HLH treatment: long-term results of the cooperative HLH-2004 study. Blood 2017; 130:2728-2738. [PMID: 28935695 DOI: 10.1182/blood-2017-06-788349] [Citation(s) in RCA: 394] [Impact Index Per Article: 56.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2017] [Accepted: 09/05/2017] [Indexed: 12/13/2022] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening hyperinflammatory syndrome comprising familial/genetic HLH (FHL) and secondary HLH. In the HLH-94 study, with an estimated 5-year probability of survival (pSu) of 54% (95% confidence interval, 48%-60%), systemic therapy included etoposide, dexamethasone, and, from week 9, cyclosporine A (CSA). Hematopoietic stem cell transplantation (HSCT) was indicated in patients with familial/genetic, relapsing, or severe/persistent disease. In HLH-2004, CSA was instead administered upfront, aiming to reduce pre-HSCT mortality and morbidity. From 2004 to 2011, 369 children aged <18 years fulfilled HLH-2004 inclusion criteria (5 of 8 diagnostic criteria, affected siblings, and/or molecular diagnosis in FHL-causative genes). At median follow-up of 5.2 years, 230 of 369 patients (62%) were alive (5-year pSu, 61%; 56%-67%). Five-year pSu in children with (n = 168) and without (n = 201) family history/genetically verified FHL was 59% (52%-67%) and 64% (57%-71%), respectively (familial occurrence [n = 47], 58% [45%-75%]). Comparing with historical data (HLH-94), using HLH-94 inclusion criteria, pre-HSCT mortality was nonsignificantly reduced from 27% to 19% (P = .064 adjusted for age and sex). Time from start of therapy to HSCT was shorter compared with HLH-94 (P =020 adjusted for age and sex) and reported neurological alterations at HSCT were 22% in HLH-94 and 17% in HLH-2004 (using HLH-94 inclusion criteria). Five-year pSu post-HSCT overall was 66% (verified FHL, 70% [63%-78%]). Additional analyses provided specific suggestions on potential pre-HSCT treatment improvements. HLH-2004 confirms that a majority of patients may be rescued by the etoposide/dexamethasone combination but intensification with CSA upfront, adding corticosteroids to intrathecal therapy, and reduced time to HSCT did not improve outcome significantly.
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755
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Ruscitti P, Rago C, Breda L, Cipriani P, Liakouli V, Berardicurti O, Carubbi F, Di Battista C, Verrotti A, Giacomelli R. Macrophage activation syndrome in Still’s disease: analysis of clinical characteristics and survival in paediatric and adult patients. Clin Rheumatol 2017; 36:2839-2845. [DOI: 10.1007/s10067-017-3830-3] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2017] [Revised: 08/28/2017] [Accepted: 09/05/2017] [Indexed: 01/10/2023]
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756
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Al-Samkari H, Berliner N. Hemophagocytic Lymphohistiocytosis. ANNUAL REVIEW OF PATHOLOGY-MECHANISMS OF DISEASE 2017; 13:27-49. [PMID: 28934563 DOI: 10.1146/annurev-pathol-020117-043625] [Citation(s) in RCA: 258] [Impact Index Per Article: 36.9] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Hemophagocytic lymphohistiocytosis is a life-threatening disorder characterized by unbridled activation of cytotoxic T lymphocytes, natural killer (NK) cells, and macrophages resulting in hypercytokinemia and immune-mediated injury of multiple organ systems. It is seen in both children and adults and is recognized as primary (driven by underlying genetic mutations that abolish critical proteins required for normal function of cytotoxic T cells and NK cells) or secondary (resulting from a malignant, infectious, or autoimmune stimulus without an identifiable underlying genetic trigger). Clinical and laboratory manifestations include fever, splenomegaly, neurologic dysfunction, coagulopathy, liver dysfunction, cytopenias, hypertriglyceridemia, hyperferritinemia, hemophagocytosis, and diminished NK cell activity. It is treated with immune suppressants, etoposide, and allogeneic hematopoietic stem cell transplantation; more than 50% of children who undergo transplant survive, but adults have quite poor outcomes even with aggressive management. Newer agents directed at subduing the uncontrolled immune response in a targeted fashion offer promise in this highly morbid disease.
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Affiliation(s)
| | - Nancy Berliner
- Brigham & Women's Hospital, Boston, Massachusetts 02115;
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757
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Rousselin A, Alavi Z, Le Moigne E, Renard S, Tremouilhac C, Delluc A, Merviel P. Hemophagocytic syndrome in pregnancy: case report, diagnosis, treatment, and prognosis. Clin Case Rep 2017; 5:1756-1764. [PMID: 29152265 PMCID: PMC5676265 DOI: 10.1002/ccr3.1172] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2017] [Revised: 06/28/2017] [Accepted: 08/07/2017] [Indexed: 01/24/2023] Open
Abstract
Diagnosis of hemophagocytic syndrome remains a challenge in particular during pregnancy. Concomitant presence of clinical and biological signs, for example, fever, pancytopenia, hyperferritinemia, and hypertriglyceridemia, should alert clinicians to suspect HPS and proceed to prompt treatments.
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Affiliation(s)
- Aline Rousselin
- Obstetrics and Gynecology Service Brest Medical University Hospital Brest France
| | - Zarrin Alavi
- Inserm CIC 1412 Brest Medical University Hospital Brest France
| | | | - Sarah Renard
- Obstetrics and Gynecology Service Brest Medical University Hospital Brest France
| | | | - Aurélien Delluc
- Department of Internal Medicine Brest Medical University Hospital Brest France
| | - Philippe Merviel
- Obstetrics and Gynecology Service Brest Medical University Hospital Brest France
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758
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Wong M, Rao A, Nemunaitis J, Czuchlewski D, Sagheer S, Arana-Yi C. Hemophagocytosis lymphocytosis presenting as pulmonary-renal syndrome: a case report and literature review. Clin Case Rep 2017; 5:1486-1489. [PMID: 28878910 PMCID: PMC5582273 DOI: 10.1002/ccr3.1082] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2017] [Accepted: 06/06/2017] [Indexed: 12/13/2022] Open
Abstract
Hemophagocytosis Lymphocytosis (HLH) is a rare and life-threatening illness that is more commonly seen in infants; however, its incidence in adults is becoming more common. Recognizing HLH in a complicated clinical scenario is key to early recognition, treatment, as well as improved morbidity and mortality.
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Affiliation(s)
- Morgan Wong
- Department of Internal Medicine University of New Mexico MSC10-5550 Albuquerque 87131 New Mexico
| | - Arpit Rao
- Division of Hematology and Oncology Department of Internal Medicine University of New Mexico Comprehensive Cancer Center MSC07-4025 Albuquerque 87131 New Mexico
| | - Jacklyn Nemunaitis
- Division of Hematology and Oncology Department of Internal Medicine University of New Mexico Comprehensive Cancer Center MSC07-4025 Albuquerque 87131 New Mexico
| | - David Czuchlewski
- Department of Pathology University of New Mexico MSC10-5550 Albuquerque 87131 New Mexico
| | - Shazib Sagheer
- Department of Internal Medicine University of New Mexico MSC10-5550 Albuquerque 87131 New Mexico
| | - Cecilia Arana-Yi
- Division of Hematology and Oncology Department of Internal Medicine University of New Mexico Comprehensive Cancer Center MSC07-4025 Albuquerque 87131 New Mexico
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759
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Ruscitti P, Cipriani P, Di Benedetto P, Liakouli V, Carubbi F, Berardicurti O, Ciccia F, Guggino G, Triolo G, Giacomelli R. Advances in immunopathogenesis of macrophage activation syndrome during rheumatic inflammatory diseases: toward new therapeutic targets? Expert Rev Clin Immunol 2017; 13:1041-1047. [PMID: 28837367 DOI: 10.1080/1744666x.2017.1372194] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Macrophage activation syndrome (MAS) is a severe, hyperinflammatory life-threatening syndrome, generally complicating different rheumatic diseases. Despite the severity of the disease, little is known about the pathogenic mechanisms and, thus, possible targeted therapies in the management of these patients. Areas covered: In this review, we aimed to update the current pathogenic knowledge of MAS, during rheumatic diseases, focusing mainly on immunologic abnormalities and on new possible therapeutic strategies. Expert commentary: The difficult pathogenic scenario of MAS, in which genetic defects, predisposing diseases, and triggers are mixed together with the high mortality rate, make it difficult to manage these patients. Although most efforts have been focused on investigating the disease in children, in recent years, several studies are trying to elucidate the possible pathogenic mechanism in adult MAS patients. In this context, genetic and immunological studies might lead to advances in the knowledge of pathogenic mechanisms and possible new therapeutic targets. In the future, the results of ongoing clinical trials are awaited in order to improve the management and, thus, the survival of these patients.
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Affiliation(s)
- Piero Ruscitti
- a Division of Rheumatology , University of L'Aquila , L'Aquila , Italy
| | - Paola Cipriani
- a Division of Rheumatology , University of L'Aquila , L'Aquila , Italy
| | | | - Vasiliky Liakouli
- a Division of Rheumatology , University of L'Aquila , L'Aquila , Italy
| | - Francesco Carubbi
- a Division of Rheumatology , University of L'Aquila , L'Aquila , Italy
| | | | - Francesco Ciccia
- b Division of Rheumatology , University of Palermo , Palermo , Italy
| | - Giuliana Guggino
- b Division of Rheumatology , University of Palermo , Palermo , Italy
| | - Giovanni Triolo
- b Division of Rheumatology , University of Palermo , Palermo , Italy
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760
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Sepulveda FE, de Saint Basile G. Hemophagocytic syndrome: primary forms and predisposing conditions. Curr Opin Immunol 2017; 49:20-26. [PMID: 28866302 DOI: 10.1016/j.coi.2017.08.004] [Citation(s) in RCA: 74] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Accepted: 08/12/2017] [Indexed: 12/18/2022]
Abstract
Hemophagocytic lymphohistiocytosis (HLH, also referred to a hemophagocytic syndrome) is a life-threatening condition in which uncontrolled activation of lymphocytes and macrophages, and thus the secretion of large amounts of inflammatory cytokines, leads to a severe hyperinflammatory state. Over the last few decades, researchers have characterized primary forms of HLH caused by genetic defects that impair lymphocytes' cytotoxic machinery. Other genetic causes of HLH not related to impaired cytotoxicity have also recently been identified. Furthermore, the so-called 'acquired' forms of HLH are encountered in the context of severe infections, autoimmune and autoinflammatory diseases, malignancy, and metabolic disorders, and may also be associated with primary immunodeficiencies. This implies that a variety of disease mechanisms can lead to HLH. Today's research seeks to gain a better understanding of the various pathogenetic and environmental factors that converge to induce HLH.
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Affiliation(s)
- Fernando E Sepulveda
- INSERM UMR1163, Laboratory of Normal and Pathological Homeostasis of the Immune System, Paris F-75015, France; Paris Descartes University-Sorbonne Paris Cité, Imagine Institute, Paris F-75015, France
| | - Geneviève de Saint Basile
- INSERM UMR1163, Laboratory of Normal and Pathological Homeostasis of the Immune System, Paris F-75015, France; Paris Descartes University-Sorbonne Paris Cité, Imagine Institute, Paris F-75015, France; Centre d'Etudes des Déficites Immunitaires, Assistance Publique-Hôpitaux de Paris, F-75015, France.
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761
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Morin S, Grateau A, Reuter D, de Kerviler E, de Margerie-Mellon C, de Bazelaire C, Zafrani L, Schlemmer B, Azoulay E, Canet E. Management of superior vena cava syndrome in critically ill cancer patients. Support Care Cancer 2017; 26:521-528. [PMID: 28836006 DOI: 10.1007/s00520-017-3860-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2017] [Accepted: 08/16/2017] [Indexed: 12/19/2022]
Abstract
PURPOSE The purpose of this study is to describe the management and outcome of critically ill cancer patients with Superior Vena Cava Syndrome (SVCS). METHODS All cancer patients admitted to the medical intensive care unit (ICU) of the Saint-Louis University Hospital for a SVCS between January 2004 and December 2016 were included. RESULTS Of the 50 patients included in the study, obstruction of the superior vena cava was partial in two-thirds of the cases and complete in one-third. Pleural effusion was reported in two-thirds of the patients, pulmonary atelectasis in 16 (32%), and pulmonary embolism in five (10%). Computed tomography of the chest showed upper airway compression in 18 (36%) cases, while echocardiography revealed 22 (44%) pericardial effusions. The causes of SVCS were diagnosed one (0-3) day after ICU admission, using interventional radiology procedures in 70% of the cases. Thirty (60%) patients had hematological malignancies, and 20 (40%) had solid tumors. Fifteen (30%) patients required invasive mechanical ventilation, seven (14%) received vasopressors, and renal replacement therapy was implemented in three (6%). ICU, in-hospital, and 6-month mortality rates were 20, 26, and 48%, respectively. The cause of SVCS was the only factor independently associated with day 180 mortality by multivariate analysis. Patients with hematological malignancies had a lower mortality than those with solid tumors (27 versus 80%) (odds ratio 0.12, 95% confidence interval (0.02-0.60), p < 0.01). CONCLUSION Airway obstruction and pleural and pericardial effusions contributed to the unstable condition of cancer patients with SVCS. The vital prognosis of SVCS was mainly related to the underlying diagnosis.
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Affiliation(s)
- Sarah Morin
- Medical Intensive Care Unit, Saint-Louis University Hospital, AP-HP, 1 avenue Claude Vellefaux, 75010, Paris, France
| | - Adeline Grateau
- Medical Intensive Care Unit, Saint-Louis University Hospital, AP-HP, 1 avenue Claude Vellefaux, 75010, Paris, France
| | - Danielle Reuter
- Medical Intensive Care Unit, Saint-Louis University Hospital, AP-HP, 1 avenue Claude Vellefaux, 75010, Paris, France
| | - Eric de Kerviler
- Department of Radiology, Saint-Louis University Hospital, AP-HP, Paris, France.,Paris Diderot University-Sorbonne Paris Cité, Paris, France
| | | | - Cédric de Bazelaire
- Department of Radiology, Saint-Louis University Hospital, AP-HP, Paris, France.,Paris Diderot University-Sorbonne Paris Cité, Paris, France
| | - Lara Zafrani
- Medical Intensive Care Unit, Saint-Louis University Hospital, AP-HP, 1 avenue Claude Vellefaux, 75010, Paris, France.,Paris Diderot University-Sorbonne Paris Cité, Paris, France
| | - Benoit Schlemmer
- Medical Intensive Care Unit, Saint-Louis University Hospital, AP-HP, 1 avenue Claude Vellefaux, 75010, Paris, France.,Paris Diderot University-Sorbonne Paris Cité, Paris, France
| | - Elie Azoulay
- Medical Intensive Care Unit, Saint-Louis University Hospital, AP-HP, 1 avenue Claude Vellefaux, 75010, Paris, France.,Paris Diderot University-Sorbonne Paris Cité, Paris, France
| | - Emmanuel Canet
- Medical Intensive Care Unit, Saint-Louis University Hospital, AP-HP, 1 avenue Claude Vellefaux, 75010, Paris, France.
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762
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Li W, Zhong Y, Shuang Y, Huang H, Huang Y, Yu L, Huang X. High concentration of miR-133 is a useful marker for the diagnosis of lymphoma- associated hemophagocytic syndrome. Cancer Biomark 2017; 20:159-164. [PMID: 28869447 DOI: 10.3233/cbm-170054] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Wuping Li
- Lymphoma and Myeloma Department, Jiangxi Cancer Hospital, Nanchang, Jiangxi 330029, China
| | - Yun Zhong
- Lymphoma and Myeloma Department, Jiangxi Cancer Hospital, Nanchang, Jiangxi 330029, China
| | - Yuerong Shuang
- Lymphoma and Myeloma Department, Jiangxi Cancer Hospital, Nanchang, Jiangxi 330029, China
| | - Hui Huang
- Lymphoma and Myeloma Department, Jiangxi Cancer Hospital, Nanchang, Jiangxi 330029, China
| | - Yan Huang
- Lymphoma and Myeloma Department, Jiangxi Cancer Hospital, Nanchang, Jiangxi 330029, China
| | - Li Yu
- Hermatology Department, The Second Affiliated Hospital, Nanchang University, Nanchang, Jiangxi 330029, China
| | - Xianbao Huang
- Hermatology Department, The First Affiliated Hospital, Nanchang University, Nanchang, Jiangxi 330029, China
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763
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T Cell Histiocyte Rich Large B Cell Lymphoma Presenting as Hemophagocytic Lymphohistiocytosis: An Uncommon Presentation of a Rare Disease. Case Rep Oncol Med 2017; 2017:6428461. [PMID: 28912991 PMCID: PMC5585646 DOI: 10.1155/2017/6428461] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Accepted: 07/19/2017] [Indexed: 12/28/2022] Open
Abstract
T cell histiocyte rich large B cell lymphoma (THRLBCL) is a rare subtype of non-Hodgkin's lymphoma characterized by malignant B cells with reactive T lymphocytes. The pathophysiology is thought to involve cytokine-mediated evasion of T cell immune response by malignant B cells. It usually presents at an advanced stage with extranodal involvement. An extremely unusual manifestation of the disease is hemophagocytic lymphohistiocytosis (HLH) which is a hyperinflammatory disorder. We present a case of a 43-year-old male who presented with recurrent fever and recent radiologic imaging showing splenomegaly and right inguinal lymphadenopathy. On presentation, he had a fever of 105°F. Laboratory work-up was consistent with pancytopenia, elevated lactate dehydrogenase, elevated D-dimer, and a ferritin of 24,247 ng/mL. The patient was started on steroid therapy. An excisional biopsy of the right inguinal lymph node was consistent with a diagnosis of THRLBCL and the patient subsequently received six cycles of chemotherapy with R-CHOP (Rituximab, Cyclophosphamide, Doxorubicin, Vincristine, and Prednisone) after which a PET-CT scan showed no evidence of biologically active disease and ferritin was down to 822 ng/mL. We discuss the clinical manifestations and diagnostic and therapeutic considerations of this rare disease along with a review of reported cases in the literature.
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764
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Otrock ZK, Hock KG, Riley SB, de Witte T, Eby CS, Scott MG. Elevated serum ferritin is not specific for hemophagocytic lymphohistiocytosis. Ann Hematol 2017; 96:1667-1672. [PMID: 28762079 DOI: 10.1007/s00277-017-3072-0] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Revised: 07/08/2017] [Accepted: 07/09/2017] [Indexed: 12/23/2022]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a rare, potentially fatal, syndrome of excessive and ineffective activation of the immune system. The majority of the reported data on HLH is from pediatric patients and lacks specificity. This makes HLH diagnosis challenging especially in adults where HLH is triggered by many conditions and can resemble many disease entities. Elevated ferritin is one of the diagnostic criteria for HLH. We determined the conditions associated with elevated ferritin at our medical center to assess how specific ferritin is for predicting HLH. We retrospectively reviewed all ferritin results >10,000 μg/L in pediatric and adult patients. The most common condition associated with elevated ferritin was hematologic malignancy in adults (25.7%) and HLH in pediatric patients (48.9%). HLH was diagnosed in 14.2% of adults and 48.9% of children with ferritin >10,000 µg/L. Hyperferritinemia occurs in a variety of conditions and is not specific for adult or pediatric HLH. Common causes of elevated ferritin should be considered before entertaining the possibility of HLH, especially in adult patients.
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Affiliation(s)
- Zaher K Otrock
- Department of Pathology and Immunology, Washington University School of Medicine, 660 S. Euclid Ave, Campus Box 8118, St. Louis, MO, 63110, USA.
| | - Karl G Hock
- Department of Pathology and Immunology, Washington University School of Medicine, 660 S. Euclid Ave, Campus Box 8118, St. Louis, MO, 63110, USA
| | - Sarah B Riley
- Forensic Toxicology Laboratory, Saint Louis University, St Louis, MO, USA
| | - Theo de Witte
- Radboud University Medical Center, Nijmegen, The Netherlands
| | - Charles S Eby
- Department of Pathology and Immunology, Washington University School of Medicine, 660 S. Euclid Ave, Campus Box 8118, St. Louis, MO, 63110, USA
| | - Mitchell G Scott
- Department of Pathology and Immunology, Washington University School of Medicine, 660 S. Euclid Ave, Campus Box 8118, St. Louis, MO, 63110, USA
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765
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Muthu V, Dhooria S, Sehgal IS, Agarwal R, Behera D, Varma N. Malaria-associated secondary haemophagocytic lymphohistiocytosis: Report of two cases & a review of literature. Indian J Med Res 2017; 145:399-404. [PMID: 28749405 PMCID: PMC5555071 DOI: 10.4103/ijmr.ijmr_740_15] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- Valliappan Muthu
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education & Research, Chandigarh 160 012, India
| | - Sahajal Dhooria
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education & Research, Chandigarh 160 012, India
| | - Inderpaul Singh Sehgal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education & Research, Chandigarh 160 012, India
| | - Ritesh Agarwal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education & Research, Chandigarh 160 012, India
| | - Digambar Behera
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education & Research, Chandigarh 160 012, India
| | - Neelam Varma
- Department of Hematology, Postgraduate Institute of Medical Education & Research, Chandigarh 160 012, India
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766
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Wang H, Xiong L, Tang W, Zhou Y, Li F. A systematic review of malignancy-associated hemophagocytic lymphohistiocytosis that needs more attentions. Oncotarget 2017; 8:59977-59985. [PMID: 28938698 PMCID: PMC5601794 DOI: 10.18632/oncotarget.19230] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Accepted: 06/29/2017] [Indexed: 12/11/2022] Open
Abstract
As an infrequent but potentially life-threatening hyperinflammatory syndrome, hemophagocytic lymphohistiocytosis (HLH) is clinically characterized with prolonged fever, hepatosplenomegaly, cytopenia, hypertriglyceridemia, hyperferritinemia and hemophagocytosis in bone marrow, liver, spleen or lymph nodes. Malignancy-associated HLH (M-HLH), one type of acquired HLH, usually presents variable overlaps of symptoms with other types of HLH, thus resulting in higher incidence of misdiagnosis and mortality. In recent years, with the increasing awareness to this disease, the diagnosis and management of HLH have gained more and more attention, and improvements have been made accordingly. As a result, the survival of patients is greatly prolonged. However, there is still no consensus on the diagnostic criteria and treatment strategies due to lack of large samples or prospective clinical trials. In order to improve recognition and diagnosis, and provide guidance regarding the treatment of M-HLH, the Study Group in HLH Subtypes of the Histiocyte Society has developed consensus recommendations for the diagnosis and management of M-HLH in 2015. In the present article, we summarized and discussed some updated understandings in M-HLH.
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Affiliation(s)
- Hongluan Wang
- Department of Hematology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi 330006, China.,Medical College, Nanchang University, Nanchang, Jiangxi 330006, China.,Department of Respiratory, Jiangxi Provincial People's Hospital, Nanchang, Jiangxi 330006, China
| | - Lixia Xiong
- Department of Hematology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi 330006, China.,Medical College, Nanchang University, Nanchang, Jiangxi 330006, China
| | - Weiping Tang
- Department of Hematology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi 330006, China.,Medical College, Nanchang University, Nanchang, Jiangxi 330006, China
| | - Ying Zhou
- Medical College, Nanchang University, Nanchang, Jiangxi 330006, China
| | - Fei Li
- Department of Hematology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi 330006, China
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767
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Kelkar AH, Shah AA, Yong SL, Ahmed Z. An unusual association between hemophagocytic lymphohistiocytosis, mixed connective tissue disease, and autoimmune hemolytic anemia: A case report. Medicine (Baltimore) 2017; 96:e7488. [PMID: 28700492 PMCID: PMC5515764 DOI: 10.1097/md.0000000000007488] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
RATIONALE In the adult patient, hemophagocytic lymphohistiocytosis (HLH) is uncommon and frequently difficult to diagnose due to its nonspecific presentation and numerous complications. PATIENT CONCERNS Herein, we present the case of a 25-year-old female who initially presented for evaluation of persistent fevers and fatigue. She was found to have splenomegaly, generalized lymphadenopathy, pancytopenia, and acute hepatic failure. DIAGNOSES, INTERVENTIONS, AND OUTCOMES Her course was further complicated by the development of nephrotic syndrome and autoimmune hemolytic anemia (AIHA). Antinuclear antibody and ribonucleoprotein were positive, with concurrent physical examination findings, indicating underlying mixed connective tissue disease (MCTD). Ferritin was greater than 40,000 ng/dL. Viral studies, including hepatitis A, B, and C, cytomegalovirus, and Epstein-Barr virus were negative. On the basis of her clinical presentation, a diagnosis of HLH secondary to MCTD was made. This was later confirmed on liver biopsy. She was started on high-dose prednisone and her symptoms completely resolved. She was then transitioned to azathioprine, hydroxychloroquine, prophylactic antibiotics, and a prednisone taper for long-term management. LESSONS This case is notable for the association of both AIHA and MCTD with HLH, providing support for a possible relationship between these 3 conditions.
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MESH Headings
- Adult
- Anemia, Hemolytic, Autoimmune/complications
- Anemia, Hemolytic, Autoimmune/diagnosis
- Anemia, Hemolytic, Autoimmune/drug therapy
- Anemia, Hemolytic, Autoimmune/pathology
- Diagnosis, Differential
- Female
- Humans
- Lymphohistiocytosis, Hemophagocytic/diagnosis
- Lymphohistiocytosis, Hemophagocytic/drug therapy
- Lymphohistiocytosis, Hemophagocytic/etiology
- Lymphohistiocytosis, Hemophagocytic/pathology
- Mixed Connective Tissue Disease/complications
- Mixed Connective Tissue Disease/diagnosis
- Mixed Connective Tissue Disease/drug therapy
- Mixed Connective Tissue Disease/pathology
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Affiliation(s)
| | | | - Sherri L. Yong
- Department of Pathology, University of Illinois College of Medicine at Peoria, Peoria
| | - Zohair Ahmed
- Department of Gastroenterology, University of Illinois College of Medicine at Chicago, Chicago, IL
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768
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Otrock ZK, Daver N, Kantarjian HM, Eby CS. Diagnostic Challenges of Hemophagocytic Lymphohistiocytosis. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2017; 17S:S105-S110. [DOI: 10.1016/j.clml.2017.02.017] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Accepted: 02/28/2017] [Indexed: 01/20/2023]
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769
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Ipe TS, Pham HP, Williams LA. Critical updates in the 7thedition of the American Society for Apheresis guidelines. J Clin Apher 2017; 33:78-94. [DOI: 10.1002/jca.21562] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2017] [Revised: 05/17/2017] [Accepted: 05/29/2017] [Indexed: 12/19/2022]
Affiliation(s)
- Tina S. Ipe
- Department of Pathology and Genomic Medicine; Houston Methodist Hospital; Houston Texas
| | - Huy P. Pham
- Department of Pathology, Division of Laboratory Medicine; University of Alabama, Birmingham, Alabama
| | - Lance A. Williams
- Department of Pathology, Division of Laboratory Medicine; University of Alabama, Birmingham, Alabama
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770
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Hust MA, Blechacz BRA, Bonilla DL, Daver N, Rojas-Hernandez CM. Adult cancer-related hemophagocytic lymphohistiocytosis - a challenging diagnosis: a case report. J Med Case Rep 2017; 11:172. [PMID: 28651636 PMCID: PMC5485603 DOI: 10.1186/s13256-017-1344-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Accepted: 06/03/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Adult hemophagocytic lymphohistiocytosis is a secondary immunopathologic phenomenon, mainly secondary to malignancy, infection, or autoimmune disorders. The performance of diagnostic criteria, studied in the pediatric population, is yet to be validated in the adult population. Some of the criteria include cytopenias and organomegaly that are inherent features to malignant processes, thus making the diagnosis of hemophagocytic lymphohistiocytosis a challenge in patients with cancer. CASE PRESENTATION We describe the case of a 54-year-old white man with history of metastatic maxillary sinus adenoid cystic carcinoma who had severe liver injury and cytopenias with progressive clinical deterioration. We performed an evaluation, by flow cytometry, of the expression of surface markers in his natural killer cells that revealed remarkable abnormalities. His syndrome eventually fulfilled criteria for hemophagocytic lymphohistiocytosis and he received therapy with steroids with interval clinical improvement. Unfortunately, he refused further cytotoxic treatment and died 2 weeks later. CONCLUSIONS The conventional criteria for the diagnosis of hemophagocytic lymphohistiocytosis are suboptimal for adult patients with cancer resulting in delays in diagnosis and timely initiation of treatment. The diagnostic criteria have to be re-evaluated in patients with cancer; novel, easily available, and accurate diagnostic methods are needed.
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Affiliation(s)
- Michael A Hust
- Department of Internal Medicine, The University of Texas Health Science Center, Houston, TX, USA
| | - Boris R A Blechacz
- Department of Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Diana L Bonilla
- Department of Immunology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Naval Daver
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Cristhiam M Rojas-Hernandez
- Section of Benign Hematology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd. Unit Number: 1464, Houston, TX, 77030, USA.
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771
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Wohlfarth P, Agis H, Gualdoni GA, Weber J, Staudinger T, Schellongowski P, Robak O. Interleukin 1 Receptor Antagonist Anakinra, Intravenous Immunoglobulin, and Corticosteroids in the Management of Critically Ill Adult Patients With Hemophagocytic Lymphohistiocytosis. J Intensive Care Med 2017. [PMID: 28631531 DOI: 10.1177/0885066617711386] [Citation(s) in RCA: 74] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BACKGROUND Hemophagocytic lymphohistiocytosis (HLH) causes multiple organ dysfunction frequently leading to intensive care unit (ICU) referral and/or death. We report on a series of critically ill adult patients treated with a non-etoposide-based regimen including interleukin 1 antagonist anakinra, intravenous immunoglobulin (IVIG), and/or corticosteroids (CS) for HLH. METHODS Eight adult (≥18 years) ICU patients having received treatment with anakinra ± IVIG ± CS for HLH between March 2014 and March 2016 at a large tertiary care university hospital (Medical University of Vienna, Vienna, Austria) were retrospectively analyzed. RESULTS Eight patients (median age: 38 years; range: 20-58 years; 4 males and 4 females) received anakinra together with IVIG (n = 7) and/or high-dose CS (n = 5) for suspected reactive HLH (median H-score: 214; range: 171-288). Seven (88%) patients required vasopressors and invasive mechanical ventilation and 6 (75%) patients required renal replacement therapy (median Sequential Organ Failure Assessment [SOFA] score at HLH diagnosis: 9.5; range: 6-14). Six patients showed a significant decline in the SOFA score at 1 and 2 weeks following treatment initiation (P = .03), and the remainder 2 patients experienced early death. Five patients survived to ICU discharge, 4 of them could further be discharged from hospital (hospital survival rate: 50%). No overt treatment-related toxicity was noted. CONCLUSION Anakinra in combination with IVIG and/or CS resulted in a hospital survival rate of 50% in 8 critically ill adult patients with HLH despite a vast degree of organ dysfunction and the need for aggressive ICU treatment. Further research on non-etoposide-based treatment strategies for HLH in critically ill adults is warranted.
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Affiliation(s)
- Philipp Wohlfarth
- 1 Intensive Care Unit 13i2, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Hermine Agis
- 1 Intensive Care Unit 13i2, Department of Medicine I, Medical University of Vienna, Vienna, Austria.,2 Clinical Division of Oncology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Guido A Gualdoni
- 3 Clinical Division of Infectious Diseases and Tropical Medicine, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Johannes Weber
- 4 Department of Anesthesia and Intensive Care Medicine, Medical University of Vienna, Vienna, Austria
| | - Thomas Staudinger
- 1 Intensive Care Unit 13i2, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Peter Schellongowski
- 1 Intensive Care Unit 13i2, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Oliver Robak
- 1 Intensive Care Unit 13i2, Department of Medicine I, Medical University of Vienna, Vienna, Austria
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772
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Daver N, McClain K, Allen CE, Parikh SA, Otrock Z, Rojas-Hernandez C, Blechacz B, Wang S, Minkov M, Jordan MB, La Rosée P, Kantarjian HM. A consensus review on malignancy-associated hemophagocytic lymphohistiocytosis in adults. Cancer 2017. [PMID: 28621800 DOI: 10.1002/cncr.30826] [Citation(s) in RCA: 133] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a syndrome of severe immune activation and dysregulation resulting in extreme and often life-threatening inflammation. HLH has been well recognized in pediatric populations, and most current diagnostic and therapeutic guidelines are based on pediatric HLH. Recently there has been recognition of HLH in adults, especially secondary to immune deregulation by an underlying rheumatologic, infectious, or malignant condition. This review is focused on malignancy-associated HLH (M-HLH), in which possible mechanisms of pathogenesis include severe inflammation, persistent antigen stimulation by the tumor cells, and loss of immune homeostasis because of chemotherapy, hematopoietic stem cell transplantation, or infection. Previously considered rare, M-HLH may occur in up to 1% of patients with hematologic malignancies. M-HLH is often missed or diagnosed late in most published studies, and it has been associated with a poor median survival of less than 2 months. Identification of the clinical and laboratory features specific to M-HLH in adults may allow early detection, consultation with HLH experts, and intervention. Improved management of adult M-HLH with optimal combinations of T-lympholytic and immunosuppressive agents and the incorporation of novel agents based on the pediatric experience hopefully will improve outcomes in adults with M-HLH. Cancer 2017;123:3229-40. © 2017 American Cancer Society.
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Affiliation(s)
- Naval Daver
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Kenneth McClain
- Histiocytosis Program, Texas Children's Cancer Center, Texas Children's Hospital, Houston, Texas
| | - Carl E Allen
- Histiocytosis Program, Texas Children's Cancer Center, Texas Children's Hospital, Houston, Texas
| | | | - Zaher Otrock
- Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, Missouri
| | | | - Boris Blechacz
- Department of Gastroenterology, Hepatology, and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Sa Wang
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Milen Minkov
- University Clinic of Pediatrics, St. Anna Children's Hospital, Medical University of Vienna, Vienna, Austria
| | - Michael B Jordan
- Langerhans Cell Histiocytosis Center, Cincinnati Children's Hospital, Cincinnati, Ohio
| | - Paul La Rosée
- Department of Internal Medicine, Schwarzwald-Baar Clinic, Villingen-Schwenningen, Germany
| | - Hagop M Kantarjian
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
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773
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Vidyarthi AR, Dhaliwal G, Monash B, Shum KL, Lee J, Zaas AK. Hot in the Tropics. J Hosp Med 2017; 12:462-466. [PMID: 28574539 DOI: 10.12788/jhm.2753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- Arpana R Vidyarthi
- Duke-NUS Graduate Medical School, Singapore; Department of Medicine, National University Health System, Singapore
| | - Gurpreet Dhaliwal
- Department of Medicine, University of California, San Francisco, California; Medical Service, San Francisco VA Medical Center, San Francisco, California
| | - Bradley Monash
- Department of Medicine, University of California, San Francisco, California
| | - Koin Lon Shum
- Department of Internal Medicine, Singapore General Hospital, Singapore
| | - Joanne Lee
- Department of Haematology-Oncology, National University Cancer Institute, Singapore
| | - Aimee K Zaas
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina
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774
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Mourad MR, Siwoski OM, Brownback KR. A 19-Year-Old College Student With Headache, Photophobia, and Flulike Illness. Chest 2017; 151:e95-e98. [PMID: 28390644 DOI: 10.1016/j.chest.2016.10.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Revised: 10/05/2016] [Accepted: 10/20/2016] [Indexed: 10/19/2022] Open
Abstract
CASE PRESENTATION A 19-year-old previously healthy man presented, minimally responsive, in respiratory distress to an ED after a 2-week history of headache, photophobia, and neck stiffness. Associated symptoms included low-grade fevers, malaise, and dark urine. He had no recent travel, ill contacts, consumption of undercooked meat, new sexual contacts, or illicit drug use. The patient resided in a campus dormitory and did not consume alcohol or tobacco.
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Affiliation(s)
- Mohamed Ramez Mourad
- Division of Pulmonary and Critical Care Medicine, University of Kansas Medical Center, Kansas City, KS
| | - Olivia M Siwoski
- Department of Internal Medicine, University of Kansas Medical Center, Kansas City, KS
| | - Kyle R Brownback
- Division of Pulmonary and Critical Care Medicine, University of Kansas Medical Center, Kansas City, KS.
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775
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Clinical utility of soluble interleukin-2 receptor in hemophagocytic syndromes: a systematic scoping review. Ann Hematol 2017; 96:1241-1251. [PMID: 28497365 DOI: 10.1007/s00277-017-2993-y] [Citation(s) in RCA: 91] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2017] [Accepted: 04/11/2017] [Indexed: 12/22/2022]
Abstract
The serum-soluble interleukin-2 receptor (sIL-2r) level is considered an important diagnostic test and disease marker in hemophagocytic syndromes/hemophagocytic lymphohistiocytosis (HPS/HLH). However, this cytokine receptor is rarely measured in clinical practice and has been excluded from recent diagnostic/classification criteria such as the HScore and macrophage activation syndrome (MAS) 16. We performed a systematic scoping review of 64 articles (1975-2016) examining the clinical utility of sIL-2r in HPS/HLH. Twenty-two articles describe sIL-2r as a sensitive diagnostic marker for HLH, but only three distinct datasets actually address sensitivity. The original HLH-2004 Guidelines reported sensitivity of 93% and specificity of 100% for sIL-2r ≥ 2400, based on a pediatric dataset (n = 152) which is published for the first time in this review. Two pediatric studies reported sensitivity of 89% for sIL-2r ≥ 2400 in diagnosis of MAS complicating juvenile idiopathic arthritis (JIA) (n = 27) and 88% for secondary HLH in acute liver failure (n = 9). Twenty articles described sIL-2r as a dynamic marker of disease activity that falls with response to treatment, and 15 described high initial sIL-2r levels >10,000 U/mL as a poor prognostic marker. The ability of sIL-2r to distinguish between subtypes of HPS/HLH was inconsistent. This review confirms the importance of soluble IL-2r as a diagnostic and disease marker in HPS/HLH, but also reveals the need for more primary data about its performance characteristics, particularly in adults. More emphasis should be made in including this simple, inexpensive test in clinical practice and studies of HPS/HLH.
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776
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Proliferation through activation: hemophagocytic lymphohistiocytosis in hematologic malignancy. Blood Adv 2017; 1:779-791. [PMID: 29296722 DOI: 10.1182/bloodadvances.2017005561] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2017] [Accepted: 04/11/2017] [Indexed: 12/16/2022] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a syndrome of cytokine-driven immune activation. Cardinal features include fever, hemophagocytosis, hepatosplenomegaly, lymphocytic infiltration, and hypercytokinemia that result in multisystem organ dysfunction and failure. Familial HLH is genetically driven, whereas secondary HLH (SHL) is caused by drugs, autoimmune disease, infection, or cancer. SHL is associated with worse outcomes, with a median overall survival typically of less than 1 year. This reflects difficulty in both diagnostic accuracy and in establishing reliable treatments, especially in cases of malignancy-induced SHL, which have significantly worse outcomes. Malignancy-induced HLH is seen almost exclusively with hematologic malignancies, constituting 97% of cases in the literature over the past 2 years. In these situations, the native immune response driven by CD8 T cells produces an overabundance of T helper 1 cytokines, notably interferon-γ, tumor necrosis factor-α, and interleukin-6, which establish a positive feedback loop of inflammation, enhancing replication of hematologic malignancies while leaving the host immune system in disarray. In this paper, we present 2 case studies of secondary HLH driven by HM, followed by a review of the literature discussing the cytokines driving HLH, diagnostic criteria, and current treatments used or undergoing investigation.
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777
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Gavand PE, Serio I, Arnaud L, Costedoat-Chalumeau N, Carvelli J, Dossier A, Hinschberger O, Mouthon L, Le Guern V, Korganow AS, Poindron V, Gourguechon C, Lavigne C, Maurier F, Labro G, Heymonet M, Artifoni M, Viau AB, Deligny C, Sene T, Terriou L, Sibilia J, Mathian A, Bloch-Queyrat C, Larroche C, Amoura Z, Martin T. Clinical spectrum and therapeutic management of systemic lupus erythematosus-associated macrophage activation syndrome: A study of 103 episodes in 89 adult patients. Autoimmun Rev 2017; 16:743-749. [PMID: 28483541 DOI: 10.1016/j.autrev.2017.05.010] [Citation(s) in RCA: 72] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Accepted: 04/16/2017] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Macrophage activation syndrome (MAS) is a life-threatening hyperinflammatory syndrome that can occur during systemic lupus erythematosus (SLE). Data on MAS in adult SLE patients are very limited. The aim of this study is to describe the clinical characteristics, laboratory findings, treatments, and outcomes of a large series of SLE-associated MAS. METHODS We conducted a retrospective study that included 103 episodes of MAS in 89 adult patients with SLE. RESULTS 103 episodes in 89 adult patients were analyzed. Median age at first MAS episode was 32 (18-80) years. MAS was inaugural in 41 patients (46%).Thirteen patients relapsed. Patients had the following features: fever (100% episodes), increased serum levels of AST (94.7%), LDH (92.3%), CRP (84.5%), ferritin (96%), procalcitonin (41/49 cases). Complications included myocarditis (n=22), acute lung injury (n=15) and seizures (n=11). In 33 episodes, patients required hospitalization in an ICU and 5 died. Thrombocytopenia and high CRP levels were associated independently with an increased risk for ICU admission. High dose steroids alone as first line therapy induced remission in 37/57 cases (65%). Additional medications as first or second line therapies included IV immunoglobulins (n=22), cyclophosphamide (n=23), etoposide (n=11), rituximab (n=3). Etoposide and cyclophosphamide-based regimens had the best efficacy. CONCLUSION MAS is a severe complication and is often inaugural. High fever and high levels of AST, LDH, CRP, ferritin and PCT should be considered as red flags for early diagnosis. High dose steroids lead to remission in two third of cases. Cyclophosphamide or etoposide should be considered for uncontrolled/severe forms.
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Affiliation(s)
| | - Ilaria Serio
- Division of Internal Medicine, Department of Medical & Surgical Sciences, University of Bologna, S Orsola-Malpighi Hospital, Bologna, Italy
| | | | - Nathalie Costedoat-Chalumeau
- AP-HP, Cochin Hospital, Internal Medicine Department, Centre de référence maladies auto-immunes et systémiques rares, Paris, France; Université Paris Descartes-Sorbonne Paris Cité, Paris, France; INSERM U 1153, Center for Epidemiology and Statistics Sorbonne Paris Cité (CRESS), Paris, Hôpital Cochin, France
| | - Julien Carvelli
- Service de médecine interne et d'immunologie clinique, CHU Conception Marseille - APHM, France
| | - Antoine Dossier
- Service de médecine interne CHU Bichat, Paris, Université paris VII, France
| | | | - Luc Mouthon
- Service de médecine interne, hôpital Cochin, Centre de Référence pour les vascularites nécrosantes et la sclérodermie systémique, DHU Authors (Autoimmune and Hormonal Diseases), Université Paris Descartes, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Véronique Le Guern
- AP-HP, Cochin Hospital, Internal Medicine Department, Centre de référence maladies auto-immunes et systémiques rares, Paris, France; Université Paris Descartes-Sorbonne Paris Cité, Paris, France; INSERM U 1153, Center for Epidemiology and Statistics Sorbonne Paris Cité (CRESS), Paris, Hôpital Cochin, France
| | | | - Vincent Poindron
- Service d'immunologie Clinique et médecine interne, CHU de Strasbourg, France
| | | | | | - François Maurier
- Service de médecine Interne et Immunologie Clinique, HP Metz Site Belle Isle, France
| | | | - Marie Heymonet
- CHU de Nancy, Internal Medicine and Clinical immunology Department, France
| | | | | | | | - Thomas Sene
- Service de médecine Interne, Groupe Hospitalier Diaconesses, Croix Saint-Simon, Paris, France
| | - Louis Terriou
- CHU Lille, Département de Médecine Interne et Immunologie Clinique, F-59000 Lille, France
| | | | - Alexis Mathian
- Service de médecine interne 2, Groupement hospitalier La Pitié-Salpétrière, Paris, France
| | | | | | - Zahir Amoura
- Service de médecine interne 2, Groupement hospitalier La Pitié-Salpétrière, Paris, France
| | - Thierry Martin
- Service d'immunologie Clinique et médecine interne, CHU de Strasbourg, France
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778
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Xing Y, Yang J, Lian G, Chen S, Chen L, Li F. Chronic active Epstein-Barr virus infection associated with hemophagocytic syndrome and extra-nodal natural killer/T-cell lymphoma in an 18-year-old girl: A case report. Medicine (Baltimore) 2017; 96:e6845. [PMID: 28489771 PMCID: PMC5428605 DOI: 10.1097/md.0000000000006845] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Revised: 04/13/2017] [Accepted: 04/17/2017] [Indexed: 12/11/2022] Open
Abstract
RATIONALE Chronic active Epstein-Barr virus infection (CAEBV) associated with hemophagocytic syndrome (HPS) and extra-nodal natural killer (NK)/T-cell lymphoma (ENKL) is a rare life-threatening disorder. This disease is easily misdiagnosed because of its varied presentations. PATIENT CONCERNS An 18-year-old girl was admitted to our hospital with a history of edema in the lower limbs and intermittent fever lasting for more than 1 month. At admission, she had severe liver injury of unknown etiology. Laboratory test results revealed pancytopenia, hyperferritinemia, hypertriglyceridemia, and hypofibrinogenemia. Results of serologic tests for EBV were positive. Results of a skin biopsy indicated EBV-positive NK/T-cell lymphoma, and bone marrow aspiration revealed focal hemophagocytosis and atypical lymphoid cells. DIAGNOSIS On the basis of these findings, we diagnosed the case as extra-nodal NK/T-cell lymphoma-associated HPS (natural killer/T-cell lymphoma-associated hemophagocytic syndrome), which is commonly induced by CAEBV. INTERVENTIONS Treatment consisted of general management of hepatitis, supplemented with albumin and empirical antibiotic therapy. OUTCOMES The patient died from massive gastrointestinal hemorrhage a week after she was discharged from the hospital. LESSONS ENKL and HPS present with varied features and are generally fatal; therefore, clinicians should proceed with caution in suspected cases. HPS should be considered when the patient presents with fever, hepatosplenomegaly, pancytopenia, and liver failure. When HPS is suspected, clinicians should determine the underlying cause, such as severe infection, including infection with viruses such as EBV; genetic predisposition; or underlying malignancies, especially lymphoma because of its strong association with HPS.
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779
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Affiliation(s)
- Sun Young Park
- Department of Pediatrics, College of Medicine, Yeungnam University, Daegu, Korea
| | - Jae Min Lee
- Department of Pediatrics, College of Medicine, Yeungnam University, Daegu, Korea
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780
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Wang J, Han W, Gao Z, Wang Y, Wu L, Zhang J, Lai W, Wang Z. Elevation of CD16 +CD56 + NK-cells and down-regulation of serum interleukin-21 (IL-21) and IL-1α after splenectomy in relapsed hemophagocytic lymphohistiocytosis of unknown cause. Hematology 2017; 22:477-483. [PMID: 28413901 DOI: 10.1080/10245332.2017.1311443] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
OBJECTIVES Encouraging progress has been made in application of splenectomy in the treatment of relapsed hemophagocytic lymphohistiocytosis (HLH) of unknown cause. The aim was to determine the roles of lymphocyte subpopulations and inflammatory cytokines in splenectomy. METHODS We retrospectively analyzed changes in lymphocyte subpopulations and levels of inflammatory cytokines at different time-points before and after splenectomy in the patients with relapsed HLH of unknown cause, as well as the correlations between these changes and the disease prognosis. RESULTS During the period from June 2006 to June 2016, we enrolled 107 patients with relapsed HLH of unknown cause, of whom 29 were treated with splenectomy. Among the 29 patients, 7 cases were non-Hodgkin lymphomas based on spleen pathology, 1 case withdrew and the remaining 21 non-lymphoma cases were available for analysis. Results showed a significant increase in both percentage of CD16+CD56+ NK cells (P = 0.003) and NK cell activity (P = 0.028) at 24 wk after splenectomy compared to their baseline pre-surgery levels. We also examined seven patients for the changes in cytokine levels before and after splenectomy and found that IL-21 and IL-1α decreased at 4 wk after splenectomy (P < 0.05). Seven non-lymphoma patients determined as no response to treatment (NR) prior to splenectomy had significantly longer survival (P = 0.001) compared to the 24 patients with relapsed HLH of unknown cause who were also determined as NR but not treated by splenectomy. DISCUSSION Splenectomy can improve clinical symptoms and survival of patients with relapsed HLH of unknown cause. The mechanism is likely related to the changes in percent NK cells and cytokines (IL-21 and IL-1α) after surgery.
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Affiliation(s)
- Jingshi Wang
- a Department of Hematology, Beijing Friendship Hospital , Capital Medical University , Beijing , China
| | - Wei Han
- b Department of General Surgery, Lu He Hospital , Capital Medical University , Beijing , China
| | - Zhuo Gao
- a Department of Hematology, Beijing Friendship Hospital , Capital Medical University , Beijing , China
| | - Yini Wang
- a Department of Hematology, Beijing Friendship Hospital , Capital Medical University , Beijing , China
| | - Lin Wu
- a Department of Hematology, Beijing Friendship Hospital , Capital Medical University , Beijing , China
| | - Jia Zhang
- a Department of Hematology, Beijing Friendship Hospital , Capital Medical University , Beijing , China
| | - Wenyuan Lai
- a Department of Hematology, Beijing Friendship Hospital , Capital Medical University , Beijing , China
| | - Zhao Wang
- a Department of Hematology, Beijing Friendship Hospital , Capital Medical University , Beijing , China
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781
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Honsig C, Beinhardt S, Tomasits J, Dienes HP. Haemophagocytic lymphohistiocytosis associated with fulminant hepatitis and multiorgan failure following primary Epstein-Barr virus and herpes simplex virus type 1 infection. BMJ Case Rep 2017; 2017:bcr-2016-218310. [PMID: 28356254 PMCID: PMC5372189 DOI: 10.1136/bcr-2016-218310] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
We present a case of severe fatal hepatitis in a young patient presumably triggered by two ubiquitous viral diseases which occurred in close succession. This case is unusual because of the exceptional chronological sequence of primary Epstein–Barr virus and herpes simplex virus type 1 infection causing systemic immune dysregulation associated with rapidly developing liver failure and consecutive multiorgan failure. Clinical, laboratory and histopathological findings indicated the development of secondary haemophagocytic lymphohistiocytosis triggered by these closely succeeding viral primary infections.
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Affiliation(s)
- Claudia Honsig
- Division of Clinical Virology, Department of Laboratory Medicine, Medical University of Vienna, Vienna, Austria
| | - Sandra Beinhardt
- Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | | | - Hans Peter Dienes
- Medical University of Vienna, Institute of Clinical Pathology, Vienna, Austria
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782
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Siddall E, Khatri M, Radhakrishnan J. Capillary leak syndrome: etiologies, pathophysiology, and management. Kidney Int 2017; 92:37-46. [PMID: 28318633 DOI: 10.1016/j.kint.2016.11.029] [Citation(s) in RCA: 181] [Impact Index Per Article: 25.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2016] [Revised: 10/25/2016] [Accepted: 11/15/2016] [Indexed: 02/06/2023]
Abstract
In various human diseases, an increase in capillary permeability to proteins leads to the loss of protein-rich fluid from the intravascular to the interstitial space. Although sepsis is the disease most commonly associated with this phenomenon, many other diseases can lead to a "sepsis-like" syndrome with manifestations of diffuse pitting edema, exudative serous cavity effusions, noncardiogenic pulmonary edema, hypotension, and, in some cases, hypovolemic shock with multiple-organ failure. The term capillary leak syndrome has been used to describe this constellation of disease manifestations associated with an increased capillary permeability to proteins. Diseases other than sepsis that can result in capillary leak syndrome include the idiopathic systemic capillary leak syndrome or Clarkson's disease, engraftment syndrome, differentiation syndrome, the ovarian hyperstimulation syndrome, hemophagocytic lymphohistiocytosis, viral hemorrhagic fevers, autoimmune diseases, snakebite envenomation, and ricin poisoning. Drugs including some interleukins, some monoclonal antibodies, and gemcitabine can also cause capillary leak syndrome. Acute kidney injury is commonly seen in all of these diseases. In addition to hypotension, cytokines are likely to be important in the pathophysiology of acute kidney injury in capillary leak syndrome. Fluid management is a critical part of the treatment of capillary leak syndrome; hypovolemia and hypotension can cause organ injury, whereas capillary leakage of administered fluid can worsen organ edema leading to progressive organ injury. The purpose of this article is to discuss the diseases other than sepsis that produce capillary leak and review their collective pathophysiology and treatment.
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Affiliation(s)
- Eric Siddall
- Columbia University Medical Center, New York, New York, USA
| | - Minesh Khatri
- Winthrop University Hospital, Mineola, New York, USA
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783
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Schwartz J, Padmanabhan A, Aqui N, Balogun RA, Connelly-Smith L, Delaney M, Dunbar NM, Witt V, Wu Y, Shaz BH. Guidelines on the Use of Therapeutic Apheresis in Clinical Practice-Evidence-Based Approach from the Writing Committee of the American Society for Apheresis: The Seventh Special Issue. J Clin Apher 2017; 31:149-62. [PMID: 27322218 DOI: 10.1002/jca.21470] [Citation(s) in RCA: 276] [Impact Index Per Article: 39.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The American Society for Apheresis (ASFA) Journal of Clinical Apheresis (JCA) Special Issue Writing Committee is charged with reviewing, updating, and categorizing indications for the evidence-based use of therapeutic apheresis in human disease. Since the 2007 JCA Special Issue (Fourth Edition), the Committee has incorporated systematic review and evidence-based approaches in the grading and categorization of apheresis indications. This Seventh Edition of the JCA Special Issue continues to maintain this methodology and rigor to make recommendations on the use of apheresis in a wide variety of diseases/conditions. The JCA Seventh Edition, like its predecessor, has consistently applied the category and grading system definitions in the fact sheets. The general layout and concept of a fact sheet that was used since the fourth edition has largely been maintained in this edition. Each fact sheet succinctly summarizes the evidence for the use of therapeutic apheresis in a specific disease entity. The Seventh Edition discusses 87 fact sheets (14 new fact sheets since the Sixth Edition) for therapeutic apheresis diseases and medical conditions, with 179 indications, which are separately graded and categorized within the listed fact sheets. Several diseases that are Category IV which have been described in detail in previous editions and do not have significant new evidence since the last publication are summarized in a separate table. The Seventh Edition of the JCA Special Issue serves as a key resource that guides the utilization of therapeutic apheresis in the treatment of human disease. J. Clin. Apheresis 31:149-162, 2016. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Joseph Schwartz
- Department of Pathology and Cell Biology, Columbia University Medical Center, New York, New York
| | - Anand Padmanabhan
- Blood Center of Wisconsin, Department of Pathology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Nicole Aqui
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Rasheed A Balogun
- Division of Nephrology, University of Virginia, Charlottesville, Virginia
| | - Laura Connelly-Smith
- Department of Medicine, Seattle Cancer Care Alliance and University of Washington, Seattle, Washington
| | - Meghan Delaney
- Bloodworks Northwest, Department of Laboratory Medicine, University of Washington, Seattle, Washington
| | - Nancy M Dunbar
- Department of Pathology and Laboratory Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Volker Witt
- Department for Pediatrics, St. Anna Kinderspital, Medical University of Vienna, Vienna, Austria
| | - Yanyun Wu
- Bloodworks Northwest, Department of Laboratory Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Beth H Shaz
- Department of Pathology and Cell Biology, Columbia University Medical Center, New York, New York.,New York Blood Center, Department of Pathology.,Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, Georgia
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784
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Abstract
BACKGROUND Hemophagocytic lymphohistiocytosis (HLH) has well been studied as a genetic disorder in children (primary HLH). Mutations in the regulatory complex of the cellular immune synapse lead to a loss of function of cytotoxic T‑cells and natural killer cells with excessive inflammation based on a cytokine storm. During the last decade, an increasing number of adult HLH patients without a family history of HLH (secondary or acquired HLH) have been reported. Various triggers - infections, malignancies or autoimmune diseases - result in an acquired loss of function of these cells and a sepsis-like disease. Missed or late diagnosis is believed to be a major cause of the high mortality. OBJECTIVES To describe the current knowledge on HLH and to raise awareness. MATERIALS AND METHODS Analysis of case reports, current studies, and expert recommendations. RESULTS Increased vigilance in identifying the adult form of HLH resulted in an increasing number of case reports over the past few years. HLH patients typically present with a clinical phenotype resembling severe sepsis or septic shock with fever, cytopenia, and organomegaly, which do not or insufficiently respond to anti-infective treatment. Early recognition of HLH distinction from sepsis, and prompt initiation of treatment - which is fundamentally different from sepsis - are crucial for improved outcome. A promising diagnostic parameter is ferritin, which has gained sufficient specificity, but only in the context of the triad of fever, cytopenia, and organomegaly. Treatment of adult HLH patients requires immunosuppression, with strict therapeutic guidance derived from the triggering disease. CONCLUSIONS Because of the similar clinical presentation to that of sepsis, HLH is often not recognized, resulting in a fatal outcome. In "sepsis" patients on the ICU with deterioration despite a standard of care, HLH needs to be considered by testing for ferritin when considering differential diagnoses. The complexity of the illness requires interdisciplinary patient care with specific integration of the hematologist in the diagnostic workup and therapeutic management, because of the frequent use of chemotherapy-based immunosuppression.
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785
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El-Masry M, Eisenbud L, Tran MH. Secondary hemophagocytic lymphohistiocytosis in the setting of metastatic renal cell carcinoma: a case report. J Med Case Rep 2017; 11:56. [PMID: 28249615 PMCID: PMC5333406 DOI: 10.1186/s13256-016-1196-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Accepted: 12/29/2016] [Indexed: 11/21/2022] Open
Abstract
Background Hemophagocytic lymphohistiocytosis is a disease process characterized by unregulated hyperactivation of the immune system associated with multiorgan involvement and high mortality rates. Early recognition is crucial and a recently validated diagnostic schema, the H-Score, may facilitate diagnosis particularly in secondary hemophagocytic lymphohistiocytosis cases. We present a patient with secondary hemophagocytic lymphohistiocytosis in association with metastatic renal cell carcinoma in whom high-dose steroid therapy induced a remarkable response. Case presentation A 35-year-old Vietnamese man with quiescent systemic lupus erythematosus was diagnosed 5 months prior to admission with left-sided renal cell carcinoma metastatic to the pancreas and spine. Ten days prior to admission, a febrile illness (temperatures to 39 °C) associated with flu-like symptoms unresponsive to levofloxacin developed. He took only two doses of pazopanib prior to admission. High fevers unresponsive to antimicrobial therapy, cytopenias, disseminated intravascular coagulation, and progressive multiorgan failure led to intubation and intensive care unit stay. Extensive infectious disease workup showed only negative results, but elevation of interleukin-2 receptor, exceedingly high ferritin levels and other features earned an H-Score of 302, consistent with >99% diagnostic probability for secondary hemophagocytic lymphohistiocytosis. High-dose steroid therapy produced a rapid clinical and biochemical response. Conclusions Hemophagocytic lymphohistiocytosis is a life-threatening disorder which is likely to be under-recognized. Increased awareness of this disease entity and its diagnosis is crucial toward early recognition and treatment. To our knowledge, our patient is only the second reported with secondary hemophagocytic lymphohistiocytosis occurring in the setting of renal cell carcinoma.
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Affiliation(s)
- Monica El-Masry
- Department of Internal Medicine, UC Irvine Health School of Medicine, 101 The City Drive S, Orange, CA, 92868, USA
| | - Lauren Eisenbud
- Department of Internal Medicine, Arrowhead Regional Medical Center, 400 N Pepper Avenue, Colton, CA, 92324, USA
| | - Minh-Ha Tran
- Department of Pathology and Laboratory Medicine, UC Irvine Health School of Medicine, 101 The City Drive S, Orange, CA, 92868, USA.
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786
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In-hospital mortality in febrile lupus patients based on 2016 EULAR/ACR/PRINTO classification criteria for macrophage activation syndrome. Semin Arthritis Rheum 2017; 47:216-221. [PMID: 28268026 DOI: 10.1016/j.semarthrit.2017.02.002] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Revised: 01/31/2017] [Accepted: 02/04/2017] [Indexed: 12/30/2022]
Abstract
OBJECTIVE To evaluate the clinical significance of the 2016 European League Against Rheumatism (EULAR)/American College of Rheumatology (ACR)/Pediatric Rheumatology International Trials Organization (PRINTO) classification criteria for macrophage activation syndrome (MAS) in patients with febrile systemic lupus erythematosus (SLE). METHODS We performed a retrospective analysis of SLE patients with fever, who were admitted to Severance Hospital between December 2005 and May 2016. Patients were evaluated for MAS using the 2016 classification criteria for MAS. Clinical features and laboratory findings were compared and overall survival rate was analyzed. Forward and backward stepwise logistic regression analysis was used to evaluate the factors associated with in-hospital mortality. RESULTS Among 157 patients with SLE, 54 (34.3%) were considered to have MAS on admission (n = 42) and during admission (n = 12). For patients who already have MAS on admission, their baseline laboratory findings demonstrated lower CRP, platelets, total protein, albumin, complement C3, fibrinogen and higher AST, ALT, total bilirubin, ferritin, and triglyceride. The overall survival rate was significantly lower in patients with MAS than without MAS (64.8% vs. 97.0%, p < 0.001). Multivariate analysis showed that the presence of MAS was significantly associated with in-hospital mortality in febrile SLE patients (OR = 64.5; 95% CI: 7.6-544.4; p < 0.001). CONCLUSIONS The 2016 classification criteria for MAS is useful to identify febrile SLE patients at high risk for in-hospital mortality. Monitoring febrile SLE patients with the new 2016 classification criteria might aid in the early detection of MAS.
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787
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Weaver LK, Behrens EM. Weathering the storm: Improving therapeutic interventions for cytokine storm syndromes by targeting disease pathogenesis. CURRENT TREATMENT OPTIONS IN RHEUMATOLOGY 2017; 3:33-48. [PMID: 28944163 DOI: 10.1007/s40674-017-0059-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Cytokine storm syndromes require rapid diagnosis and treatment to limit the morbidity and mortality caused by the hyperinflammatory state that characterizes these devastating conditions. Herein, we discuss the current knowledge that guides our therapeutic decision-making and personalization of treatment for patients with cytokine storm syndromes. Firstly, ICU-level supportive care is often required to stabilize patients with fulminant disease while additional diagnostic evaluations proceed to determine the underlying cause of cytokine storm. Pharmacologic interventions should be focused on removing the inciting trigger of inflammation and initiation of an individualized immunosuppressive regimen when immune activation is central to the underlying disease pathophysiology. Monitoring for a clinical response is required to ensure that changes in the therapeutic regimen can be made as clinically warranted. Escalation of immunosuppression may be required if patients respond poorly to the initial therapeutic interventions, while a slow wean of immunosuppression in patients who improve can limit medication-related toxicities. In certain scenarios, a decision must be made whether an individual patient requires hematopoietic cell transplantation to prevent recurrence of disease. Despite these interventions, significant morbidity and mortality remains for cytokine storm patients. Therefore, we use this review to propose a clinical schema to guide current and future attempts to design rational therapeutic interventions for patients suffering from these devastating conditions, which we believe speeds the diagnosis of disease, limits medication-related toxicities, and improves clinical outcomes by targeting the heterogeneous and dynamic mechanisms driving disease in each individual patient.
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Affiliation(s)
- Lehn K Weaver
- Division of Pediatric Rheumatology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Edward M Behrens
- Division of Pediatric Rheumatology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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788
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Ni B, Gu W, Mei Y, Miao K, Zhang S, Shao Y. A Rare Life-threatening Kodamaea ohmeri Endocarditis Associated With Hemophagocytic Lymphohistiocytosis. ACTA ACUST UNITED AC 2017; 71:51-53. [PMID: 28153549 DOI: 10.1016/j.rec.2016.12.035] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2016] [Accepted: 12/05/2016] [Indexed: 11/19/2022]
Affiliation(s)
- Buqing Ni
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Weidong Gu
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Yaning Mei
- Department of Laboratory Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Kourong Miao
- Department of Hematology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Shijiang Zhang
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Yongfeng Shao
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China.
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789
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Cavallari M, Ciccone M, Falzoni S, Cavazzini F, Formigaro L, Di Virgilio F, Rotola A, Rigolin GM, Cuneo A. "Hemophagocytic Lymphohistiocytosis after EBV reactivation and ibrutinib treatment in relapsed/refractory Chronic Lymphocytic Leukemia". Leuk Res Rep 2017; 7:11-13. [PMID: 28180067 PMCID: PMC5288319 DOI: 10.1016/j.lrr.2017.01.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2016] [Revised: 11/23/2016] [Accepted: 01/15/2017] [Indexed: 12/01/2022] Open
Abstract
Hemophagocytic Lymphohistiocytosis (HLH) is a rare syndrome characterized by ineffective T-cell and NK response. We report the clinical course of a patient with relapsed CLL who developed acute symptoms soon after starting ibrutinib. Hyperpyrexia, splenomegaly, hyperferritinemia, hypertriglyceridemia, cytopenias, and a typical cytokine pattern, i.e. high interleukin (IL)−6, IL10 and IL18, were consistent with a diagnosis of HLH. Coexistent Epstein Barr virus reactivation was documented. Ibrutinib-induced impairment of NK degranulation, associated with EBV reactivation and CLL-related immunodeficiency may have contributed to the development of HLH in our patient. This is the first report describing a case of well-documented HLH in relapsed CLL under ibrutinib. There was a strict temporal association between ibrutinib start and HLH. The patient had concomitant EBV reactivation, a known possible trigger of HLH. The effect of ibrutinib on NK and T-cell was a possible contributing factor to the onset of HLH.
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Affiliation(s)
- Maurizio Cavallari
- Hematology Section, Azienda Ospedaliero-Universitaria Arcispedale S. Anna, Ferrara, Italy
| | - Maria Ciccone
- Hematology Section, Azienda Ospedaliero-Universitaria Arcispedale S. Anna, Ferrara, Italy
| | - Simonetta Falzoni
- Section of Pathology, Department of Oncology and Experimental Biology, University of Ferrara, Ferrara, Italy
| | - Francesco Cavazzini
- Hematology Section, Azienda Ospedaliero-Universitaria Arcispedale S. Anna, Ferrara, Italy
| | - Luca Formigaro
- Hematology Section, Azienda Ospedaliero-Universitaria Arcispedale S. Anna, Ferrara, Italy
| | - Francesco Di Virgilio
- Section of Pathology, Department of Oncology and Experimental Biology, University of Ferrara, Ferrara, Italy
| | - Antonella Rotola
- Section of Microbiology & Medical Genetics, Department of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - Gian Matteo Rigolin
- Hematology Section, Azienda Ospedaliero-Universitaria Arcispedale S. Anna, Ferrara, Italy
| | - Antonio Cuneo
- Hematology Section, Azienda Ospedaliero-Universitaria Arcispedale S. Anna, Ferrara, Italy
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790
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Hanoun M, Dührsen U. The Maze of Diagnosing Hemophagocytic Lymphohistiocytosis: Single-Center Experience of a Series of 6 Clinical Cases. Oncology 2017; 92:173-178. [PMID: 28052298 DOI: 10.1159/000454733] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2016] [Accepted: 11/23/2016] [Indexed: 12/14/2022]
Abstract
Clinical symptoms of hemophagocytic lymphohistiocytosis (HLH) are based on an excessive inflammatory response. Not only the diversity of the putative underlying etiologies of this rare syndrome but also the subsequent large variety of symptoms complicate the diagnosis of HLH in adult patients. However, early diagnosis and immediate treatment initiation are imperative for clinical outcome. In this article, we will review the diagnostic criteria of HLH and, in this context, discuss 6 cases, each of whom presented with a different clinical appearance causally associated with distinct malignant and nonmalignant diseases, exemplifying the spectrum of associations and manifestations of HLH.
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Affiliation(s)
- Maher Hanoun
- Department of Hematology, University Hospital, University of Duisburg-Essen, Essen, Germany
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791
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Mustafa Ali M, Ruano Mendez AL, Carraway HE. Hemophagocytic Lymphohistiocytosis in a Patient With Hodgkin lymphoma and Concurrent EBV, CMV, and Candida Infections. J Investig Med High Impact Case Rep 2017; 5:2324709616684514. [PMID: 28210636 PMCID: PMC5298562 DOI: 10.1177/2324709616684514] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2016] [Revised: 11/17/2016] [Accepted: 11/23/2016] [Indexed: 11/16/2022] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a syndrome characterized by immune activation and subsequent widespread organ damage. Patients affected by HLH commonly develop fever, cytopenias, liver damage, neurologic manifestations, and hypercytokinemia. In this case, we describe a 60-year-old male who presented with HLH and concurrent Epstein-Barr virus, cytomegalovirus, and Candida infections and was subsequently diagnosed with a Hodgkin lymphoma. This case highlights the importance of considering a cancer diagnosis in the differential diagnosis of patients presenting with HLH.
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792
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Grzybowski B, Vishwanath VA. Hemophagocytic Lymphohistiocytosis: A Diagnostic Conundrum. J Pediatr Neurosci 2017; 12:55-60. [PMID: 28553383 PMCID: PMC5437791 DOI: 10.4103/jpn.jpn_140_16] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a syndrome of excessive immune activation causing widespread inflammation and tissue destruction leading to multi-organ dysfunction and failure. Making the diagnosis of HLH could be quite challenging due to the broad range of presenting symptoms and their lack of specificity. After ruling out considerations for differential diagnoses, recognizing the most common presenting signs and symptoms of HLH, including neurologic dysfunction, and having a high clinical suspicion for HLH in the setting of inflammatory/demyelinating diseases are important for prompt diagnosis and treatment.
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Affiliation(s)
- Brittany Grzybowski
- Department of Emergency Medicine, Keck School of Medicine of USC, Los Angeles, CA 90033, USA
| | - Vijay A Vishwanath
- Department of Neurology, Division of Pediatric Neurology, Albany Medical Center, Albany, NY 12208, USA
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793
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Takada H, Kimura N, Yoshihashi-Nakazato Y, Kawahata K, Kohsaka H. Discoid Lupus Erythematosus Complicated with Pregnancy-induced Hemophagocytic Syndrome. Intern Med 2017. [PMID: 28626188 PMCID: PMC5505918 DOI: 10.2169/internalmedicine.56.8156] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
A 35-year-old woman with discoid lupus erythematosus (DLE) was admitted at 11 weeks' gestation with a persistent fever. Laboratory studies revealed pancytopenia, elevated liver enzymes, and hyperferritinemia. Bone marrow aspiration confirmed the diagnosis of hemophagocytic syndrome (HPS). She had no findings of infection or active systemic lupus erythematosus. The administration of high-dose corticosteroids resolved the clinical and laboratory findings. She delivered a healthy baby at 35 weeks' gestation. This case suggests that DLE can be a predisposing factor for pregnancy-induced HPS.
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Affiliation(s)
- Hideto Takada
- Department of Rheumatology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Japan
| | - Naoki Kimura
- Department of Rheumatology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Japan
| | - Yoko Yoshihashi-Nakazato
- Department of Rheumatology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Japan
| | - Kimito Kawahata
- Department of Rheumatology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Japan
| | - Hitoshi Kohsaka
- Department of Rheumatology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Japan
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794
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Hemophagocytic lymphohistiocytosis in adults: An under recognized entity. BBA CLINICAL 2016; 7:36-40. [PMID: 28070498 PMCID: PMC5219626 DOI: 10.1016/j.bbacli.2016.12.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Revised: 12/01/2016] [Accepted: 12/15/2016] [Indexed: 11/21/2022]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a syndrome of severe immune activation with macrophage and T-cell infiltration resulting in, multi organ damage. HLH may be primary or secondary in etiology. A high index of suspicion is essential for early diagnosis and treatment. Diagnostic criteria need to be refined and newer treatment options to be explored in order to improve survival especially in adult HLH and malignancy-associated HLH (M-HLH). We report a case of malignancy associated HLH (M-HLH) in adult treated on one of the only FDA-approved protocols for adult HLH to highlight the diagnostic and therapeutic challenges of this disease entity.
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795
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Filippone EJ, Singh P, Frank AM, Gupta A, Farber JL. Rapidly Fatal Hemophagocytic Lymphohistiocytosis Developing Within Six Days Following Deceased-Donor Renal Transplantation: Case Report. Transplant Proc 2016; 48:3123-3127. [PMID: 27932162 DOI: 10.1016/j.transproceed.2016.03.031] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2016] [Accepted: 03/30/2016] [Indexed: 12/12/2022]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is an often fatal hyperinflammatory syndrome that may complicate malignancy, infection, rheumatic disease, or immunosuppression. HLH after kidney transplantation is most often triggered by infection, usually Herpes viruses such as cytomegalovirus and Epstein-Barr virus (EBV). It usually occurs early after transplantation. We present a case of HLH triggered by reactivation of EBV that pursued a rapidly fatal course within 6 days of receiving a deceased-donor kidney transplant. This case serves to remind transplant clinicians to consider HLH when cytopenias and hyperinflammation are atypical for the usual post-transplantation course. We discuss pitfalls in diagnosis and suggestions for treatment in this setting.
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Affiliation(s)
- E J Filippone
- Division of Nephrology, Department of Medicine, Sydney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania.
| | - P Singh
- Division of Nephrology, Department of Medicine, Sydney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - A M Frank
- Department of Surgery, Sydney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - A Gupta
- Department of Medicine, Albert Einstein Medical Center, Philadelphia, Pennsylvania
| | - J L Farber
- Department of Pathology, Sydney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania
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796
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Ruiz-Sada P, Atutxa-Fernández JA, Fernández-Ferrer S, Palacios-García L. Fatality as a Feature of Medical Care. ROMANIAN JOURNAL OF INTERNAL MEDICINE 2016; 54:250-252. [DOI: 10.1515/rjim-2016-0040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Indexed: 11/15/2022] Open
Abstract
Abstract
Taking advantage of an interesting clinical scenario, we want to introduce a discussion about fatality in our daily practice and the need to accept that. An 80 year-old man with non-traumatic spontaneous bleeding tendency came to the clinics. Although being on warfarin as a consequence of primary thrombotic prophylaxis due to an atrial fibrillation, full assessment was performed. Not only the rare entity found on him, but also the severe complication that happened afterwards challenged clinicians and led them to risky treatment options.
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Affiliation(s)
- Pablo Ruiz-Sada
- M.D, Internal Medicine Department, HCU, Basurto (Bilbao), Avenida Montevideo s/n, Spain
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797
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Ruscitti P, Cipriani P, Masedu F, Iacono D, Ciccia F, Liakouli V, Guggino G, Carubbi F, Berardicurti O, Di Benedetto P, Valenti M, Triolo G, Valentini G, Giacomelli R. Adult-onset Still's disease: evaluation of prognostic tools and validation of the systemic score by analysis of 100 cases from three centers. BMC Med 2016; 14:194. [PMID: 27903264 PMCID: PMC5131497 DOI: 10.1186/s12916-016-0738-8] [Citation(s) in RCA: 118] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2016] [Accepted: 11/03/2016] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Adult-onset Still's disease (AOSD) is rare inflammatory disease of unknown etiology that usually affects young adults. The more common clinical manifestations are spiking fevers, arthritis, evanescent rash, elevated liver enzymes, lymphadenopathy, hepatosplenomegaly, and serositis. The multi-visceral involvement of the disease and the different complications, such as macrophage activation syndrome, may strongly decrease the life expectancy of AOSD patients. METHODS This study aimed to identify the positive and negative features correlated with the outcome of patients. A retrospective analysis of AOSD patients prospectively admitted to three rheumatologic centers was performed to identify the clinical features present at the time of diagnosis and to predict the possible outcome. Furthermore, we investigated the as yet to be validated prognostic value of the systemic score previously proposed. RESULTS One hundred consecutive AOSD patients were enrolled. The mean systemic score showed that the majority of patients had a multi-organ involvement. Sixteen patients showed different complications, mainly the macrophage activation syndrome. A strong increase of inflammatory markers was observed. All patients received steroids at different dosages, 55 patients in association with immunosuppressive drugs and 32 in association with biologic agents. Sixteen patients died during the follow-up. Regression analysis showed that the higher values of the systemic score and the presence of AOSD-related complications, assessed at the time of diagnosis, were significantly correlated with patient mortality. A prognostic impact of the systemic score of ≥ 7.0 was reported. CONCLUSIONS Our study showed that a higher systemic score and the presence of AOSD-related complications at the time of diagnosis were significantly associated with mortality. Of note, a cut-off at 7.0 of the systemic score showed a strong prognostic impact in identifying patients at risk of AOSD-related death.
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Affiliation(s)
- Piero Ruscitti
- Rheumatology Section, Department of Biotechnological and Applied Clinical Science, School of Medicine, University of L'Aquila, Delta 6 Building, Via dell'Ospedale, 67100, L'Aquila, Italy.
| | - Paola Cipriani
- Rheumatology Section, Department of Biotechnological and Applied Clinical Science, School of Medicine, University of L'Aquila, Delta 6 Building, Via dell'Ospedale, 67100, L'Aquila, Italy
| | - Francesco Masedu
- Medical Statistic Section, Department of Biotechnological and Applied Clinical Science, School of Medicine, University of L'Aquila, L'Aquila, Italy
| | - Daniela Iacono
- Rheumatology Section, Department of Clinical and Experimental Medicine, Second University of Naples, Naples, Italy
| | - Francesco Ciccia
- Rheumatology Section, Department of Internal Medicine, University of Palermo, Palermo, Italy
| | - Vasiliki Liakouli
- Rheumatology Section, Department of Biotechnological and Applied Clinical Science, School of Medicine, University of L'Aquila, Delta 6 Building, Via dell'Ospedale, 67100, L'Aquila, Italy
| | - Giuliana Guggino
- Rheumatology Section, Department of Internal Medicine, University of Palermo, Palermo, Italy
| | - Francesco Carubbi
- Rheumatology Section, Department of Biotechnological and Applied Clinical Science, School of Medicine, University of L'Aquila, Delta 6 Building, Via dell'Ospedale, 67100, L'Aquila, Italy
| | - Onorina Berardicurti
- Rheumatology Section, Department of Biotechnological and Applied Clinical Science, School of Medicine, University of L'Aquila, Delta 6 Building, Via dell'Ospedale, 67100, L'Aquila, Italy
| | - Paola Di Benedetto
- Rheumatology Section, Department of Biotechnological and Applied Clinical Science, School of Medicine, University of L'Aquila, Delta 6 Building, Via dell'Ospedale, 67100, L'Aquila, Italy
| | - Marco Valenti
- Medical Statistic Section, Department of Biotechnological and Applied Clinical Science, School of Medicine, University of L'Aquila, L'Aquila, Italy
| | - Giovanni Triolo
- Rheumatology Section, Department of Internal Medicine, University of Palermo, Palermo, Italy
| | - Gabriele Valentini
- Rheumatology Section, Department of Clinical and Experimental Medicine, Second University of Naples, Naples, Italy
| | - Roberto Giacomelli
- Rheumatology Section, Department of Biotechnological and Applied Clinical Science, School of Medicine, University of L'Aquila, Delta 6 Building, Via dell'Ospedale, 67100, L'Aquila, Italy
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798
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Koifman J, Granton J, Thenganatt J. A case of pulmonary arterial hypertension associated with adult hemophagocytic lymphohistiocytosis. Pulm Circ 2016; 6:614-615. [PMID: 28090306 PMCID: PMC5210061 DOI: 10.1086/688490] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Accepted: 06/30/2016] [Indexed: 01/28/2023] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is an aggressive, life-threatening syndrome of excessive immune activation. Presentation is most common among the pediatric population, and cases in adults are rare. The number of nonhematologic presentations described in relation to HLH has been growing. We present a case involving a woman who developed HLH after autologous stem cell transplantation for mantle cell lymphoma. Months later, she received a diagnosis of pulmonary arterial hypertension (PAH) while undergoing treatment for her HLH. To our knowledge, PAH associated with adult HLH has only been described in the literature once before. PAH may now be a potential differential diagnosis for patients with HLH who present with respiratory symptoms.
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Affiliation(s)
- Julius Koifman
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - John Granton
- Division of Respirology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - John Thenganatt
- Division of Respirology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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799
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800
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Hernández-Jiménez P, Díaz-Pedroche C, Laureiro J, Madrid O, Martín E, Lumbreras C. Hemophagocytic lymphohistiocytosis: Analysis of 18 cases. ACTA ACUST UNITED AC 2016. [DOI: 10.1016/j.medcle.2016.12.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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