801
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Ruscitti P, Cipriani P, Ciccia F, Masedu F, Liakouli V, Carubbi F, Berardicurti O, Guggino G, Di Benedetto P, Di Bartolomeo S, Valenti M, Triolo G, Giacomelli R. Prognostic factors of macrophage activation syndrome, at the time of diagnosis, in adult patients affected by autoimmune disease: Analysis of 41 cases collected in 2 rheumatologic centers. Autoimmun Rev 2016; 16:16-21. [PMID: 27664384 DOI: 10.1016/j.autrev.2016.09.016] [Citation(s) in RCA: 59] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2016] [Accepted: 07/29/2016] [Indexed: 12/21/2022]
Abstract
Macrophage activation syndrome (MAS) is a rare, life-threatening disease in which early diagnosis and aggressive therapeutic strategy may improve the outcome. Due to its rarity, epidemiologic data are still lacking. Hyperferritinemia is frequently associated with MAS and might modulate the cytokine storm, which is involved in the development of multiple organ failure. In this paper, we investigated clinical data, treatments, and outcome of a homogeneous cohort of 41 adult MAS patients, complicating autoimmune rheumatic diseases. MAS-related death occurred in 17 patients (42.5%) during the follow-up, and older age and increased serum ferritin levels, at the time of diagnosis, were significantly associated with mortality. In conclusion, adult MAS is associated with high mortality rate. Some clinical features at diagnosis may be predictive of MAS-associated death.
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Affiliation(s)
- Piero Ruscitti
- Division of Rheumatology, University of L'Aquila, L'Aquila, Italy
| | - Paola Cipriani
- Division of Rheumatology, University of L'Aquila, L'Aquila, Italy
| | | | - Francesco Masedu
- Division of Medical Statistic Unit, University of L'Aquila, L'Aquila, Italy
| | | | | | | | | | | | | | - Marco Valenti
- Division of Medical Statistic Unit, University of L'Aquila, L'Aquila, Italy
| | - Giovanni Triolo
- Division of Rheumatology, University of Palermo, Palermo, Italy
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802
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Pascutti MF, Erkelens MN, Nolte MA. Impact of Viral Infections on Hematopoiesis: From Beneficial to Detrimental Effects on Bone Marrow Output. Front Immunol 2016; 7:364. [PMID: 27695457 PMCID: PMC5025449 DOI: 10.3389/fimmu.2016.00364] [Citation(s) in RCA: 100] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Accepted: 09/02/2016] [Indexed: 01/17/2023] Open
Abstract
The ability of the bone marrow (BM) to generate copious amounts of blood cells required on a daily basis depends on a highly orchestrated process of proliferation and differentiation of hematopoietic stem and progenitor cells (HSPCs). This process can be rapidly adapted under stress conditions, such as infections, to meet the specific cellular needs of the immune response and the ensuing physiological changes. This requires a tight regulation in order to prevent either hematopoietic failure or transformation. Although adaptation to bacterial infections or systemic inflammation has been studied and reviewed in depth, specific alterations of hematopoiesis to viral infections have received less attention so far. Viruses constantly pose a significant health risk and demand an adequate, balanced response from our immune system, which also affects the BM. In fact, both the virus itself and the ensuing immune response can have a tremendous impact on the hematopoietic process. On one hand, this can be beneficial: it helps to boost the cellular response of the body to resolve the viral infection. But on the other hand, when the virus and the resulting antiviral response persist, the inflammatory feedback to the hematopoietic system will become chronic, which can be detrimental for a balanced BM output. Chronic viral infections frequently have clinical manifestations at the level of blood cell formation, and we summarize which viruses can lead to BM pathologies, like aplastic anemia, pancytopenia, hemophagocytic lymphohistiocytosis, lymphoproliferative disorders, and malignancies. Regarding the underlying mechanisms, we address specific effects of acute and chronic viral infections on blood cell production. As such, we distinguish four different levels in which this can occur: (1) direct viral infection of HSPCs, (2) viral recognition by HSPCs, (3) indirect effects on HSPCs by inflammatory mediators, and (4) the role of the BM microenvironment on hematopoiesis upon virus infection. In conclusion, this review provides a comprehensive overview on how viral infections can affect the formation of new blood cells, aiming to advance our understanding of the underlying cellular and molecular mechanisms to improve the treatment of BM failure in patients.
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Affiliation(s)
- Maria Fernanda Pascutti
- Landsteiner Laboratory, Department of Hematopoiesis, Sanquin, Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands
| | - Martje N. Erkelens
- Landsteiner Laboratory, Department of Hematopoiesis, Sanquin, Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands
| | - Martijn A. Nolte
- Landsteiner Laboratory, Department of Hematopoiesis, Sanquin, Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands
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803
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Clinical features and survival of extranodal natural killer/T cell lymphoma with and without hemophagocytic syndrome. Ann Hematol 2016; 95:2023-2031. [PMID: 27595760 DOI: 10.1007/s00277-016-2805-9] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Accepted: 08/24/2016] [Indexed: 12/31/2022]
Abstract
Extranodal natural killer (NK)/T cell lymphoma-associated hemophagocytic syndrome (HPS) (NK/T-LAHS) is a heterogeneous and life-threatening disease, which warrants investigation of its risk factors and clinical features. We retrospectively analyzed the clinical records of 202 patients with extranodal NK/T cell lymphoma and compared the characteristics and survival of extranodal NK/T cell lymphoma patients with and without HPS. The cumulative incidence of NK/T-LAHS was 11.4 % (23/202). In a multivariate logistic regression model, younger age (p = 0.012), bone marrow involvement (p = 0.012), and reduced serum albumin (p < 0.001) were independent risk factors for developing HPS in patients with extranodal NK/T cell lymphoma. The survival of extranodal NK/T cell lymphoma patients was aggravated when complicated with HPS, with an overall 2-year survival of 72.1 and 30.4 %, respectively (p < 0.001). Six patients with HPS onset at lymphoma diagnosis tended to have a poor performance status (p = 0.040), while the rate of elevated bilirubin was significantly higher in 17 patients with HPS onset at lymphoma relapse (p = 0.045). After HPS onset, treatment response was poor (response rate, 17.4 %) and survival was dismal with a median of 26 days. Univariate analysis showed that patients with lactate dehydrogenase >1000 U/L (p = 0.048) and disseminated intravascular coagulation (p = 0.004) had shorter survival time. Extranodal NK/T cell lymphoma was frequently complicated with HPS, and survival was discouraging in this circumstance. Intensive chemotherapy regimens including L-asparaginase or pegaspargase and allogeneic stem cell transplantation should be investigated.
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804
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Costantino C, Stenzel P. Kikuchi-Fujimoto disease with lymph node, spleen, and liver involvement: Report of a fatal adult case with hemophagocytic lymphohistiocytosis. HUMAN PATHOLOGY: CASE REPORTS 2016. [DOI: 10.1016/j.ehpc.2015.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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805
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Abstract
In this issue of Blood, Das and colleagues report their results on the use of the Janus kinase 1/2 (JAK1/2) inhibitor ruxolitinib in murine models of hemophagocytic lymphohistiocytosis (HLH), and the HLH-sibling macrophage activation syndrome (MAS).
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806
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Denimal D, Ménégaut L, Rossi C, Duvillard L, Masson D. Extreme hyperferritinemia in the setting of acute myeloid leukaemia: a case report of hemophagocytic lymphohistiocytosis. Biochem Med (Zagreb) 2016; 26:255-9. [PMID: 27346972 PMCID: PMC4910283 DOI: 10.11613/bm.2016.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Accepted: 03/06/2016] [Indexed: 11/25/2022] Open
Abstract
Introduction Major hyperferritinemia is a rare feature in clinical laboratories associated with a wide variety of disorders, including hemophagocytic lymphohistiocytosis (HLH). The diagnosis of HLH is based on clinical and biological criteria, such as those proposed by the Histiocyte Society. However, several of these criteria are not relevant in the specific setting of hematologic malignancies. Materials and methods A 69-year-old male was treated for an acute myeloid leukaemia. On day 15 after the start of chemotherapy, he developed severe sepsis with high fever, low blood pressure and hepatosplenomegaly. Results Blood tests were marked by extreme hyperferritinemia (191,000 µg/L, reference range: 26-388 µg/L) with increased C-reactive protein (87.0 mg/L) and procalcitonin (1.94 µg/L) and aspartate aminotransferase (499 U/L 37 °C) in the setting of chemotherapy-induced aplasia. This unusual extreme ferritinemia led to suspect HLH triggered by an invasive infection. Under intensive treatment, the clinical status improved and ferritin levels significantly decreased. Conclusions The diagnosis of HLH is usually based on clinical and biological criteria, mainly fever, splenomegaly, cytopenias, hypertriglyceridemia, hypofibrinogenemia, hemophagocytosis and hyperferritinemia. In this patient, the diagnosis of HLH was challenging because several criteria, such as hypertriglyceridemia, hemophagocytosis and hypofibrinogenemia, were absent. In addition, some criteria of HLH are not relevant in the setting of hematologic malignancy, in which fever, splenomegaly, cytopenias and elevated lactate dehydrogenase are commonly observed independently of HLH. This unusual case of extremely high ferritinemia emphasizes the important weight of the ferritin level for the diagnosis of HLH in adult patients in the setting of hematologic malignancies.
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Affiliation(s)
- Damien Denimal
- Department of Biochemistry, University Hospital Centre Dijon-Burgundy, France
| | - Louise Ménégaut
- Department of Biochemistry, University Hospital Centre Dijon-Burgundy, France
| | - Cédric Rossi
- Department of Clinical Hematology, University Hospital Centre Dijon-Burgundy, France
| | - Laurence Duvillard
- Department of Biochemistry, University Hospital Centre Dijon-Burgundy, France
| | - David Masson
- Department of Biochemistry, University Hospital Centre Dijon-Burgundy, France
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807
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Rokx C, van Laar JAM, Rijnders BJA. Suggested Relationship Between Hemophagocytic Lymphohistiocytosis and Bartonella henselae. Clin Infect Dis 2016; 63:427-8. [DOI: 10.1093/cid/ciw301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2016] [Accepted: 03/14/2016] [Indexed: 11/13/2022] Open
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808
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Deroux A, Andry F, Bouillet L. Syndrome d’activation macrophagique sous tocilizumab : mythe ou réalité ? Rev Med Interne 2016; 37:564-6. [DOI: 10.1016/j.revmed.2015.10.348] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2015] [Revised: 08/13/2015] [Accepted: 10/24/2015] [Indexed: 12/21/2022]
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809
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Oh HS, Kim M, Lee JO, Kim H, Kim ES, Park KU, Kim HB, Song KH. Hemophagocytic lymphohistiocytosis associated with SFTS virus infection: A case report with literature review. Medicine (Baltimore) 2016; 95:e4476. [PMID: 27495089 PMCID: PMC4979843 DOI: 10.1097/md.0000000000004476] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Severe fever with thrombocytopenia syndrome (SFTS) is a new emerging zoonosis. Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening syndrome caused by hyperinflammation. Here, we report the case of SFTS-associated HLH. CASE SUMMARY A 62-year-old man was admitted to local hospital with 8 days of fever and chill. He had leukopenia, thrombocytopenia, and developed seizure. An attending physician examined bone marrow to rule out hematologic malignancy. He was transferred to tertiary referral hospital for suspicious HLH. We decided to confirm its histologic feature for sure. Bone marrow and liver biopsy showed hemophagocyotic histiocytes. Serological tests for other infections were all negative except SFTS virus polymerase chain reactions (PCRs) as positive from serum, bone marrow, bronchoalveolar lavage fluid, and liver biopsy specimen. A definitive diagnosis was SFTS-associated HLH. During 2 weeks of conservative treatment, he succeeded in recovery from multiple organ failure. CONCLUSION SFTS should be considered one of differential diagnosis of HLH. In certain endemic areas, SFTS infection deserves clinicians' attention because it can be presented hematologic diseases as HLH.
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Affiliation(s)
| | | | | | | | | | - Kyoung Un Park
- Department of Pathology, Seoul National University Bundang Hospital, Seongnam, South Korea
| | | | - Kyoung-Ho Song
- Department of Internal Medicine
- Correspondence: Kyoung-Ho Song, Department of Internal Medicine, Seoul National University Bundang Hospital, 82 Gumi-ro 173 beon-gil, Bundang-gu, Seongnam 463-707, South Korea (e-mail: ; )
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810
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Wang HY, Yang CF, Chiou TJ, Yang SH, Gau JP, Yu YB, Chen PM, Hsu HC, Fung CP, Lin HY, Tzeng CH, Liu JH, Hsiao LT. Risk of hemophagocytic lymphohistiocytosis in adults with fevers of unknown origin: the clinical utility of a new scoring system on early detection. Hematol Oncol 2016; 35:835-844. [DOI: 10.1002/hon.2333] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Revised: 06/06/2016] [Accepted: 06/24/2016] [Indexed: 11/12/2022]
Affiliation(s)
- Hao-Yuan Wang
- Division of Hematology and Oncology, Department of Medicine; Taipei Veterans General Hospital; Taipei Taiwan
- Faculty of Medicine, School of Medicine; National Yang-Ming University; Taipei Taiwan
| | - Ching-Fen Yang
- Faculty of Medicine, School of Medicine; National Yang-Ming University; Taipei Taiwan
- Department of Pathology and Laboratory Medicine; Taipei Veterans General Hospital; Taipei Taiwan
| | - Tzeon-Jye Chiou
- Faculty of Medicine, School of Medicine; National Yang-Ming University; Taipei Taiwan
- Division of Transfusion Medicine, Department of Medicine; Taipei Veterans General Hospital; Taipei Taiwan
| | - Sheng-Hsiang Yang
- Faculty of Medicine, School of Medicine; National Yang-Ming University; Taipei Taiwan
- Division of Oncology and Hematology, Department of Medicine; National Yang-Ming University Hospital; Yilan Taiwan
| | - Jyh-Pyng Gau
- Division of Hematology and Oncology, Department of Medicine; Taipei Veterans General Hospital; Taipei Taiwan
- Faculty of Medicine, School of Medicine; National Yang-Ming University; Taipei Taiwan
| | - Yuan-Bin Yu
- Division of Hematology and Oncology, Department of Medicine; Taipei Veterans General Hospital; Taipei Taiwan
- Faculty of Medicine, School of Medicine; National Yang-Ming University; Taipei Taiwan
| | - Po-Min Chen
- Division of Hematology and Oncology, Department of Medicine; Taipei Veterans General Hospital; Taipei Taiwan
- Faculty of Medicine, School of Medicine; National Yang-Ming University; Taipei Taiwan
| | - Hui-Chi Hsu
- Faculty of Medicine, School of Medicine; National Yang-Ming University; Taipei Taiwan
- Division of General Medicine, Department of Medicine; Taipei Veterans General Hospital; Taipei Taiwan
| | - Chang-Phone Fung
- Faculty of Medicine, School of Medicine; National Yang-Ming University; Taipei Taiwan
- Division of Infectious Disease, Department of Medicine; Taipei Veterans General Hospital; Taipei Taiwan
| | - Hsiao-Yi Lin
- Faculty of Medicine, School of Medicine; National Yang-Ming University; Taipei Taiwan
- Division of Allergy, Immunology, and Rheumatology, Department of Medicine; Taipei Veterans General Hospital; Taipei Taiwan
| | - Cheng-Hwai Tzeng
- Division of Hematology and Oncology, Department of Medicine; Taipei Veterans General Hospital; Taipei Taiwan
- Faculty of Medicine, School of Medicine; National Yang-Ming University; Taipei Taiwan
| | - Jin-Hwang Liu
- Division of Hematology and Oncology, Department of Medicine; Taipei Veterans General Hospital; Taipei Taiwan
- Faculty of Medicine, School of Medicine; National Yang-Ming University; Taipei Taiwan
| | - Liang-Tsai Hsiao
- Division of Hematology and Oncology, Department of Medicine; Taipei Veterans General Hospital; Taipei Taiwan
- Faculty of Medicine, School of Medicine; National Yang-Ming University; Taipei Taiwan
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811
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Gerfaud-Valentin M, Cottin V, Jamilloux Y, Hot A, Gaillard-Coadon A, Durieu I, Broussolle C, Iwaz J, Sève P. Parenchymal lung involvement in adult-onset Still disease: A STROBE-compliant case series and literature review. Medicine (Baltimore) 2016; 95:e4258. [PMID: 27472698 PMCID: PMC5265835 DOI: 10.1097/md.0000000000004258] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Parenchymal lung involvement (PLI) in adult-onset Still's disease (AOSD) has seldom, if ever, been studied. We examine here retrospective cohort AOSD cases and present a review of the literature (1971-2014) on AOSD-related PLI cases.Patients with PLI were identified in 57 AOSD cases. For inclusion, the patients had to fulfill Yamaguchi or Fautrel classification criteria, show respiratory symptoms, and have imaging evidence of pulmonary involvement, and data allowing exclusion of infectious, cardiogenic, toxic, or iatrogenic cause of PLI should be available. This AOSD + PLI group was compared with a control group (non-PLI-complicated AOSD cases from the same cohort).AOSD + PLI was found in 3 out of the 57 patients with AOSD (5.3%) and the literature mentioned 27 patients. Among these 30 AOSD + PLI cases, 12 presented an acute respiratory distress syndrome (ARDS) and the remaining 18 another PLI. In the latter, a nonspecific interstitial pneumonia computed tomography pattern prevailed in the lower lobes, pulmonary function tests showed a restrictive lung function, the alveolar differential cell count was neutrophilic in half of the cases, and the histological findings were consistent with bronchiolitis and nonspecific interstitial pneumonia. Corticosteroids were fully efficient in all but 3 patients. Ten out of 12 ARDS cases occurred during the first year of the disease course. All ARDS-complicated AOSD cases received corticosteroids with favorable outcomes in 10 (2 deceased). Most PLIs occurred during the systemic onset of AOSD.PLI may occur in 5% of AOSDs, of which ARDS is the most severe. Very often, corticosteroids are efficient in controlling this complication.
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Affiliation(s)
- Mathieu Gerfaud-Valentin
- Hospices Civils de Lyon, Hôpital Universitaire de la Croix Rousse, Service de Médecine Interne
- Université de Lyon, Lyon
- Université Lyon 1, Villeurbanne
- Correspondence: Mathieu Gerfaud-Valentin, Hospices Civils de Lyon, Hôpital Universitaire de la Croix Rousse, Service de Médecine Interne, 103 Grande Rue de la Croix Rousse, F-69004 Lyon, France (e-mail: )
| | - Vincent Cottin
- Université de Lyon, Lyon
- Université Lyon 1, Villeurbanne
- Hospices civils de Lyon, Hôpital Louis Pradel, Centre national de référence des maladies pulmonaires rares, centre de compétences de l’hypertension pulmonaire, service de pneumologie, Bron
| | - Yvan Jamilloux
- Hospices Civils de Lyon, Hôpital Universitaire de la Croix Rousse, Service de Médecine Interne
- Université de Lyon, Lyon
- Université Lyon 1, Villeurbanne
| | - Arnaud Hot
- Université de Lyon, Lyon
- Université Lyon 1, Villeurbanne
- Hospices Civils de Lyon, Hôpital Edouard Herriot, Service de Médecine Interne, Lyon
| | - Agathe Gaillard-Coadon
- Hospices Civils de Lyon, Hôpital Universitaire de la Croix Rousse, Service de Médecine Interne
- Université de Lyon, Lyon
- Université Lyon 1, Villeurbanne
| | - Isabelle Durieu
- Université de Lyon, Lyon
- Université Lyon 1, Villeurbanne
- Hospices Civils de Lyon, Centre Hospitalier Lyon Sud, Service de Médecine Interne, Pierre-Bénite
| | - Christiane Broussolle
- Hospices Civils de Lyon, Hôpital Universitaire de la Croix Rousse, Service de Médecine Interne
- Université de Lyon, Lyon
- Université Lyon 1, Villeurbanne
| | - Jean Iwaz
- Université de Lyon, Lyon
- Université Lyon 1, Villeurbanne
- Hospices Civils de Lyon, Service de Biostatistique, Lyon
- CNRS UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Équipe Biostatistique Santé, Pierre-Bénite, France
| | - Pascal Sève
- Hospices Civils de Lyon, Hôpital Universitaire de la Croix Rousse, Service de Médecine Interne
- Université de Lyon, Lyon
- Université Lyon 1, Villeurbanne
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812
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Al-Helou G, Anklesaria Z, Kohlwes J, Ahari J, Dhaliwal G. When the Illness Goes Off Script-An Exercise in Clinical Reasoning. J Gen Intern Med 2016; 31:803-7. [PMID: 26976289 PMCID: PMC4907950 DOI: 10.1007/s11606-016-3632-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2015] [Revised: 01/08/2016] [Accepted: 02/08/2016] [Indexed: 12/02/2022]
Affiliation(s)
- Georges Al-Helou
- Pulmonary and Critical Care Division, George Washington University Hospital, Washington, DC, USA.
| | - Zafia Anklesaria
- Pulmonary and Critical Care Division, University of California, Los Angeles, CA, USA
| | - Jeffrey Kohlwes
- Department of Medicine, University of California, San Francisco, CA, USA.,Medical Service, San Francisco VA Medical Center, San Francisco, CA, USA
| | - Jalil Ahari
- Pulmonary and Critical Care Division, George Washington University Hospital, Washington, DC, USA
| | - Gurpreet Dhaliwal
- Department of Medicine, University of California, San Francisco, CA, USA.,Medical Service, San Francisco VA Medical Center, San Francisco, CA, USA
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813
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Batu ED, Erden A, Seyhoğlu E, Kilic L, Büyükasık Y, Karadag O, Bilginer Y, Bilgen SA, Akdogan A, Kiraz S, Ertenli AI, Özen S, Kalyoncu U. Assessment of the HScore for reactive haemophagocytic syndrome in patients with rheumatic diseases. Scand J Rheumatol 2016; 46:44-48. [PMID: 27359073 DOI: 10.3109/03009742.2016.1167951] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
OBJECTIVES Reactive haemophagocytic syndrome (RHS) is a hyperinflammatory disorder often occurring in the background of several disorders such as infections, malignancies, and rheumatic diseases. Recently, a score known as the HScore was developed for the diagnosis of RHS. In the original study, most of the patients had underlying haematological malignancy or infection and the best cut-off value for the HScore was 169 (sensitivity 93%; specificity 86%). In this study we aimed to analyse the performance of the HScore in rheumatic disease-related RHS. METHOD The patients with rheumatic disorders evaluated in the Departments of Rheumatology and Paediatric Rheumatology at Hacettepe University, Ankara, Turkey between 2002 and 2014 were reviewed retrospectively. The first group (n = 30) consisted of patients with RHS; the control group (n = 64) included patients with active rheumatic diseases without RHS. RESULTS In the RHS group, 14 (46.7%) had adult-onset Still's disease (AOSD), 10 (33.3%) systemic juvenile idiopathic arthritis (SJIA), and six (20%) systemic lupus erythematosus (SLE). The control group (n = 64) consisted of 32 (50%) AOSD, 13 (20.3%) SJIA, and 19 (29.7%) SLE patients. Applying the HScore to the RHS patients, the best cut-off value was 190.5 with a sensitivity of 96.7% and specificity of 98.4%. When we excluded the patients from the control group who had not had bone marrow aspiration (n = 23), the same cut-off (190.5) performed best (sensitivity 96.7%; specificity 97.6%). Applying the 2004 haemophagocytic lymphohistiocytosis (HLH-2004) criteria gave a sensitivity of 56.6% and a specificity of 100% in the whole study group. CONCLUSIONS In our study, a cut-off value for the HScore different from the original study performed better. Further studies are warranted to determine optimum cut-off values in different studies.
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Affiliation(s)
- E D Batu
- a Department of Paediatrics, Division of Rheumatology , Hacettepe University Faculty of Medicine , Ankara , Turkey
| | - A Erden
- b Department of Internal Medicine, Division of Rheumatology , Hacettepe University Faculty of Medicine , Ankara , Turkey
| | - E Seyhoğlu
- c Department of Internal Medicine , Hacettepe University Faculty of Medicine , Ankara , Turkey
| | - L Kilic
- b Department of Internal Medicine, Division of Rheumatology , Hacettepe University Faculty of Medicine , Ankara , Turkey
| | - Y Büyükasık
- d Department of Internal Medicine, Division of Haematology , Hacettepe University Faculty of Medicine , Ankara , Turkey
| | - O Karadag
- b Department of Internal Medicine, Division of Rheumatology , Hacettepe University Faculty of Medicine , Ankara , Turkey
| | - Y Bilginer
- a Department of Paediatrics, Division of Rheumatology , Hacettepe University Faculty of Medicine , Ankara , Turkey
| | - S A Bilgen
- b Department of Internal Medicine, Division of Rheumatology , Hacettepe University Faculty of Medicine , Ankara , Turkey
| | - A Akdogan
- b Department of Internal Medicine, Division of Rheumatology , Hacettepe University Faculty of Medicine , Ankara , Turkey
| | - S Kiraz
- b Department of Internal Medicine, Division of Rheumatology , Hacettepe University Faculty of Medicine , Ankara , Turkey
| | - A I Ertenli
- b Department of Internal Medicine, Division of Rheumatology , Hacettepe University Faculty of Medicine , Ankara , Turkey
| | - S Özen
- a Department of Paediatrics, Division of Rheumatology , Hacettepe University Faculty of Medicine , Ankara , Turkey
| | - U Kalyoncu
- b Department of Internal Medicine, Division of Rheumatology , Hacettepe University Faculty of Medicine , Ankara , Turkey
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814
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Collapsing glomerulopathy associated with hemophagocytic syndrome in a patient with NK/T cell lymphoma. Clin Nephrol Case Stud 2016; 4:11-17. [PMID: 29043136 PMCID: PMC5437998 DOI: 10.5414/cncs108586] [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: 03/02/2015] [Accepted: 06/15/2015] [Indexed: 11/18/2022] Open
Abstract
Hemophagocytic syndrome (HPS) is a rare condition caused by dysregulated activation of the immune system leading to infiltration of bone marrow and organs by nonmalignant macrophages that phagocytose blood cells. Primary HPS is caused by inherited immune dysregulation whereas secondary HPS is triggered by neoplastic, infectious or autoimmune diseases. Clinically, the syndrome presents with continuous high-grade fever in association with multi-organ involvement. Few data are available regarding renal manifestations of HPS. We report a 60-year-old patient with NK/T cell nasopharyngeal extranodal lymphoma who presented with acute kidney injury and nephrotic range proteinuria in association with fever and pancytopenia. A kidney biopsy was consistent with collapsing glomerulopathy. A final diagnosis of HPS was made on the basis of clinical, laboratory, and bone marrow biopsy findings in accordance with established diagnostic criteria. Steroid therapy was initiated. However, the patient failed to recover his renal function and remained hemodialysis-dependent. Key diagnostic and therapeutic challenges and strategies used to overcome those challenges are discussed.
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815
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Acute Disseminated Encephalomyelitis. J Clin Apher 2016; 31:163-202. [PMID: 27322219 DOI: 10.1002/jca.21474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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816
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Brisse E, Matthys P, Wouters CH. Understanding the spectrum of haemophagocytic lymphohistiocytosis: update on diagnostic challenges and therapeutic options. Br J Haematol 2016; 174:175-87. [PMID: 27292929 DOI: 10.1111/bjh.14144] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
The cytokine storm syndrome 'haemophagocytic lymphohistiocytosis' (HLH) is an under-recognized hyperinflammatory disorder, causing high morbidity and mortality risk in children and adults. It can be subdivided into a primary, genetic form and a secondary, acquired form that complicates diverse infections, malignancies and autoimmune or autoinflammatory disorders. Both subtypes present with the same spectrum of non-specific symptoms, making accurate diagnosis and rapid treatment initiation challenging. In the last decade, increased awareness and international collaborative efforts fuelled a marked progress in diagnostic protocols and novel treatment strategies for HLH and new diagnostic guidelines are being tailored to specific secondary HLH subtypes. Therapy is gradually shifting its focus from overall immunosuppression towards targeting specific cytokines, cell types or signalling pathways underlying pathophysiology. Nevertheless, continued research efforts remain indispensable to customize therapy to individual patient needs.
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Affiliation(s)
- Ellen Brisse
- Laboratory of Immunobiology, Rega Institute, KU Leuven, Leuven, Belgium
| | - Patrick Matthys
- Laboratory of Immunobiology, Rega Institute, KU Leuven, Leuven, Belgium
| | - Carine H Wouters
- Laboratory of Paediatric Immunology, KU Leuven, University Hospital Gasthuisberg, Leuven, Belgium
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817
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Brisse E, Wouters CH, Matthys P. Advances in the pathogenesis of primary and secondary haemophagocytic lymphohistiocytosis: differences and similarities. Br J Haematol 2016; 174:203-17. [PMID: 27264204 DOI: 10.1111/bjh.14147] [Citation(s) in RCA: 93] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Haemophagocytic lymphohistiocytosis (HLH) comprises a heterogeneous spectrum of hyperinflammatory conditions that are inherited (primary HLH) or acquired in a context of infections, malignancies or autoimmune/autoinflammatory disorders (secondary HLH). Genetic defects in the cytotoxic machinery of natural killer and CD8(+) T cells underlie primary HLH, with residual cytotoxicity determining disease severity. Improved sequencing techniques have expanded the range of causal mutations and have redefined many cases of secondary HLH as primary HLH and vice versa, blurring the distinction between both subtypes. These insights allow HLH to be conceptualized as a threshold disease, in which interplay between various genetic and environmental factors causes progressive inflammation into a critical point, beyond which uncontrolled activation of immune cells and excessive cytokine production give rise to the cardinal symptoms of HLH. Various pathogenic pathways may thus converge to a common end stage of fulminant HLH.
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Affiliation(s)
- Ellen Brisse
- Laboratory of Immunobiology, Rega Institute, KU Leuven, Leuven, Belgium
| | - Carine H Wouters
- Laboratory of Paediatric Immunology, KU Leuven, University Hospital Gasthuisberg, Leuven, Belgium
| | - Patrick Matthys
- Laboratory of Immunobiology, Rega Institute, KU Leuven, Leuven, Belgium
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818
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819
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Tamamyan GN, Kantarjian HM, Ning J, Jain P, Sasaki K, McClain KL, Allen CE, Pierce SA, Cortes JE, Ravandi F, Konopleva MY, Garcia-Manero G, Benton CB, Chihara D, Rytting ME, Wang S, Abdelall W, Konoplev SN, Daver NG. Malignancy-associated hemophagocytic lymphohistiocytosis in adults: Relation to hemophagocytosis, characteristics, and outcomes. Cancer 2016; 122:2857-66. [PMID: 27244347 DOI: 10.1002/cncr.30084] [Citation(s) in RCA: 80] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Revised: 04/02/2016] [Accepted: 04/19/2016] [Indexed: 12/24/2022]
Abstract
BACKGROUND Malignancy-associated hemophagocytic lymphohistiocytosis (HLH) in adults is a highly lethal disorder. Knowledge gaps have resulted in under diagnosis or delayed diagnosis. METHODS The University of Texas MD Anderson Cancer Center pathology database (1991-2014) was retrospectively interrogated for the keywords "hemophagocytosis" and/or "lymphohistiocytosis." Seventy-seven adult patients were identified. All had an underlying malignancy. Sixteen patients who had insufficient documentation were excluded. RESULTS The majority of patients who had pathologic evidence of hemophagocytosis/lymphohistiocytosis had an incomplete workup to confirm or refute HLH using the 2004 HLH criteria (HLH-2004; n = 8 variables), which is a common problem in adult HLH. Only 13 of 61 patients (21%) met the HLH-2004 diagnostic criteria based on available retrospective data. To identify potentially missed cases of HLH, the published literature was reviewed, and selected additional variables known to be associated with adult HLH were selected, resulting in extended diagnostic criteria of 18 variables. Thirty-five patients met the extended criteria, and 33 had follow-up data available. The median overall survival of the 13 patients who met both the extended criteria and the HLH-2004 criteria was similar to that of the 20 patients who met the extended criteria but NOT the HLH-2004 criteria (1.43 vs 1.76 months, respectively; P = .34) indicating a similar underlying, aggressive, systemic process. Twenty-six patients did not meet either criteria, and 17 had follow-up data available. The median overall survival of the 17 patients who had pathologic hemophagocytosis or lymphohistiocytosis but met neither criteria was significantly superior to the survival of those who met both the extended criteria and the HLH-2004 criteria and those who met the extended criteria but not the HLH-2004 criteria (17.27 vs 1.43 vs 1.76, respectively; P = .002). CONCLUSIONS The addition of diagnostic laboratory variables that are more easily and rapidly available in smaller institutions and primary care settings than the HLH-2004 variables may be a good surrogate to raise early suspicion of malignancy-associated HLH. Prospective validation is warranted. Cancer 2016. © 2016 American Cancer Society. Cancer 2016;122:2857-2866. © 2016 American Cancer Society.
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Affiliation(s)
- Gevorg N Tamamyan
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas.,Department of Oncology, Yerevan State Medical University, Yerevan, Armenia
| | - Hagop M Kantarjian
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jing Ning
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Preetesh Jain
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Koji Sasaki
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Kenneth L 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
| | - Sherry A Pierce
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jorge E Cortes
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Farhad Ravandi
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Marina Y Konopleva
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | | | - Christopher B Benton
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Dai Chihara
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Michael E Rytting
- Department of Leukemia, 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
| | - Waleed Abdelall
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Sergej N Konoplev
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Naval G Daver
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
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820
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A matched case-control study of toxoplasmosis after allogeneic haematopoietic stem cell transplantation: still a devastating complication. Clin Microbiol Infect 2016; 22:636-41. [PMID: 27172809 DOI: 10.1016/j.cmi.2016.04.025] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Revised: 04/26/2016] [Accepted: 04/30/2016] [Indexed: 11/22/2022]
Abstract
Toxoplasmosis (TXP) is a life-threatening complication of allogeneic haematopoietic stem cell transplantation (AHSCT). Little is known about the risk factors and there is no consensus on prophylactic measures. To investigate the risk factors, we conducted a single-centre, retrospective matched case-control study among adults who underwent AHSCT from January 2006 to March 2015 in our hospital. TXP cases were identified from the prospectively maintained hospital's database. The 1:2 control population consisted of the two patients who received an AHSCT immediately before and after each case with similar donor relationship (related, unrelated) but who did not develop TXP. Risk factors were identified by conditional logistic regression. Clinical features and outcome of TXP were examined. Twenty-three (3.9%) cases of TXP (20 diseases, three infections) were identified among 588 AHSCT recipients. Twenty (87%) cases had a positive pre-transplant Toxoplasma gondii serology. In comparison with 46 matched control patients, risk factors were the absence of effective anti-Toxoplasma prophylaxis (odds ratio (OR) 11.95; 95% CI 3.04-46.88; p <0.001), high-grade (III-IV) acute graft-versus-host-disease (OR 3.1; 95% CI 1.04-9.23; p 0.042) and receipt of the tumour necrosis factor-α blocker etanercept (OR 12.02; 95% CI 1.33-108.6; p 0.027). Mortality attributable to TXP was 43.5% (n = 10). Non-relapse mortality rates during the study period of cases and controls were 69.6% (n = 16) and 17.4% (n = 8), respectively. Lung involvement was the dominant clinical feature (n = 14). Two cases were associated with graft failure, one preceded by haemophagocytic syndrome. Given TXP-related morbidity and attributable mortality, anti-Toxoplasma prophylaxis is essential for optimized management of seropositive AHSCT recipients.
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821
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Filippone EJ, Farber JL. Hemophagocytic lymphohistiocytosis: an update for nephrologists. Int Urol Nephrol 2016; 48:1291-1304. [DOI: 10.1007/s11255-016-1294-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Accepted: 04/11/2016] [Indexed: 12/11/2022]
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822
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Zhang Z, Wang J, Ji B, Bahr Greenwood TV, Zhang Y, Wang Y, Kong D, Li A, Jiang Y, Guo Y, Liu X, Wang Y, Dou A, Li N, Henter JI, Sun G, Zheng C. Clinical presentation of hemophagocytic lymphohistiocytosis in adults is less typical than in children. Clinics (Sao Paulo) 2016; 71:205-9. [PMID: 27166770 PMCID: PMC4825195 DOI: 10.6061/clinics/2016(04)05] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2015] [Accepted: 02/01/2016] [Indexed: 01/16/2023] Open
Abstract
OBJECTIVE Hemophagocytic lymphohistiocytosis in adults is largely underdiagnosed. To improve the rate and accuracy of diagnosis in adults, the clinical and laboratory characteristics of hemophagocytic lymphohistiocytosis were analyzed in and compared between adults and children in a Chinese cohort. METHOD Data from 50 hemophagocytic lymphohistiocytosis patients, including 34 adults and 16 children who fulfilled the 2004 hemophagocytic lymphohistiocytosis diagnostic criteria, were collected and analyzed. RESULTS 1. Etiological factors: The proportion of Epstein-Barr virus infection was lower in adults compared with children, whereas fungal infection and natural killer/T cell lymphoma were more frequent in adults (P<0.05). 2. Clinical manifestations and laboratory findings: Over 90% of adults and pediatric patients presented with fever, thrombocytopenia and high serum ferritin levels. However, in adults, the proportions of hepatomegaly, splenomegaly and jaundice were much lower (P<0.01) than in children, and serous cavity effusion was more frequent in adult patients (P<0.05). More children had hemoglobin <90 g/L, total bilirubin >19 mmol/L and lactate dehydrogenase >500 U/L compared with adults (P<0.05). 3. The time interval from the onset of symptoms to clinical diagnosis was significantly shorter in pediatric patients than in adults (P<0.05). CONCLUSIONS Certain clinical features were different between the two groups. The less characteristic clinical presentation of hemophagocytic lymphohistiocytosis in adults may make the disease more difficult to diagnose. Our findings suggest that hemophagocytic lymphohistiocytosis should be considered when an adult patient presents with the above-mentioned symptoms.
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Affiliation(s)
- Zuojuan Zhang
- Department of Hematology, The Second Hospital of Shandong University, Jinan, China
| | - Juandong Wang
- Department of Hematology, The Second Hospital of Shandong University, Jinan, China
| | - Buqiang Ji
- Department of Hematology, Linyi People's Hospital, Linyi, China
| | | | - Yuan Zhang
- Center of Evidence-based Medicine, Shandong University, Jinan, China
| | - Yongjing Wang
- Department of Hematology, The Second Hospital of Shandong University, Jinan, China
| | - Dexiao Kong
- Department of Hematology, The Second Hospital of Shandong University, Jinan, China
| | - Ai Li
- Department of Hematology, The Second Hospital of Shandong University, Jinan, China
| | - Yang Jiang
- Department of Hematology, The Second Hospital of Shandong University, Jinan, China
| | - Yanan Guo
- Department of Hematology, The Second Hospital of Shandong University, Jinan, China
| | - Xiaoli Liu
- Department of Hematology, The Second Hospital of Shandong University, Jinan, China
| | - Yingxue Wang
- Department of Hematology, The Second Hospital of Shandong University, Jinan, China
| | - Aixia Dou
- Department of Hematology, The Second Hospital of Shandong University, Jinan, China
| | - Nailin Li
- Clinical Pharmacology Unit, Department of Medicine-Solna, Karolinska Institutet at Karolinska University Hospital (Solna), Stockholm, Sweden
| | - Jan-Inge Henter
- Department of Hematology, The Second Hospital of Shandong University, Jinan, China
| | - Guizhen Sun
- Department of Hematology, Linyi People's Hospital, Linyi, China
| | - Chengyun Zheng
- Department of Hematology, The Second Hospital of Shandong University, Jinan, China
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823
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Domínguez-Muñoz MÁ, Morales-Camacho RM, Prats-Martín C, Ávila R, Vargas MT, Burillo S, Bernal R, Borrero JJ. Unusual co-occurrence of Hodgkin lymphoma and hemophagocytic lymphohistiocytosis in a bone marrow aspirate. Ann Hematol 2016; 95:1019-21. [PMID: 27021302 DOI: 10.1007/s00277-016-2647-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2016] [Accepted: 03/15/2016] [Indexed: 10/22/2022]
Affiliation(s)
- M Ángeles Domínguez-Muñoz
- UGC de Hematología. Hospital Universitario Virgen del Rocío, Instituto de Biomedicina de Sevilla (IBIS)/CSIC/Universidad de Sevilla, Avda. Manuel Siurot sn, CP 41013, Sevilla, Spain.
| | - Rosario M Morales-Camacho
- UGC de Hematología. Hospital Universitario Virgen del Rocío, Instituto de Biomedicina de Sevilla (IBIS)/CSIC/Universidad de Sevilla, Avda. Manuel Siurot sn, CP 41013, Sevilla, Spain
| | - Concepción Prats-Martín
- UGC de Hematología. Hospital Universitario Virgen del Rocío, Instituto de Biomedicina de Sevilla (IBIS)/CSIC/Universidad de Sevilla, Avda. Manuel Siurot sn, CP 41013, Sevilla, Spain
| | - Rainiero Ávila
- UGC de Anatomía Patológica. Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - María Teresa Vargas
- UGC de Hematología. Hospital Universitario Virgen del Rocío, Instituto de Biomedicina de Sevilla (IBIS)/CSIC/Universidad de Sevilla, Avda. Manuel Siurot sn, CP 41013, Sevilla, Spain
| | - Sergio Burillo
- Servicio de Inmunología. Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - Ricardo Bernal
- UGC de Hematología. Hospital Universitario Virgen del Rocío, Instituto de Biomedicina de Sevilla (IBIS)/CSIC/Universidad de Sevilla, Avda. Manuel Siurot sn, CP 41013, Sevilla, Spain
| | - Juan José Borrero
- UGC de Anatomía Patológica. Hospital Universitario Virgen del Rocío, Sevilla, Spain
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824
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Cesarine J, Filippone LM, Filippone EJ. Hemophagocytic lymphohistiocytosis in the ED. Am J Emerg Med 2016; 34:2057.e5-2057.e8. [PMID: 27066745 DOI: 10.1016/j.ajem.2016.03.034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Accepted: 03/11/2016] [Indexed: 12/17/2022] Open
Affiliation(s)
- Joseph Cesarine
- Department of Emergency Medicine, Cooper Medical School of Rowan University, Camden, NJ
| | - Lisa M Filippone
- Department of Emergency Medicine, Cooper Medical School of Rowan University, Camden, NJ
| | - Edward J Filippone
- Division of Nephrology, Department of Medicine, Sydney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA 19107.
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825
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Revised classification of histiocytoses and neoplasms of the macrophage-dendritic cell lineages. Blood 2016; 127:2672-81. [PMID: 26966089 DOI: 10.1182/blood-2016-01-690636] [Citation(s) in RCA: 851] [Impact Index Per Article: 106.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Accepted: 03/02/2016] [Indexed: 12/11/2022] Open
Abstract
The histiocytoses are rare disorders characterized by the accumulation of macrophage, dendritic cell, or monocyte-derived cells in various tissues and organs of children and adults. More than 100 different subtypes have been described, with a wide range of clinical manifestations, presentations, and histologies. Since the first classification in 1987, a number of new findings regarding the cellular origins, molecular pathology, and clinical features of histiocytic disorders have been identified. We propose herein a revision of the classification of histiocytoses based on histology, phenotype, molecular alterations, and clinical and imaging characteristics. This revised classification system consists of 5 groups of diseases: (1) Langerhans-related, (2) cutaneous and mucocutaneous, and (3) malignant histiocytoses as well as (4) Rosai-Dorfman disease and (5) hemophagocytic lymphohistiocytosis and macrophage activation syndrome. Herein, we provide guidelines and recommendations for diagnoses of these disorders.
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826
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Chen J, Wang X, He P, Li Y, Si M, Fan Z, Chang X, Xie Q, Jiao X. Viral etiology, clinical and laboratory features of adult hemophagocytic lymphohistiocytosis. J Med Virol 2016; 88:541-9. [PMID: 26287378 PMCID: PMC7166822 DOI: 10.1002/jmv.24359] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/11/2015] [Indexed: 02/05/2023]
Abstract
Secondary hemophagocytic lymphohistiocytosis (SHLH) is a potentially fatal hyperinflammatory syndrome with a heterogeneous etiology and has nonspecific clinical and laboratory findings. The diagnosis and treatment of adult SHLH is challenging because the etiology of the disease is difficult to identify, and the majority of reported cases are pediatric patients. The aim of this study was to describe the etiology, clinical characteristics, and outcomes of adult SHLH. Fifty-four adult patients who fulfilled the criteria of SHLH were enrolled in the study. Viral etiology, blood biomarkers, and clinical manifestations of SHLH were analyzed in these patients. Twenty-four SHLH patients had viraemia, whereas 30 SHLH patients were secondary to other diseases. Epstein-Barr virus (EBV) was the most common virus that associated SHLH among all viruses studied. Severe SHLH patients with EBV-viraemia presented significantly high levels of ferritin, lactate dehydrogenase, aspartate transaminase (AST), and alanine transaminase (ALT). Positively relationships existed between EBV DNA titers and levels of AST and ALT (P < 0.05). The prognosis of SHLH patients with EBV viraemia was worse than that of non-EBV SHLH and non-viral SHLH. Our data reveal that EBV is the major pathogen in virus-associated SHLH, and EBV load influence disease development in SHLH patients with EBV infection that prognosis is worse than other viruses associated SHLH.
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Affiliation(s)
- Jinghong Chen
- Shantou Center for Disease Control and PreventionShantouGuangdongChina
- Cell Biology and Genetics Department of Shantou University Medical CollegeShantouGuangdongChina
| | - Xuehua Wang
- Hospital of Shantou University Medical CollegeShantouGuangdongChina
| | - Ping He
- Cell Biology and Genetics Department of Shantou University Medical CollegeShantouGuangdongChina
| | - Yazhen Li
- Cell Biology and Genetics Department of Shantou University Medical CollegeShantouGuangdongChina
| | - Mengya Si
- Cell Biology and Genetics Department of Shantou University Medical CollegeShantouGuangdongChina
| | - Zhichen Fan
- Cell Biology and Genetics Department of Shantou University Medical CollegeShantouGuangdongChina
| | - Xiaolan Chang
- Cell Biology and Genetics Department of Shantou University Medical CollegeShantouGuangdongChina
| | - Qindong Xie
- Cell Biology and Genetics Department of Shantou University Medical CollegeShantouGuangdongChina
| | - Xiaoyang Jiao
- Cell Biology and Genetics Department of Shantou University Medical CollegeShantouGuangdongChina
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827
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Lehmberg K, Nichols KE, Henter JI, Girschikofsky M, Greenwood T, Jordan M, Kumar A, Minkov M, La Rosée P, Weitzman S. Consensus recommendations for the diagnosis and management of hemophagocytic lymphohistiocytosis associated with malignancies. Haematologica 2016; 100:997-1004. [PMID: 26314082 DOI: 10.3324/haematol.2015.123562] [Citation(s) in RCA: 69] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
The hyperinflammatory syndrome hemophagocytic lymphohistiocytosis can occur in the context of malignancies. Malignancy-triggered hemophagocytic lymphohistiocytosis should be regarded separately from hemophagocytic lymphohistiocytosis during chemotherapeutic treatment, which is frequently associated with an infectious trigger. The substantial overlap between the features of hemophagocytic lymphohistiocytosis with features of neoplasms makes its identification difficult when it occurs in malignant conditions. To facilitate recognition and diagnostic workup, and provide guidance regarding the treatment of malignancy-associated hemophagocytic lymphohistiocytosis, consensus recommendations were developed by the Study Group on Hemophagocytic Lymphohistiocytosis Subtypes of the Histiocyte Society, an interdisciplinary group consisting of pediatric and adult hemato-oncologists and immunologists.
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Affiliation(s)
- Kai Lehmberg
- Department of Pediatric Hematology and Oncology, University Medical Center Eppendorf, Hamburg, Germany
| | - Kim E Nichols
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Jan-Inge Henter
- Childhood Cancer Research Unit, Department of Women's and Children's Health, Karolinska Institutet, Karolinska University Hospital Solna, Stockholm, Sweden
| | - Michael Girschikofsky
- Department of Medicine I, Hematology and Stem Cell Transplantation, Hemostasis and Medical Oncology, Elisabethinen Hospital, Linz, Austria
| | - Tatiana Greenwood
- Childhood Cancer Research Unit, Department of Women's and Children's Health, Karolinska Institutet, Karolinska University Hospital Solna, Stockholm, Sweden
| | - Michael Jordan
- Department of Immunology, Cincinnati Children's Hospital, OH, USA
| | - Ashish Kumar
- Department of Immunology, Cincinnati Children's Hospital, OH, USA
| | - Milen Minkov
- Department of Pediatric Hematology and Oncology, St. Anna Children's Hospital, Vienna, Austria
| | - Paul La Rosée
- Klinik für Innere Medizin II, Abt. Hämatologie und internistische Onkologie, Universitätsklinikum Jena, Germany
| | - Sheila Weitzman
- Department of Hematology and Oncology, Sick Kids Hospital, Toronto, Canada
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828
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Brisse E, Imbrechts M, Put K, Avau A, Mitera T, Berghmans N, Rutgeerts O, Waer M, Ninivaggi M, Kelchtermans H, Boon L, Snoeck R, Wouters CH, Andrei G, Matthys P. Mouse Cytomegalovirus Infection in BALB/c Mice Resembles Virus-Associated Secondary Hemophagocytic Lymphohistiocytosis and Shows a Pathogenesis Distinct from Primary Hemophagocytic Lymphohistiocytosis. THE JOURNAL OF IMMUNOLOGY 2016; 196:3124-34. [PMID: 26903481 DOI: 10.4049/jimmunol.1501035] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/04/2015] [Accepted: 01/22/2016] [Indexed: 01/04/2023]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening immunological disorder that is characterized by systemic inflammation, widespread organ damage, and hypercytokinemia. Primary HLH is caused by mutations in granule-mediated cytotoxicity, whereas secondary HLH occurs, without a known genetic background, in a context of infections, malignancies, or autoimmune and autoinflammatory disorders. Clinical manifestations of both HLH subtypes are often precipitated by a viral infection, predominantly with Herpesviridae. Exploiting this knowledge, we established an animal model of virus-associated secondary HLH by infecting immunocompetent wild-type mice with the β-herpesvirus murine CMV. C57BL/6 mice developed a mild inflammatory phenotype, whereas BALB/c mice displayed the clinicopathologic features of HLH, as set forth in the Histiocyte Society diagnostic guidelines: fever, cytopenia, hemophagocytosis, hyperferritinemia, and elevated serum levels of soluble CD25. BALB/c mice also developed lymphadenopathy, liver dysfunction, and decreased NK cell numbers. Lymphoid and myeloid cells were in a hyperactivated state. Nonetheless, depletion of CD8(+) T cells could not inhibit or cure the HLH-like syndrome, highlighting a first dissimilarity from mouse models of primary HLH. Immune cell hyperactivation in BALB/c mice was accompanied by a cytokine storm. Notably, plasma levels of IFN-γ, a key pathogenic cytokine in models of primary HLH, were the highest. Nevertheless, murine CMV-infected IFN-γ-deficient mice still developed the aforementioned HLH-like symptoms. In fact, IFN-γ-deficient mice displayed a more complete spectrum of HLH, including splenomegaly, coagulopathy, and decreased NK cell cytotoxicity, indicating a regulatory role for IFN-γ in the pathogenesis of virus-associated secondary HLH as opposed to its central pathogenic role in primary HLH.
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Affiliation(s)
- Ellen Brisse
- Laboratory of Immunobiology, Rega Institute, University of Leuven, 3000 Leuven, Belgium
| | - Maya Imbrechts
- Laboratory of Immunobiology, Rega Institute, University of Leuven, 3000 Leuven, Belgium
| | - Karen Put
- Laboratory of Immunobiology, Rega Institute, University of Leuven, 3000 Leuven, Belgium
| | - Anneleen Avau
- Laboratory of Immunobiology, Rega Institute, University of Leuven, 3000 Leuven, Belgium
| | - Tania Mitera
- Laboratory of Immunobiology, Rega Institute, University of Leuven, 3000 Leuven, Belgium
| | - Nele Berghmans
- Laboratory of Molecular Immunology, Rega Institute, University of Leuven, 3000 Leuven, Belgium
| | - Omer Rutgeerts
- Laboratory of Experimental Transplantation, University of Leuven, 3000 Leuven, Belgium
| | - Mark Waer
- Laboratory of Experimental Transplantation, University of Leuven, 3000 Leuven, Belgium
| | - Marisa Ninivaggi
- Synapse BV, Cardiovascular Research Institute Maastricht School for Cardiovascular Diseases, Maastricht University, 6229 Maastricht, the Netherlands
| | - Hilde Kelchtermans
- Synapse BV, Cardiovascular Research Institute Maastricht School for Cardiovascular Diseases, Maastricht University, 6229 Maastricht, the Netherlands
| | - Louis Boon
- Epirus Biopharmaceuticals Netherlands, 3584 Utrecht, the Netherlands
| | - Robert Snoeck
- Laboratory of Virology and Chemotherapy, Rega Institute, University of Leuven, 3000 Leuven, Belgium; and
| | - Carine H Wouters
- Laboratory of Pediatric Immunology, University Hospital Gasthuisberg, University of Leuven, 3000 Leuven, Belgium
| | - Graciela Andrei
- Laboratory of Virology and Chemotherapy, Rega Institute, University of Leuven, 3000 Leuven, Belgium; and
| | - Patrick Matthys
- Laboratory of Immunobiology, Rega Institute, University of Leuven, 3000 Leuven, Belgium;
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829
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Rosado FG, Rinker EB, Plummer WD, Dupont WD, Spradlin NM, Reichard KK, Kim AS. The diagnosis of adult-onset haemophagocytic lymphohistiocytosis: lessons learned from a review of 29 cases of bone marrow haemophagocytosis in two large academic institutions. J Clin Pathol 2016; 69:805-9. [PMID: 26896491 DOI: 10.1136/jclinpath-2015-203577] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Accepted: 01/26/2016] [Indexed: 12/24/2022]
Abstract
AIMS Haemophagocytic lymphohistiocytosis (HLH) is divided into paediatric (primary) and adult (secondary) types. While paediatric-HLH has been extensively characterised, similar studies in adults are limited. This study aims to evaluate the significance of the HLH diagnostic criteria as well as other clinical parameters in adults with bone marrow evidence of haemophagocytosis. METHODS We conducted a 10-year retrospective search of the pathology archives of two institutions for cases with bone marrow haemophagocytosis. We included those cases that fulfilled the currently established HLH diagnostic criteria. For the 29 cases that met inclusion criteria, we assessed clinical features, co-morbidities, therapy and clinical outcome. The effect of 19 clinical variables on mortality outcomes was assessed using logistic and hazard regression analyses. RESULTS Of cases for which an aetiology could be identified, infectious diseases were the most common association (14 of 19, 74%). Fever and elevated ferritin were the most frequently available criteria used to establish HLH. The overall mortality rate was 61% despite HLH-specific therapy, which had been initiated in 48% of the cases. The remaining cases were treated with supportive therapy and antibiotics. The most statistically significant marker of mortality was an elevated absolute neutrophil count (ANC), a feature not typical of HLH. CONCLUSIONS Since elevated ANC correlates with poor outcomes in sepsis, and not HLH, we postulate that many of the patients fulfilling HLH diagnostic criteria in this study likely had sepsis/systemic inflammatory response syndrome rather than HLH. Our results highlight the need to define HLH diagnostic criteria specific to the adult population.
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Affiliation(s)
- Flavia G Rosado
- Department of Pathology, West Virginia University, Morgantown, West Virginia, USA
| | - Elizabeth B Rinker
- Department of Pathology, Louisiana State University Health Sciences Center, New Orleans, Louisiana, USA
| | - W D Plummer
- Department of Biostatistics, Vanderbilt University, Nashville, Tennessee, USA
| | - William D Dupont
- Department of Biostatistics, Vanderbilt University, Nashville, Tennessee, USA
| | - Natalie M Spradlin
- Department of Hematology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Kaaren K Reichard
- Department of Pathology and Laboratory Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Annette S Kim
- Department of Pathology, Brigham and Women's Hospital, Boston, Massachusetts, USA
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830
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Fonseca VR, Espada E, Geraldes R, Ortiz S, Sousa R, Lopez D, Silva MT, Victorino R. Synchronous brain and intravascular B-cell lymphoma after remission of an adult hemophagocytic syndrome. Clin Case Rep 2016; 4:327-30. [PMID: 27099719 PMCID: PMC4831375 DOI: 10.1002/ccr3.507] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2015] [Revised: 12/21/2015] [Accepted: 01/17/2016] [Indexed: 11/10/2022] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) should be considered in the differential diagnosis of adult patients with white matter disease. Brain involvement can be life‐threatening and should prompt aggressive therapy. Even after HLH remission, the possibility of subsequent deterioration due to emergence of an aggressive intravascular lymphoma is highlighted here.
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Affiliation(s)
- Válter R Fonseca
- Serviço de Medicina IICHLN - Hospital de Santa Maria Lisboa Portugal; Faculdade de Medicina da Universidade de Lisboa Instituto de Medicina Molecular Lisboa Portugal
| | - Eduardo Espada
- Faculdade de Medicina da Universidade de Lisboa Instituto de Medicina Molecular Lisboa Portugal; Serviço de Hematologia e Transplantação de Medula CHLN - Hospital de Santa Maria Lisboa Portugal
| | - Ruth Geraldes
- Faculdade de Medicina da Universidade de Lisboa Instituto de Medicina Molecular Lisboa Portugal; Serviço de Neurologia CHLN - Hospital de Santa Maria Lisboa Portugal
| | - Santiago Ortiz
- Serviço de Anatomia Patológica CHLN - Hospital de Santa Maria Lisboa Portugal
| | - Rita Sousa
- Serviço de Imagiologia Neurológica CHLN - Hospital de Santa Maria Lisboa Portugal
| | - Dolores Lopez
- Serviço de Anatomia Patológica CHLN - Hospital de Santa Maria Lisboa Portugal
| | | | - Rui Victorino
- Serviço de Medicina IICHLN - Hospital de Santa Maria Lisboa Portugal; Faculdade de Medicina da Universidade de Lisboa Instituto de Medicina Molecular Lisboa Portugal
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831
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832
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Koshy M, Mishra AK, Agrawal B, Kurup AR, Hansdak SG. Dengue fever complicated by hemophagocytosis. Oxf Med Case Reports 2016; 2016:121-4. [PMID: 27274854 PMCID: PMC4887830 DOI: 10.1093/omcr/omw043] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Dengue is a common acute viral febrile illness in the tropics. Although the usual presentation is that of a self-limiting illness, its complications are protean. We report a 29-year-old man who presented with an acute febrile illness and was diagnosed with dengue hemorrhagic fever. Despite appropriate supportive therapy, the patient initially improved, but subsequently had clinical deterioration. Evaluation revealed features of hemophagocytic lymphohistiocytosis. He was successfully treated with glucocorticoids and had an uneventful recovery. This case adds to the limited adult cases of virus-associated hemophagocytic syndrome in the literature and the need for prompt recognition and treatment of this rare complication.
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Affiliation(s)
- Maria Koshy
- Department of Medicine, Unit 4, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | - Ajay Kumar Mishra
- Department of Medicine, Unit 4, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | - Bhumi Agrawal
- Department of Pathology, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | - Akhil Rajendra Kurup
- Department of Medicine, Unit 4, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | - Samuel George Hansdak
- Department of Medicine, Unit 4, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
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833
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Cetica V, Sieni E, Pende D, Danesino C, De Fusco C, Locatelli F, Micalizzi C, Putti MC, Biondi A, Fagioli F, Moretta L, Griffiths GM, Luzzatto L, Aricò M. Genetic predisposition to hemophagocytic lymphohistiocytosis: Report on 500 patients from the Italian registry. J Allergy Clin Immunol 2016; 137:188-196.e4. [PMID: 26342526 PMCID: PMC4699615 DOI: 10.1016/j.jaci.2015.06.048] [Citation(s) in RCA: 108] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2014] [Revised: 06/04/2015] [Accepted: 06/10/2015] [Indexed: 12/31/2022]
Abstract
BACKGROUND Hemophagocytic lymphohistiocytosis (HLH) is a rare life-threatening disease affecting mostly children but also adults and characterized by hyperinflammatory features. A subset of patients, referred to as having familial hemophagocytic lymphohistiocytosis (FHL), have various underlying genetic abnormalities, the frequencies of which have not been systematically determined previously. OBJECTIVE This work aims to further our understanding of the pathogenic bases of this rare condition based on an analysis of our 25 years of experience. METHODS From our registry, we have analyzed a total of 500 unselected patients with HLH. RESULTS Biallelic pathogenic mutations defining FHL were found in 171 (34%) patients; the proportion of FHL was much higher (64%) in patients given a diagnosis during the first year of life. Taken together, mutations of the genes PRF1 (FHL2) and UNC13D (FHL3) accounted for 70% of cases of FHL. Overall, a genetic diagnosis was possible in more than 90% of our patients with FHL. Perforin expression and the extent of degranulation have been more useful for diagnosing FHL than hemophagocytosis and the cytotoxicity assay. Of 281 (56%) patients classified as having "sporadic" HLH, 43 had monoallelic mutations in one of the FHL-defining genes. Given this gene dosage effect, FHL is not strictly recessive. CONCLUSION We suggest that the clinical syndrome HLH generally results from the combined effects of an exogenous trigger and genetic predisposition. Within this combination, different weights of exogenous and genetic factors account for the wide disease spectrum that ranges from HLH secondary to severe infection to FHL.
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Affiliation(s)
- Valentina Cetica
- Department Pediatric Hematology Oncology, Azienda Ospedaliero-Universitaria Meyer Children Hospital, Florence, Italy
| | - Elena Sieni
- Department Pediatric Hematology Oncology, Azienda Ospedaliero-Universitaria Meyer Children Hospital, Florence, Italy
| | - Daniela Pende
- Istituto di Ricovero e Cura a Carattere Scientifico Azienda Ospedaliera Universitaria San Martino-Istituto Nazionale per la Ricerca sul Cancro, Genoa, Italy
| | - Cesare Danesino
- Medical Genetics, Department of Molecular Medicine, University of Pavia and Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Carmen De Fusco
- Pediatric Hematology and Oncology, Pausilipon Hospital, Naples, Italy
| | - Franco Locatelli
- Department of Pediatric Hematology and Oncology, IRCCS Ospedale Pediatrico Bambino Gesù, Rome, and the University of Pavia, Pavia, Italy
| | | | | | - Andrea Biondi
- Pediatric Clinic, University of Milan Bicocca, San Gerardo Hospital/Fondazione MBBM, Monza, Italy
| | - Franca Fagioli
- Pediatric Onco-Hematology, Stem Cell Transplantation and Cellular Therapy Division, Regina Margherita Children's Hospital, Turin, Italy
| | | | - Gillian M Griffiths
- Cambridge Institute for Medical Research, University of Cambridge Biomedical Campus, Addenbrooke's Hospital, Cambridge, United Kingdom
| | | | - Maurizio Aricò
- Istituto Toscano Tumori (I.T.T.), Florence, Italy; Azienda Sanitaria Provinciale, Ragusa, Italy.
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834
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A Rare Cause of Hemophagocytic Lymphohistiocytosis: FusobacteriumInfection—A Case Report and Review of the Literature. Case Rep Hematol 2016; 2016:4839146. [PMID: 27563473 PMCID: PMC4987471 DOI: 10.1155/2016/4839146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2016] [Accepted: 07/20/2016] [Indexed: 12/02/2022] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a rare syndrome characterized by excessive activation of the immune system. Bacterial infections are very rare precipitants of this disease. A 19-year-old gentleman presented with headache, fatigue, and malaise. He was found to be hypotensive, tachycardic, and febrile. Broad spectrum antibiotics were initiated, and a lumbar puncture ruled out meningitis. Patient progressively developed shock that required use of vasopressors, as well as renal and respiratory failure. Blood cultures grew Fusobacterium necrophorum. Given continued fevers despite appropriate antimicrobials, a bone marrow biopsy was performed revealing increased histiocytes with hemophagocytosis. Dexamethasone was added with dramatic clinical improvement. Our case highlights Fusobacterium as a rare precipitant of HLH and proves that a high index of clinical suspicion is crucial for early diagnosis of HLH, allowing for prompt initiation of HLH-specific immunosuppressive therapy that can be life-saving.
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835
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Abstract
Scrub typhus is associated with various clinical symptoms. However, the pathogenesis of scrub typhus infection remains to be elucidated. A 73-year-old man was admitted to our hospital with consciousness disturbance and suspected meningoencephalitis. The patient's laboratory data showed deterioration and were indicative of hemophagocytic lymphohistiocytosis (HLH). A whole body examination to detect the trigger disease revealed an eschar, which is a characteristic of scrub typhus, on his back. His symptoms showed dramatic improvement after the administration of minocycline (MINO). This case report highlights that the clinical course of a case of scrub typhus meningoencephalitis that was cured with MINO.
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Affiliation(s)
- Tameto Naoi
- Division of Neurology, Department of Internal Medicine, Shin-Oyama City Hospital, Japan
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836
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Progressive Diffuse Osteonecrosis in a Patient with Secondary Hemophagocytic Lymphohistiocytosis. Case Rep Radiol 2015; 2015:730719. [PMID: 26693376 PMCID: PMC4677016 DOI: 10.1155/2015/730719] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2015] [Revised: 10/07/2015] [Accepted: 10/27/2015] [Indexed: 11/17/2022] Open
Abstract
This is a case report with serial imaging showing progression of diffuse osteonecrosis in a patient after a diagnosis of secondary hemophagocytic lymphohistiocytosis (HLH). While bone marrow involvement in HLH has been long noted at histological evaluation and is itself one of the diagnosis criteria, to the best of our knowledge, there has been no previous publication addressing osseous image findings in a patient with HLH.
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837
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Cytokine and viral load kinetics in human herpesvirus 8-associated multicentric Castleman’s disease complicated by hemophagocytic lymphohistiocytosis. Int J Hematol 2015; 103:469-72. [DOI: 10.1007/s12185-015-1928-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Revised: 12/09/2015] [Accepted: 12/11/2015] [Indexed: 10/22/2022]
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838
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Fleischmann R, Böhmerle W, von Laffert M, Jöhrens K, Mengel A, Hotter B, Lindenberg R, Scheibe F, Köhnlein M, von Bahr Greenwood T, Henter JI, Meisel A. Adult hemophagocytic lymphohistiocytosis causing multi organ dysfunction in a patient with multiple autoimmune disorders: when the immune system runs amok. Clin Case Rep 2015; 4:165-70. [PMID: 26862416 PMCID: PMC4736532 DOI: 10.1002/ccr3.467] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2015] [Accepted: 11/05/2015] [Indexed: 12/04/2022] Open
Abstract
We report a case of several autoimmune disorders eventually presenting as severe multi organ dysfunction syndrome caused by adult hemophagocytic lymphohistiocytosis (HLH). Clinical and laboratory tests might lead to fatal misinterpretation without awareness of its diagnostic evaluation, as HLH shares common features with sepsis and immune‐mediated systemic inflammatory response syndromes.
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Affiliation(s)
- Robert Fleischmann
- Neurological Intensive Care Unit Department of Neurology Charité - Universitätsmedizin Berlin 10117 Berlin Germany
| | - Wolfgang Böhmerle
- Neurological Intensive Care Unit Department of Neurology Charité - Universitätsmedizin Berlin 10117 Berlin Germany
| | | | - Korinna Jöhrens
- Department of Pathology Charité - Universitätsmedizin Berlin 10117 Berlin Germany
| | - Annerose Mengel
- Neurological Intensive Care Unit Department of Neurology Charité - Universitätsmedizin Berlin 10117 Berlin Germany
| | - Benjamin Hotter
- Neurological Intensive Care Unit Department of Neurology Charité - Universitätsmedizin Berlin 10117 Berlin Germany
| | - Robert Lindenberg
- Neurological Intensive Care Unit Department of Neurology Charité - Universitätsmedizin Berlin 10117 Berlin Germany
| | - Franziska Scheibe
- Neurological Intensive Care Unit Department of Neurology Charité - Universitätsmedizin Berlin 10117 Berlin Germany
| | - Martin Köhnlein
- Neurological Intensive Care Unit Department of Neurology Charité - Universitätsmedizin Berlin 10117 Berlin Germany
| | - Tatiana von Bahr Greenwood
- Childhood Cancer Research Unit Department of Women׳s and Children׳s Health Karolinska Institutet Karolinska University Hospital Solna 17176 Stockholm Sweden
| | - Jan Inge Henter
- Childhood Cancer Research Unit Department of Women׳s and Children׳s Health Karolinska Institutet Karolinska University Hospital Solna 17176 Stockholm Sweden
| | - Andreas Meisel
- Neurological Intensive Care Unit Department of Neurology Charité - Universitätsmedizin Berlin 10117 Berlin Germany
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839
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Wang J, Wang D, Zhang Q, Duan L, Tian T, Zhang X, Li J, Qiu H. The significance of pre-therapeutic F-18-FDG PET-CT in lymphoma-associated hemophagocytic lymphohistiocytosis when pathological evidence is unavailable. J Cancer Res Clin Oncol 2015; 142:859-71. [PMID: 26666755 PMCID: PMC4791461 DOI: 10.1007/s00432-015-2094-z] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2015] [Accepted: 11/30/2015] [Indexed: 11/07/2022]
Abstract
Purpose
The significance of positron emission tomography/computed tomography (PET–CT) in identifying patients with lymphoma-associated hemophagocytic lymphohistiocytosis (LAHLH) when pathological evidence is unavailable remains uncertain. Methods In this retrospective study, 44 HLH patients who underwent PET–CT before clinical treatment were enrolled, and 18 of them were highly suspected as LAHLH by PET–CT. We compared the PET–CT parameters between confirmed LAHLH and non-LAHLH patients. The efficacy of initial therapies for highly suspected LAHLH patients was analyzed as well. Results
We found that the SUVSp, SUVBM, SUVLN, SUVmax, SUVLN/Li, and SUVmax/Li in LAHLH group were significantly higher than those in non-LAHLH group (p = 0.003, p = 0.034, p = 0.003, p < 0.001, p = 0.039, and p = 0.035, respectively). HLH patients with an SUVmax value >5.5, an SUVLN value >3.3, and an SUVSp value >4.8 were more likely to be LAHLH (p < 0.001, p = 0.003, and p = 0.003, respectively). And the incidence of multiple lymphadenopathy with increased FDG uptake or the incidence of multiple bone lesions in LAHLH patients was significantly higher than those in non-LAHLH group (92.9 vs. 35.7 %, p = 0.004; 42.9 vs. 0 %, p = 0.016, respectively). Furthermore, by comparing the efficacy of initial therapies for highly suspected LAHLH patients (n = 18), we indicated that the CR rate was significantly higher in lymphoma-chemotherapy group than in immunosuppressive therapy group (90 and 25 %, respectively; p = 0.013). OS analysis revealed that highly suspected LAHLH patients treated with lymphoma-chemotherapy had better prognosis (264 days) than those treated with immunosuppressive therapy (15 days) (p < 0.0001). Conclusions When pathological evidence is absent, PET–CT may play an important role in identifying HLH patients underlying lymphoma. Once highly suspected as LAHLH by PET–CT, lymphoma-chemotherapies that directly treat the underling lymphoma may have a relatively favorable effect and better clinical outcomes than immunosuppressive therapy.
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Affiliation(s)
- Jujuan Wang
- Department of Hematology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, 300 Guangzhou Road, Nanjing, 210029, China
| | - Dongjiao Wang
- Department of Hematology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, 300 Guangzhou Road, Nanjing, 210029, China
| | - Qingbo Zhang
- Department of PET-CT Centre, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, 300 Guangzhou Road, Nanjing, 210029, China
| | - Limin Duan
- Department of Geriatrics, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, 300 Guangzhou Road, Nanjing, 210029, China
| | - Tian Tian
- Department of Geriatrics, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, 300 Guangzhou Road, Nanjing, 210029, China
| | - Xiaoyan Zhang
- Department of Hematology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, 300 Guangzhou Road, Nanjing, 210029, China
| | - Jianyong Li
- Department of Hematology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, 300 Guangzhou Road, Nanjing, 210029, China
| | - Hongxia Qiu
- Department of Hematology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, 300 Guangzhou Road, Nanjing, 210029, China. .,Department of Geriatrics, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, 300 Guangzhou Road, Nanjing, 210029, China.
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840
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Lerolle N, Laanani M, Rivière S, Galicier L, Coppo P, Meynard JL, Molina JM, Azoulay E, Aumont C, Marzac C, Fardet L, Lambotte O. Diversity and combinations of infectious agents in 38 adults with an infection-triggered reactive haemophagocytic syndrome: a multicenter study. Clin Microbiol Infect 2015; 22:268.e1-8. [PMID: 26686809 DOI: 10.1016/j.cmi.2015.11.018] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2015] [Revised: 10/25/2015] [Accepted: 11/29/2015] [Indexed: 12/21/2022]
Abstract
Reactive haemophagocytic syndrome (HS) is a rare condition that occurs in patients with infections, haematological malignancies or autoimmune diseases. Although various microorganisms are thought to trigger HS, most of the literature data on this topic have been gathered in single-centre case series. Here, we sought to characterize infectious triggers in a large, multicentre cohort of patients with HS. Patients were included in the present study if HS was solely due to one or more infections. Detailed microbiological data were recorded. Of the 162 patients with HS in the cohort, 40 (25%) had at least one infection and 38 of the latter (including 14 women, 36.8%) were included. The median age was 46 years. Seven patients were presumed to be immunocompetent (18.4%), whereas 19 patients (50%) were infected with human immunodeficiency virus and 12 patients (31.6%) were immunocompromised for other reasons. Twenty-seven patients (71.1%) had a single infection, whereas six (15.8%) and five (13.1%) patients had, respectively, two and three concomitant infections. We observed pyogenic bacterial infections (n = 7), tuberculosis (n = 10), non-tuberculous mycobacteriosis (n = 3), viral infections (n = 17: 11 cytomegalovirus, three Epstein-Barr virus, two human herpesvirus 8, one herpes simplex virus 2), parasitic infections (n = 8: four disseminated toxoplasmosis, one leishmaniasis, three malaria), fungal infections (n = 5: four pulmonary pneumocystosis and one candidaemia). Eighteen patients (47.4%) received corticosteroids and/or etoposide. Twelve patients died (31.6%). All multiple infections and all deaths occurred in immunocompromised patients. When compared with patients suffering from malignancy-associated HS, patients with infection-triggered HS were younger and more likely to be immunocompromised, and had a better outcome.
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Affiliation(s)
- N Lerolle
- Service de Médecine Interne-Immunologie clinique, Hôpital Bicêtre, Université Paris Sud, Paris, France.
| | - M Laanani
- INSERM CESP Centre for Research in Epidemiology and Population Health, Epidemiology of HIV and STI Group, Paris, France
| | - S Rivière
- Service de Médecine Interne, Hôpital Saint Antoine, Université Paris 6, Paris, France
| | - L Galicier
- Service d'Immunologie Clinique, Hôpital Saint Louis, Université Paris Diderot, Paris, France
| | - P Coppo
- Service d'Hématologie, Hôpital Saint Antoine, Université Paris 6, Centre de Référence des Microangiopathies Thrombotiques, Paris, France
| | - J-L Meynard
- Service de Maladies Infectieuses, Hôpital Saint Antoine, Université Paris 6, Paris, France
| | - J-M Molina
- Service de Maladies Infectieuses, Hôpital Saint Louis, Université Paris Diderot, Paris, France
| | - E Azoulay
- Service de Réanimation Médicale, Hôpital Saint Antoine, Université Paris 6, Paris, France
| | - C Aumont
- Service d'Hématologie Biologique, Hôpital Bicêtre, Université Paris Sud, Paris, France
| | - C Marzac
- Service d'Hématologie Biologique, Hôpital Saint Antoine, Université Paris 6, Paris, France
| | - L Fardet
- Service de Dermatologie, Hôpital Henri Mondor, Université Paris 12, Paris, France
| | - O Lambotte
- Service de Médecine Interne-Immunologie clinique, Hôpital Bicêtre, Université Paris Sud, Paris, France
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841
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Ruscitti P, Ciccia F, Cipriani P, Guggino G, Di Benedetto P, Rizzo A, Liakouli V, Berardicurti O, Carubbi F, Triolo G, Giacomelli R. The CD68(+)/H-ferritin(+) cells colonize the lymph nodes of the patients with adult onset Still's disease and are associated with increased extracellular level of H-ferritin in the same tissue: correlation with disease severity and implication for pathogenesis. Clin Exp Immunol 2015; 183:397-404. [PMID: 26540556 DOI: 10.1111/cei.12738] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/04/2015] [Indexed: 12/11/2022] Open
Abstract
In this work, we aimed to evaluate the levels of ferritin enriched in H subunits (H-ferritin) and ferritin enriched in L subunits (L-ferritin) and the cells expressing these two molecules in the lymph node (LN) biopsies obtained from adult-onset Still's disease (AOSD) patients, and the possible correlation among these data and the severity of the disease. Ten patients with AOSD underwent LN biopsy. All the samples were stained by immunofluorescence. A statistical analysis was performed to estimate the possible correlation among both H-ferritin and L-ferritin tissue expression and the clinical picture of the disease. Furthermore, the same analysis was performed to evaluate the possible correlation among the number of CD68(+)/H-ferritin(+) or CD68(+)/L-ferritin(+) cells and the clinical picture. Immunofluorescence analysis demonstrated an increased tissue H-ferritin expression in the LNs of AOSD patients. This increased expression correlated with the severity of the disease. An increased number of CD68 macrophages expressing H-ferritin was observed in the LN samples of our patients. Furthermore, we observed that the number of CD68(+)/H-ferritin(+) cells correlated significantly with the severity of the clinical picture. Our data showed an imbalance between the levels of H- and L-ferritin in LNs of AOSD patients and the evidence of an increased number of CD68(+)/H-ferritin(+) cells in the same organs. Furthermore, a correlation among both the tissue H-ferritin levels and the CD68(+)/H-ferritin(+) cells and the clinical picture was observed.
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Affiliation(s)
- P Ruscitti
- Division of Rheumatology, Department of Biotechnological and Applied Clinical Science, School of Medicine, University of L'Aquila, L'Aquila, Italy
| | - F Ciccia
- Division of Rheumatology, Department of Internal Medicine, University of Palermo, Palermo, Italy
| | - P Cipriani
- Division of Rheumatology, Department of Biotechnological and Applied Clinical Science, School of Medicine, University of L'Aquila, L'Aquila, Italy
| | - G Guggino
- Division of Rheumatology, Department of Internal Medicine, University of Palermo, Palermo, Italy
| | - P Di Benedetto
- Division of Rheumatology, Department of Biotechnological and Applied Clinical Science, School of Medicine, University of L'Aquila, L'Aquila, Italy
| | - A Rizzo
- General Pathology, Ospedali Riuniti Villa Sofia-Cervello, Palermo, Italy
| | - V Liakouli
- Division of Rheumatology, Department of Biotechnological and Applied Clinical Science, School of Medicine, University of L'Aquila, L'Aquila, Italy
| | - O Berardicurti
- Division of Rheumatology, Department of Biotechnological and Applied Clinical Science, School of Medicine, University of L'Aquila, L'Aquila, Italy
| | - F Carubbi
- Division of Rheumatology, Department of Biotechnological and Applied Clinical Science, School of Medicine, University of L'Aquila, L'Aquila, 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 Science, School of Medicine, University of L'Aquila, L'Aquila, Italy
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842
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Barba T, Maucort-Boulch D, Iwaz J, Bohé J, Ninet J, Hot A, Lega JC, Guérin C, Argaud L, Broussolle C, Jamilloux Y, Richard JC, Sève P. Hemophagocytic Lymphohistiocytosis in Intensive Care Unit: A 71-Case Strobe-Compliant Retrospective Study. Medicine (Baltimore) 2015; 94:e2318. [PMID: 26705219 PMCID: PMC4697985 DOI: 10.1097/md.0000000000002318] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a critical condition that may lead to organ failure and early death. The aim of this retrospective observational study was to describe a cohort of HLH patients admitted to intensive care unit (ICU) and investigate the risk factors of early death.A positive HLH diagnosis was defined by an HScore ≥ 169. Univariate and multivariate analyses were carried out to investigate hospital and 28-day mortality risk factors. Between January 2002 and July 2014, 71 HLH cases were seen at our institution.The overall 28-day mortality (start at ICU admission) and hospital mortality were 38% and 68%, respectively. The factors associated with increased 28-day mortality were the sequential organ failure assessment score at ICU admission (P < .001) and advance in age (P = 0.03). The factors associated with increased hospital mortality were a high sequential organ failure assessment score at ICU admission (P < 0.01), advance in age (P = 0.04), and the presence of lymphoma-related HLH or HLH of unknown origin (P < 0.01).Organ failure overtops the classical early-death risk factors in adult ICU-admitted HLH patients. This failure and the subsequent early death may be prevented by timely specific cytotoxic therapies and the control of the underlying disease.
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Affiliation(s)
- Thomas Barba
- From the Hospices Civils de Lyon, Department of Internal Medicine, Croix-Rousse University Hospital, Lyon; Université Lyon I, Villeurbanne (TB, CB, YJ, PS); Hospices Civils de Lyon, Service de Biostatistique, Lyon; CNRS UMR 5558, Equipe Biostatistique-Santé, Pierre-Bénite; Université Lyon I, Villeurbanne (DM-B, JI); Hospices Civils de Lyon, Intensive Care Unit, Centre Hospitalier Lyon Sud, Pierre-Bénite; Université Lyon I, Villeurbanne (JB); Hospices Civils de Lyon, Department of Internal Medicine, Edouard Herriot University Hospital, Lyon; Université Lyon I (JN, AH); Hospices Civils de Lyon, Department of Internal Medicine, Centre Hospitalier Lyon Sud, Pierre-Bénite; Université Lyon I (JCL); Hospices Civils de Lyon, Intensive Care Unit, Croix-Rousse University Hospital, Lyon; Université Lyon I, Villeurbanne (CG, JCR); and Hospices Civils de Lyon, Intensive Care Unit, Edouard Herriot University Hospital, Lyon; Université Lyon I, Villeurbanne, France (LA)
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843
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Lim SH, Park S, Jang JH, Kim K, Kim HJ, Kim SH, Kang CI, Chung DR, Peck KR, Lee J, Cha HS, Koh EM, Ko YH, Kim WS, Jung CW, Kim SJ. Clinical significance of bone marrow hemophagocytosis in adult patients with malignancy and non-malignancy-induced hemophagocytic lymphohistiocytosis. Ann Hematol 2015; 95:325-35. [PMID: 26453074 DOI: 10.1007/s00277-015-2523-8] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2015] [Accepted: 10/04/2015] [Indexed: 10/23/2022]
Abstract
Bone marrow hemophagocytosis is a frequently observed but not mandatory finding for the diagnosis of hemophagocytic lymphohistiocytosis (HLH). However, the impact of bone marrow hemophagocytosis on the diagnosis of HLH is still not clear in adult patients. Thus, we retrospectively analyzed adult patients with bone marrow hemophagocytosis between 2000 and 2014 to determine its clinical significance. Among 264 patients with bone marrow hemophagocytosis, malignant disorders were the predominant underlying cause (n = 170, 64 %), especially T/NK-cell (n = 88) and B-cell (n = 45) lymphomas compared to infectious disease (48/264, 18 %). The data for HLH-2004 diagnostic criteria was available in 182 patients, and only 29 % (77/264) of patients with ≥ five positive criteria could be diagnosed with HLH. Among the criteria for the diagnosis of HLH, increased serum ferritin (89 %) was more common than hypofibrinogenemia, hypertriglyceridemia, and bicytopenia (<40 %). The median overall survival was worse in patients with malignancy (9.0 months, 95 % confidence interval [CI] 5.6-12.5) than in those with non-malignant disorders (71.8 months, 95 % CI 56.5-87.1, P < 0.001). In patients with malignancy, the overall survival of patients fulfilling the HLH-2004 criteria was significantly worse than patients who did not (P < 0.001). In conclusion, our results suggest that bone marrow hemophagocytosis might be an important finding in the diagnosis of HLH in adult patients. Considering the high incidence of malignancy as a predisposing disorder for HLH, immediate evaluation should be performed in adult patients with bone marrow hemophagocytosis.
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Affiliation(s)
- Sung Hee Lim
- Division of Hematology-Oncology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Silvia Park
- Division of Hematology-Oncology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Jun Ho Jang
- Division of Hematology-Oncology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Kihyun Kim
- Division of Hematology-Oncology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Hee-Jin Kim
- Department of Laboratory Medicine & Genetics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Sun-Hee Kim
- Department of Laboratory Medicine & Genetics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Cheol-In Kang
- Division of Infectious Diseases, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Doo Ryeon Chung
- Division of Infectious Diseases, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Kyong Ran Peck
- Division of Infectious Diseases, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Jaejoon Lee
- Division of Rheumatology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Hoon-Suk Cha
- Division of Rheumatology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Eun-Mi Koh
- Division of Rheumatology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Young Hyeh Ko
- Department of Pathology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Won Seog Kim
- Division of Hematology-Oncology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Chul Won Jung
- Division of Hematology-Oncology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Seok Jin Kim
- Division of Hematology-Oncology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea. .,Department of Health Sciences and Technology, SAIHST, Sungkyunkwan University, 50 Irwon-dong, Seoul, Gangnam-gu, 135-710, South Korea.
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844
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Hemophagocytic Lymphohistiocytosis Complicating Dengue and Plasmodium vivax Coinfection. Case Rep Med 2015; 2015:696842. [PMID: 26504465 PMCID: PMC4609418 DOI: 10.1155/2015/696842] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2015] [Revised: 07/26/2015] [Accepted: 08/05/2015] [Indexed: 02/05/2023] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a rare disorder. Dysfunction of cytotoxic T and natural killer (NK) cells causes uncontrolled activity of lymphocytes and histiocytes which leads to HLH. Infections, malignancies, and autoimmune disorders are associated with development of HLH. Dengue and Plasmodium vivax are rare causes of HLH. We report the first ever case of a young man who developed fatal HLH that complicated Dengue Hemorrhagic Fever (DHF) and Plasmodium vivax infection.
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845
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Valade S, Azoulay E, Galicier L, Boutboul D, Zafrani L, Stepanian A, Canet E, Lemiale V, Venot M, Veyradier A, Mariotte E. Coagulation Disorders and Bleedings in Critically Ill Patients With Hemophagocytic Lymphohistiocytosis. Medicine (Baltimore) 2015; 94:e1692. [PMID: 26448017 PMCID: PMC4616770 DOI: 10.1097/md.0000000000001692] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Reactive hemophagocytic lymphohistiocytosis (HLH) is a life-threatening condition related to a cytokine storm leading to multiorgan dysfunction. A better understanding of coagulation disorders, frequently reported in HLH patients, may improve outcomes. Critically ill HLH patients managed in a multidisciplinary national reference center were retrospectively included. Relationships between coagulation disorders, severe bleedings, and outcomes were assessed. One hundred and seventeen patients fulfilled the HLH 2004 criteria. The most common HLH etiology was hematologic conditions (73%), followed by infectious diseases (20%), systemic rheumatic diseases (5%), and undetermined HLH etiology (3%). All patients exerted thrombocytopenia. Coagulation disorders were diagnosed in 79 (68%) patients (61 had hypofibrinogenemia < 1.5 g/L, 51 had prothrombin time [PT] < 0%). The worst median value throughout ICU stay was 52% (38-65) for PT with a factor V level of 35% (27-43), 1.59 (1.30-2.09) for the activated partial thromboplastin time (APTT) ratio, and 2.33 g/L (1.13-3.86) for the fibrinogen level. Disseminated intravascular coagulation (DIC) was found in 50% of patients. Coagulation disorders were more frequent in immunocompromised patients, those with histological/cytological feature of hemophagocytosis, those with the highest ferritin concentrations, and in patients with HLH not related to infection. These patients were more prone to receive mechanical ventilation, vasopressors, or renal replacement therapy. Twenty-six (22%) patients presented severe bleeding complications, including 5 patients dying from hemorrhagic shock. Strikingly, the only coagulation parameter significantly associated with severe bleeding was low fibrinogen with a cutoff value of 2 g/L (P = 0.03). Overall, 33 (28%) patients died in the ICU and hospital mortality was 44%. Coagulation disorders were associated with higher mortality, especially fibrinogen < 2 g/L (P = 0.04) and PT value (P = 0.03). The occurrence of bleeding complications was not associated with higher risk of hospital death. Risk factors associated with mortality by multivariate analysis were fibrinogen level < 2 g/L (OR 2.42 [1.08-5.41]), SOFA score > 6 (OR 3.04 [1.32-6.98]), and age > 46 years (OR 2.26 [1.02-5.04]). Up to two-third of critically ill HLH patients present with coagulation disorders. Hypofibrinogenemia or DIC was found in half of the patients and low PT in 40%. These patients require more life support and have a higher mortality rate. Fibrinogen < 2 g/L is associated with the occurrence of severe bleeding and mortality.
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Affiliation(s)
- Sandrine Valade
- From the Medical ICU, Saint Louis Teaching Hospital, Assistance Publique-Hôpitaux de Paris, 1 avenue Claude Vellefaux, Paris, France (SV, EA, LZ, EC, VL, MV, EM); Paris Diderot University, Sorbonne Paris Cité, Paris, France (SV, EA, LG, DB, LZ, AS, EC, VL, MV, AV, EM); Department of Clinical Immunology, Saint-Louis Teaching Hospital, Assistance Publique-Hôpitaux de Paris, 1 avenue Claude Vellefaux, Paris, France (LG, DB); and Hemostasis Laboratory, Lariboisière Teaching Hospital, 2 rue Ambroise Paré, Paris, France (AS, AV)
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846
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Otrock ZK, Gonzalez MD, Eby CS. Ehrlichia-Induced Hemophagocytic Lymphohistiocytosis: A Case Series and Review of Literature. Blood Cells Mol Dis 2015; 55:191-3. [DOI: 10.1016/j.bcmd.2015.06.009] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Accepted: 06/22/2015] [Indexed: 10/23/2022]
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847
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Nikiforow S. The Role of Hematopoietic Stem Cell Transplantation in Treatment of Hemophagocytic Lymphohistiocytosis. Hematol Oncol Clin North Am 2015; 29:943-59. [DOI: 10.1016/j.hoc.2015.06.011] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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848
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Samra B, Yasmin M, Arnaout S, Azzi J. Idiopathic Hemophagocytic Lymphohistiocytosis During Pregnancy Treated with Steroids. Hematol Rep 2015; 7:6100. [PMID: 26487936 PMCID: PMC4591502 DOI: 10.4081/hr.2015.6100] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2015] [Revised: 09/07/2015] [Accepted: 09/07/2015] [Indexed: 12/17/2022] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a rare and severe clinical syndrome characterized by a dysregulated hyperinflammatory immune response. The diagnosis of HLH during pregnancy is especially challenging due to the rarity of this condition. The highly variable clinical presentation, laboratory findings, and associated diagnoses accompanying this syndrome further complicate the problem. A pronounced hyperferritinemia in the setting of systemic signs and symptoms along with a negative infectious and rheumatological workup should raise suspicions for HLH. While treatment ideally consists of immunosuppressive chemotherapy and hematopoietic stem cell transplant, the potential toxicity to both the pregnant woman and the fetus poses a challenging decision. We report the first case of idiopathic HLH presenting as fever of unknown origin in a pregnant woman successfully treated with steroids.
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Affiliation(s)
- Bachar Samra
- Department of Internal Medicine, Staten Island University Hospital , NY, USA
| | - Mohamad Yasmin
- Department of Internal Medicine, Staten Island University Hospital , NY, USA
| | - Sami Arnaout
- Department of Internal Medicine, Staten Island University Hospital , NY, USA
| | - Jacques Azzi
- Department of Internal Medicine, Staten Island University Hospital , NY, USA
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849
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Multicenter study of combination DEP regimen as a salvage therapy for adult refractory hemophagocytic lymphohistiocytosis. Blood 2015; 126:2186-92. [PMID: 26289641 DOI: 10.1182/blood-2015-05-644914] [Citation(s) in RCA: 112] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2015] [Accepted: 08/13/2015] [Indexed: 12/17/2022] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a refractory immune disorder with a significant risk of death. Although standard therapy has dramatically improved survival in HLH patients, approximately 30%, especially adults, show no response to current treatment strategies. This prospective study aimed to investigate the efficacy of liposomal doxorubicin treatment combined with etoposide and methylprednisolone (doxorubicin-etoposide-methylprednisolone; DEP) as a salvage therapy for adult refractory HLH. Adult patients who did not achieve at least partial response 2 weeks after initial standard HLH therapy were enrolled in this study between June 2013 and June 2014. Response to salvage therapy was assessed at 2 and 4 weeks after initiation of DEP therapy and patients were followed until death or until November 2014. Sixty-three refractory HLH patients were enrolled, including 29 cases of lymphoma-associated HLH, 22 cases of Epstein-Barr virus-associated HLH, and 4 cases of familial HLH. There were 8 cases with unknown underlying diseases. Seventeen cases (27.0%) achieved complete response and 31 cases (49.2%) achieved partial response. The overall response was 76.2% (48/63). Patients who showed no response to DEP died within 4 weeks after salvage therapy. Twenty-nine of the 48 patients who achieved partial or complete response survived to subsequent chemotherapy, allogenic hematopoietic stem cell transplantation, or splenectomy. Our study suggests that DEP regimen is an effective salvage regimen for adult refractory HLH, which can prolong patient survival as we continue to understand the responsible mechanisms and bridge the gap between HLH and its underlying diseases. This study was registered in the Chinese Clinical Trials Registry Platform (http://www.chictr.org.cn/) as ChiCTR-IPC-14005514.
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850
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Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a rare but potentially fatal syndrome of pathologic immune dysregulation characterized by clinical signs and symptoms of extreme inflammation. HLH can occur as a genetic or sporadic disorder and, though seen as an inherited condition affecting primarily a pediatric population, can occur at any age and can be encountered in association with a variety of underlying diseases. Clinically the syndrome, whether genetic or acquired, is characterized by fever, hepatosplenomegaly, cytopenias, and activated macrophages in hematopoietic organs. Therapy centers on suppression of this hyperinflammatory state with cytotoxic, immunosuppressive therapy and treatment of any existing HLH triggers.
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Affiliation(s)
| | - Nancy Berliner
- Division of Hematology, Brigham and Women's Hospital, Harvard Medical School, Mid-Campus 3, 75 Francis Street, Boston, MA 02115, USA.
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