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Benezech S, Walzer T, Charrier E, Heidelberg D, De Saint-Basile G, Bertrand Y, Belot A. Late-onset hemophagocytic lymphohistiocytosis with neurological presentation. Clin Case Rep 2017; 5:1743-1749. [PMID: 29152263 PMCID: PMC5676276 DOI: 10.1002/ccr3.1135] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Revised: 07/15/2017] [Accepted: 07/22/2017] [Indexed: 02/02/2023] Open
Abstract
Missense mutations in genes involved in familial hemophagocytic lymphohistiocytosis can delay the onset of this life-threatening disease. In children and adults, early recognition of aspecific features as neurological symptoms is crucial as urgent treatment is required.
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Affiliation(s)
- Sarah Benezech
- Department of Pediatrics Hospices Civils de Lyon Lyon France
| | - Thierry Walzer
- Institut National de la Santé et de la Recherche Médicale U1111 Université de Lyon 1 Lyon France
| | - Emily Charrier
- Institut National de la Santé et de la Recherche Médicale U1111 Université de Lyon 1 Lyon France
| | | | - Geneviève De Saint-Basile
- Institut National de la Santé et de la Recherche Médicale U768 CHU Paris - Hôpital Necker-Enfants Malades Paris France
| | - Yves Bertrand
- Hospices Civils de LyonInstitut d'Hématologie et Oncologie Pédiatrique Lyon France
| | - Alexandre Belot
- Institut National de la Santé et de la Recherche Médicale U1111 Université de Lyon 1 Lyon France.,Department of Rheumatology Hospices Civils de Lyon Lyon France
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Liu D, Hu X, Jiang X, Gao B, Wan C, Chen C. Characterization of a novel splicing mutation in UNC13D gene through amplicon sequencing: a case report on HLH. BMC MEDICAL GENETICS 2017; 18:135. [PMID: 29157204 PMCID: PMC5696762 DOI: 10.1186/s12881-017-0489-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Accepted: 11/02/2017] [Indexed: 11/23/2022]
Abstract
Background Hemophagocytic lymphohistiocytosis (HLH) is a rare but fatal disease caused by uncontrolled proliferation of activated lymphocytes and macrophages. Six genes including SH2D1A, PRF1, UNC13D, STX11, STXBP2 and XIAP were reported as causative genes in most cases. Case presentation Here we report a novel splicing mutation in UNC13D gene, which was identified in an 18-year-old female. Patient was diagnosed as HLH base on HLH-2004 guidelines, no history of inherited diseases was revealed in this family, parents were healthy and non-consanguineous. Splenomegaly and hemophagocytosis in bone marrow were observed in clinical examination. Amplicon sequencing for the whole coding region of 6 HLH-related genes was performed on Ion S5XL genetic analyzer. In all, four heterozygous mutations were detected, including 2 nonpathogenic SNPs (PRF1:c.900C > T, STX11:c.*70G > A) and 2 splicing mutations in UNC13D gene (UNC13D:c.1299 + 1G > A and UNC13D:c.2709 + 1G > A), both of which were predicted to be potentially pathogenic by human splicing finder (HSF3) tool. The result was confirmed by two-generation pedigree analysis base on sanger sequencing. Conclusions Two compound heterozygous splicing mutations in UNC13D gene were identified and considered to be potential pathogenesis in a female patient of HLH. The mutation UNC13D:c.1299 + 1G > A was reported in HLH for the first time. The inheritance mode and source of the mutation in the proband was examined by family analysis. Our data suggest that further studies of the spectrum of HLH-related mutations in China are warranted. Electronic supplementary material The online version of this article (10.1186/s12881-017-0489-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Dongling Liu
- School of Nursing, Zhengzhou University, Zhengzhou, Henan, 450052, China
| | - Xijiang Hu
- Wuhan Children's Hospital (Wuhan Maternal and Child Healthcare Hospital), Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, 430016, China
| | - Xiwen Jiang
- DaAn Gene Co., Ltd. Of Sun Yat-sen University, The Medicine and Biological Engineering Technology Research Center of the Ministry of Health, Guangzhou, Guangdong, China
| | - Bo Gao
- Department of Laboratory Medicine, Taihe Hospital, Hubei University of Medicine, Shiyan, Hubei, China
| | - Cheng Wan
- Department of Biomedical Engineering, College of Engineering, Peking University, Beijing, 100871, China.
| | - Changying Chen
- School of Nursing, Zhengzhou University, Zhengzhou, Henan, 450052, China.
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53
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Beken B, Aytac S, Balta G, Kuskonmaz B, Uckan D, Unal S, Cetin M, Gumruk F. The clinical and laboratory evaluation of familial hemophagocytic lymphohistiocytosis and the importance of hepatic and spinal cord involvement: a single center experience. Haematologica 2017; 103:231-236. [PMID: 29146706 PMCID: PMC5792267 DOI: 10.3324/haematol.2017.178038] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2017] [Accepted: 11/13/2017] [Indexed: 12/31/2022] Open
Abstract
Familial hemophagocytic lymphohistiocytosis is an autosomal recessive, life-threatening condition characterized by defective immune response. A retrospective analysis was performed on 57 patients diagnosed with familial hemophagocytic lymphohistiocytosis at Hacettepe University Pediatric Hematology Department, Ankara, Turkey. Mutation analysis was performed on 37 patients, and of these: 11 had UNC13D, 10 had PRF1 and 3 had STX11 gene mutation. Of these patients, 44% were found to have central nervous system involvement on admission and spinal cord involvement was also seen in 5 patients. Remission was achieved in 24 patients with the treatment, in a median time of 76 days (min-max: 15–705 days). Time to remission was prolonged 3.1 times in patients with a ferritin level 1500 mg/dL or more. When patients were grouped according to age [Group 1 (≤ 2 years), Group 2 (>2 years)]; patients in Group 1 had higher ferritin and aspartate aminotransferase levels but lower fibrinogen levels. The 5-year survival rate was also lower in Group 1. When patients in Group 1 were divided into two sub-groups according to hepatic involvement, the 5-year survival rate of patients who had hepatic involvement was significantly lower than those patients without hepatic involvement (0.7%, 27%, respectively) (P=0.002). The 5-year survival rate of patients who underwent hematopoietic stem cell transplantation was significantly higher than the patients who didn’t (44%, 16%, respectively) (P=0.02). In conclusion, age two years and under, ferritin level above 1500 mg/dL, spinal cord or hepatic involvement should be considered as poor prognostic factors in familial hemophagocytic lymphohistiocytosis.
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Affiliation(s)
- Burcin Beken
- Hacettepe University Department of Pediatrics, Ankara, Turkey
| | - Selin Aytac
- Hacettepe University Department of Pediatric Hematology, Ankara, Turkey
| | - Gunay Balta
- Hacettepe University Department of Pediatric Hematology, Ankara, Turkey
| | - Baris Kuskonmaz
- Hacettepe University Department of Pediatric Hematology, Ankara, Turkey
| | - Duygu Uckan
- Hacettepe University Department of Pediatric Hematology, Ankara, Turkey
| | - Sule Unal
- Hacettepe University Department of Pediatric Hematology, Ankara, Turkey
| | - Mualla Cetin
- Hacettepe University Department of Pediatric Hematology, Ankara, Turkey
| | - Fatma Gumruk
- Hacettepe University Department of Pediatric Hematology, Ankara, Turkey
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Chen X, Zhang Y, Wang F, Wang M, Teng W, Lin Y, Han X, Jin F, Xu Y, Cao P, Fang J, Zhu P, Tong C, Liu H. Germline cytotoxic lymphocytes defective mutations in Chinese patients with lymphoma. Oncol Lett 2017; 14:5249-5256. [PMID: 29113160 PMCID: PMC5656022 DOI: 10.3892/ol.2017.6898] [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: 02/25/2016] [Accepted: 07/07/2017] [Indexed: 11/06/2022] Open
Abstract
Certain patients with lymphoma may harbor mutations in perforin 1 (PRF1), unc-13 homolog D (UNC13D), syntaxin 11 (STX11), STXBP2 (syntaxin binding protein 2) or SH2 domain containing 1A (SH2D1A), which causes functional defects of cytotoxic lymphocytes. Data regarding the association between genetic defects and the development of lymphoma in Chinese patients are limited to date. In the present study, 90 patients with lymphoma were analyzed for UNC13D, PRF1, STXBP2, STX11, SH2D1A and X-linked inhibitor of apoptosis. Mutations were observed in 24 (26.67%) patients; 16 patients exhibited mutations in UNC13D, 7 exhibited PRF1 mutations, and 1 exhibited monoallelic mutation in STX11. UNC13D c.2588G>A/p.G863D mutation was detected in 9 patients (10.00%) and in 4/210 controls (1.90%). This mutation was predicted to be pathogenic and it predominantly existed in the Chinese population. These findings suggest that impaired cytotoxic machinery may represent a predisposing factor for the development of lymphoma. Furthermore, these data describe a distinct mutation spectrum in Chinese patients with lymphoma, whereby UNC13D is the most frequently mutated gene. In addition, these findings suggest UNC13D c.2588G>A mutation is a founder mutation in Chinese patients.
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Affiliation(s)
- Xue Chen
- Department of Pathology and Laboratory Medicine Division, Hebei Yanda Lu Daopei Hospital, Sanhe, Hebei 065201, P.R. China
| | - Yang Zhang
- Department of Pathology and Laboratory Medicine Division, Hebei Yanda Lu Daopei Hospital, Sanhe, Hebei 065201, P.R. China
| | - Fang Wang
- Department of Pathology and Laboratory Medicine Division, Hebei Yanda Lu Daopei Hospital, Sanhe, Hebei 065201, P.R. China
| | - Mangju Wang
- Department of Hematology, Peking University First Hospital, Beijing 100034, P.R. China
| | - Wen Teng
- Department of Pathology and Laboratory Medicine Division, Hebei Yanda Lu Daopei Hospital, Sanhe, Hebei 065201, P.R. China
| | - Yuehui Lin
- Department of Pathology and Laboratory Medicine Division, Hebei Yanda Lu Daopei Hospital, Sanhe, Hebei 065201, P.R. China
| | - Xiangping Han
- Department of Pathology and Laboratory Medicine Division, Hebei Yanda Lu Daopei Hospital, Sanhe, Hebei 065201, P.R. China
| | - Fangyuan Jin
- Department of Pathology and Laboratory Medicine Division, Hebei Yanda Lu Daopei Hospital, Sanhe, Hebei 065201, P.R. China
| | - Yuanli Xu
- Department of Pathology and Laboratory Medicine Division, Hebei Yanda Lu Daopei Hospital, Sanhe, Hebei 065201, P.R. China
| | - Panxiang Cao
- Department of Pathology and Laboratory Medicine Division, Hebei Yanda Lu Daopei Hospital, Sanhe, Hebei 065201, P.R. China
| | - Jiancheng Fang
- Department of Pathology and Laboratory Medicine Division, Hebei Yanda Lu Daopei Hospital, Sanhe, Hebei 065201, P.R. China
| | - Ping Zhu
- Department of Hematology, Peking University First Hospital, Beijing 100034, P.R. China
| | - Chunrong Tong
- Department of Pathology and Laboratory Medicine Division, Hebei Yanda Lu Daopei Hospital, Sanhe, Hebei 065201, P.R. China
| | - Hongxing Liu
- Department of Pathology and Laboratory Medicine Division, Hebei Yanda Lu Daopei Hospital, Sanhe, Hebei 065201, P.R. China
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Kernan KF, Carcillo JA. Hyperferritinemia and inflammation. Int Immunol 2017; 29:401-409. [PMID: 28541437 PMCID: PMC5890889 DOI: 10.1093/intimm/dxx031] [Citation(s) in RCA: 328] [Impact Index Per Article: 46.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Accepted: 05/23/2017] [Indexed: 12/18/2022] Open
Abstract
Understanding of ferritin biology has traditionally centered on its role in iron storage and homeostasis, with low ferritin levels indicative of deficiency and high levels indicative of primary or secondary hemochromatosis. However, further work has shown that iron, redox biology and inflammation are inexorably linked. During infection, increased ferritin levels represent an important host defense mechanism that deprives bacterial growth of iron and protects immune cell function. It may also be protective, limiting the production of free radicals and mediating immunomodulation. Additionally, hyperferritinemia is a key acute-phase reactants, used by clinicians as an indication for therapeutic intervention, aimed at controlling inflammation in high-risk patients. One school of thought maintains that hyperferritinemia is an 'innocent bystander' biomarker of uncontrolled inflammation that can be used to gauge effectiveness of intervention. Other schools of thought maintain that ferritin induction could be a protective negative regulatory loop. Others maintain that ferritin is a key mediator of immune dysregulation, especially in extreme hyperferritinemia, via direct immune-suppressive and pro-inflammatory effects. There is a clear need for further investigation of the role of ferritin in uncontrolled inflammatory conditions both as a biomarker and mediator of disease because its occurrence identifies patients with high mortality risk and its resolution predicts their improved survival.
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Affiliation(s)
- Kate F Kernan
- Department of Critical Care Medicine, University of Pittsburgh, 3550 Terrace Street, Pittsburgh, PA 15261, USA
| | - Joseph A Carcillo
- Department of Critical Care Medicine, University of Pittsburgh, 3550 Terrace Street, Pittsburgh, PA 15261, USA
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56
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Abstract
Hemophagocytic lymphohistocytosis (HLH) is a potentially fatal hyperinflammatory syndrome that is characterized by proliferation of histiocytes and hemophagocytosis in different organs. The diagnostic criteria include fever, hepatosplenomegaly, bicytopenia, high serum ferritin level, decreased natural killer cell activity, elevated soluble CD25 level, high serum fasting triglyceride level or low fibrinogen level, and hemophagocytosis in the bone marrow, spleen, or lymph nodes. HLH can be classified as primary and secondary. Secondary HLH can be related to infections. Here we report a case of Brucella-related HLH, which has been rarely reported in the literature.
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57
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Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening syndrome characterized by a dysregulated hyperinflammatory response associated with aberrant activation of lymphocytes and macrophages that results in hypercytokinemia. It is classically divided into two types: (1) primary or familial HLH and (2) secondary HLH. Familial HLH is generally an autosomal recessive condition, whereas secondary HLH is usually associated with infectious diseases, autoinflammatory and autoimmune diseases (where it is more commonly known as macrophage activation syndrome), malignancy, immunosuppression, hematopoietic stem cell transplantation, organ transplantation, HIV infection, and metabolic diseases. Although its clinical presentation is often similar to bacterial sepsis or systemic inflammatory response syndrome, HLH can be life-threatening. As such, it is imperative to recognize and diagnose HLH in a timely manner to optimize care. [Pediatr Ann. 2017;46(8):e309-e313.].
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58
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Finding a Balance between Protection and Pathology: The Dual Role of Perforin in Human Disease. Int J Mol Sci 2017; 18:ijms18081608. [PMID: 28757574 PMCID: PMC5578000 DOI: 10.3390/ijms18081608] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Revised: 07/20/2017] [Accepted: 07/20/2017] [Indexed: 01/08/2023] Open
Abstract
Perforin is critical for controlling viral infection and tumor surveillance. Clinically, mutations in perforin are viewed as unfavorable, as lack of this pore-forming protein results in lethal, childhood disease, familial hemophagocytic lymphohistiocytosis type 2 (FHL 2). However, many mutations in the coding region of PRF1 are not yet associated with disease. Animal models of viral-associated blood–brain barrier (BBB) disruption and experimental cerebral malaria (ECM) have identified perforin as critical for inducing pathologic central nervous system CNS vascular permeability. This review focuses on the role of perforin in both protecting and promoting human disease. It concludes with a novel hypothesis that diversity observed in the PRF1 gene may be an example of selective advantage that protects an individual from perforin-mediated pathology, such as BBB disruption.
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59
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Prognostic factors of early death in children with hemophagocytic lymphohistiocytosis. Cytokine 2017; 97:80-85. [PMID: 28582648 DOI: 10.1016/j.cyto.2017.03.013] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2016] [Revised: 03/10/2017] [Accepted: 03/31/2017] [Indexed: 11/20/2022]
Abstract
Hemophagocytic lymphohistiocytosis is a rapidly progressing and fatal disease. Early identification of early death for HLH patients based on the laboratory findings at the time of diagnosis could improve the overall survival. A retrospective study was performed on 95 Chinese pediatric patients with HLH. Patients' data including clinical features and laboratory findings at diagnosis were collected. In a multivariate Cox proportional hazard regression model analysis, albumin≤27.75g/L (hazard ratio (HR)=11.82, 95% confidence interval (CI) 2.58-54.23; P=0.001), LDH≥3707.5 U/L (HR=4.15, 95%CI 1.43-12.01; P=0.009), and IL-10≥456pg/ml (HR=12.39, 95%CI 1.59-96.79; P=0.016) at diagnosis were independent prognostic factors of early death. The risk of early death was 33-fold increase in patients with three risk factors (HR=33.33; 95%CI 8.40-125.00; P<0.001), and 12-fold increase in patients with two risk factors (HR=12.80; 95%CI 2.34-69.80; P=0.002) when compared to it in patients with zero to one risk factor. Our results reveal that HLH patients with the risk of early death can be identified by laboratory findings at diagnosis, which may help guide the treatment decision making for this disease.
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60
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Mukda E, Trachoo O, Pasomsub E, Tiyasirichokchai R, Iemwimangsa N, Sosothikul D, Chantratita W, Pakakasama S. Exome sequencing for simultaneous mutation screening in children with hemophagocytic lymphohistiocytosis. Int J Hematol 2017; 106:282-290. [PMID: 28353193 DOI: 10.1007/s12185-017-2223-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2016] [Revised: 03/21/2017] [Accepted: 03/24/2017] [Indexed: 10/19/2022]
Abstract
In the present study, we used exome sequencing to analyze PRF1, UNC13D, STX11, and STXBP2, as well as genes associated with primary immunodeficiency disease (RAB27A, LYST, AP3B1, SH2D1A, ITK, CD27, XIAP, and MAGT1) in Thai children with hemophagocytic lymphohistiocytosis (HLH). We performed mutation analysis of HLH-associated genes in 25 Thai children using an exome sequencing method. Genetic variations found within these target genes were compared to exome sequencing data from 133 healthy individuals. Variants identified with minor allele frequencies <5% and novel mutations were confirmed using Sanger sequencing. Exome sequencing data revealed 101 non-synonymous single nucleotide polymorphisms (SNPs) in all subjects. These SNPs were classified as pathogenic (n = 1), likely pathogenic (n = 16), variant of unknown significance (n = 12), or benign variant (n = 72). Homozygous, compound heterozygous, and double-gene heterozygous variants, involving mutations in PRF1 (n = 3), UNC13D (n = 2), STXBP2 (n = 3), LYST (n = 3), XIAP (n = 2), AP3B1 (n = 1), RAB27A (n = 1), and MAGT1 (n = 1), were demonstrated in 12 patients. Novel mutations were found in most patients in this study. In conclusion, exome sequencing demonstrated the ability to identify rare genetic variants in HLH patients. This method is useful in the detection of mutations in multi-gene associated diseases.
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Affiliation(s)
- Ekchol Mukda
- Molecular Medicine Program, Multidisciplinary Unit, Faculty of Science, Mahidol University, Bangkok, Thailand.,Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Rama IV Road, Rajathevi, Bangkok, 10400, Thailand
| | - Objoon Trachoo
- Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Ekawat Pasomsub
- Department of Pathology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Rawiphorn Tiyasirichokchai
- Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Rama IV Road, Rajathevi, Bangkok, 10400, Thailand
| | - Nareenart Iemwimangsa
- Department of Pathology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Darintr Sosothikul
- Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Wasun Chantratita
- Department of Pathology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Samart Pakakasama
- Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Rama IV Road, Rajathevi, Bangkok, 10400, Thailand.
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Abstract
Epstein-Barr Virus (EBV) infects human B cells and drives them into continuous proliferation. Two key viral factors in this process are the latent membrane proteins LMP1 and LMP2A, which mimic constitutively activated CD40 receptor and B-cell receptor signaling, respectively. EBV-infected B cells elicit a powerful T-cell response that clears the infected B cells and leads to life-long immunity. Insufficient immune surveillance of EBV-infected B cells causes life-threatening lymphoproliferative disorders, including mostly germinal center (GC)-derived B-cell lymphomas. We have modeled acute EBV infection of naive and GC B cells in mice through timed expression of LMP1 and LMP2A. Although lethal when induced in all B cells, induction of LMP1 and LMP2A in just a small fraction of naive B cells initiated a phase of rapid B-cell expansion followed by a proliferative T-cell response, clearing the LMP-expressing B cells. Interfering with T-cell activity prevented clearance of LMP-expressing B cells. This was also true for perforin deficiency, which in the human causes a life-threatening EBV-related immunoproliferative syndrome. LMP expression in GC B cells impeded the GC reaction but, upon loss of T-cell surveillance, led to fatal B-cell expansion. Thus, timed expression of LMP1 together with LMP2A in subsets of mouse B cells allows one to study major clinically relevant features of human EBV infection in vivo, opening the way to new therapeutic approaches.
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García-Montoya L, Sáenz-Tenorio CN, Janta I, Menárguez J, López-Longo FJ, Monteagudo I, Naredo E. Hemophagocytic lymphohistiocytosis in a patient with Sjögren's syndrome: case report and review. Rheumatol Int 2016; 37:663-669. [PMID: 27853859 PMCID: PMC7102319 DOI: 10.1007/s00296-016-3601-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Accepted: 11/04/2016] [Indexed: 02/06/2023]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a very rare syndrome with a mortality up to 95% of cases if not treated. It is characterised by an excessive activation of the immune system that leads to a disproportionate and destructive inflammatory response. The high mortality rates are in part due to a delay in the diagnosis, and therefore clinicians must maintain a high index of suspicion. When the treatment is started early, the survival rate reaches around 55% of cases. HLH usually presents with persistent fever, pancytopenia, and organomegaly and is associated with very high levels of serum ferritin. In this manuscript, we present the case of a patient with primary Sjögren's syndrome who developed HLH after an acute infection by Cytomegalovirus. We will describe and discuss the pathogenesis, differential diagnosis and a pragmatic approach to the treatment for this critically important and, when diagnosed early, potentially curable syndrome.
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Affiliation(s)
- L García-Montoya
- Department of Rheumatology, Hospital General Universitario Gregorio Marañón, 46, Dr. Esquerdo, 28007, Madrid, Spain.
| | - C N Sáenz-Tenorio
- Department of Rheumatology, Hospital General Universitario Gregorio Marañón, 46, Dr. Esquerdo, 28007, Madrid, Spain
| | - I Janta
- Department of Rheumatology, Hospital General Universitario Gregorio Marañón, 46, Dr. Esquerdo, 28007, Madrid, Spain
| | - J Menárguez
- Department of Rheumatology, Hospital General Universitario Gregorio Marañón, 46, Dr. Esquerdo, 28007, Madrid, Spain
| | - F J López-Longo
- Department of Rheumatology, Hospital General Universitario Gregorio Marañón, 46, Dr. Esquerdo, 28007, Madrid, Spain
| | - I Monteagudo
- Department of Rheumatology, Hospital General Universitario Gregorio Marañón, 46, Dr. Esquerdo, 28007, Madrid, Spain
| | - E Naredo
- Department of Rheumatology, Hospital General Universitario Gregorio Marañón, 46, Dr. Esquerdo, 28007, Madrid, Spain
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Ramachandran S, Zaidi F, Aggarwal A, Gera R. Recent advances in diagnostic and therapeutic guidelines for primary and secondary hemophagocytic lymphohistiocytosis. Blood Cells Mol Dis 2016; 64:53-57. [PMID: 28433836 DOI: 10.1016/j.bcmd.2016.10.023] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2016] [Accepted: 10/30/2016] [Indexed: 12/21/2022]
Abstract
BACKGROUND Hemophagocytic lymphohistiocytosis (HLH) is a hyperinflammatory syndrome characterized by excessive activation of macrophages and T cells resulting from defective cytotoxicity. It is potentially life threatening due to the large amounts of cytokines released by the activated macrophages and lymphocytes secondary to a hyperinflammatory response. It has a high fatality in children with an incidence of approximately 1.2cases/million per year. METHOD The literature was extensively searched in PubMed, MEDLINE and Google scholar. RESULTS A variable and nonspecific symptomatology can delay the diagnosis and hence requires a high index of suspicion in both primary and secondary HLH.
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Affiliation(s)
- Smita Ramachandran
- Department of Pediatrics, Safdarjung Hospital, Mahatma Gandhi Marg, Raj Nagar, Safdargunj, Ansari Nagar West, New Delhi, Delhi 110029, India.
| | - Fauzia Zaidi
- Department of Pediatrics, Safdarjung Hospital, Mahatma Gandhi Marg, Raj Nagar, Safdargunj, Ansari Nagar West, New Delhi, Delhi 110029, India.
| | - Archana Aggarwal
- Department of Pediatrics, Safdarjung Hospital, Mahatma Gandhi Marg, Raj Nagar, Safdargunj, Ansari Nagar West, New Delhi, Delhi 110029, India.
| | - Rani Gera
- Department of Pediatrics, Safdarjung Hospital, Mahatma Gandhi Marg, Raj Nagar, Safdargunj, Ansari Nagar West, New Delhi, Delhi 110029, India.
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Morimoto A, Nakazawa Y, Ishii E. Hemophagocytic lymphohistiocytosis: Pathogenesis, diagnosis, and management. Pediatr Int 2016; 58:817-25. [PMID: 27289085 DOI: 10.1111/ped.13064] [Citation(s) in RCA: 130] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2016] [Revised: 06/03/2016] [Accepted: 06/09/2016] [Indexed: 12/14/2022]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening hyperinflammatory syndrome that is classified into primary and secondary HLH. Primary HLH consists of monogenic disorders that mainly affect the perforin-mediated cytotoxicity of cytotoxic T lymphocytes and natural killer cells. Secondary HLH occurs as a complication in various settings such as infection, malignancy, autoimmune disease, and post-allogeneic hematopoietic stem cell transplantation. Both primary and secondary HLH are characterized by uncontrolled hypercytokinemia that results in myelosuppression and vascular endothelium damage. More than 10% of patients with HLH die within 2 months of diagnosis due to bleeding in the visceral organs, opportunistic infection due to neutropenia, or multiple organ failure. The most obvious presentations of HLH are persistent fever refractory to antimicrobial agents and hyperferritinemia due to hypersecretion of various cytokines. The first rule is not to overlook signs of hypercytokinemia and to settle the hyperactivated immunological state as soon as possible. In addition, to improve outcome, it is essential to identify the disorders underlying HLH and provide disorder-appropriate treatment.
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Affiliation(s)
- Akira Morimoto
- Department of Pediatrics, Jichi Medical University of Medicine, Shimotsuke, Tochigi, Japan.
| | - Yozo Nakazawa
- Department of Pediatrics, Shinshu University School of Medicine, Matsumoto, Nagano, Japan
| | - Eiichi Ishii
- Department of Pediatrics, Ehime University Graduate School of Medicine, Toon, Ehime, Japan
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Bustos-Morán E, Blas-Rus N, Martín-Cófreces NB, Sánchez-Madrid F. Orchestrating Lymphocyte Polarity in Cognate Immune Cell-Cell Interactions. INTERNATIONAL REVIEW OF CELL AND MOLECULAR BIOLOGY 2016; 327:195-261. [PMID: 27692176 DOI: 10.1016/bs.ircmb.2016.06.004] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
The immune synapse (IS) is a specialized structure established between different immune cells that fulfills several functions, including a role as a communication bridge. This intimate contact between a T cell and an antigen-presenting cell promotes the proliferation and differentiation of lymphocytes involved in the contact. T-cell activation requires the specific triggering of the T-cell receptor (TCR), which promotes the activation of different signaling pathways inducing the polarization of the T cell. During this process, different adhesion and signaling receptors reorganize at specialized membrane domains, concomitantly to the polarization of the tubulin and actin cytoskeletons, forming stable polarization platforms. The centrosome also moves toward the IS, driving the movement of different organelles, such as the biosynthetic, secretory, degrading machinery, and mitochondria, to sustain T-cell activation. A proper orchestration of all these events is essential for T-cell effector functions and the accomplishment of a complete immune response.
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Affiliation(s)
- Eugenio Bustos-Morán
- Vascular Pathophysiology Area, Spanish National Center of Cardiovascular Research (CNIC), Madrid, Spain
| | - Noelia Blas-Rus
- Department of Immunology, La Princesa Hospital, Autonomus University of Madrid (UAM), Health Research Institute of Princesa Hospital (ISS-IP), Madrid, Spain
| | - Noa Beatriz Martín-Cófreces
- Vascular Pathophysiology Area, Spanish National Center of Cardiovascular Research (CNIC), Madrid, Spain.,Department of Immunology, La Princesa Hospital, Autonomus University of Madrid (UAM), Health Research Institute of Princesa Hospital (ISS-IP), Madrid, Spain
| | - Francisco Sánchez-Madrid
- Vascular Pathophysiology Area, Spanish National Center of Cardiovascular Research (CNIC), Madrid, Spain.,Department of Immunology, La Princesa Hospital, Autonomus University of Madrid (UAM), Health Research Institute of Princesa Hospital (ISS-IP), Madrid, Spain
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Allogeneic hematopoietic stem-cell transplantation for adult and adolescent hemophagocytic lymphohistiocytosis: a single center analysis. Int J Hematol 2016; 104:628-635. [PMID: 27431489 DOI: 10.1007/s12185-016-2062-7] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2015] [Revised: 07/13/2016] [Accepted: 07/13/2016] [Indexed: 12/23/2022]
Abstract
Myeloablative conditioning-based allogeneic hematopoietic stem-cell transplantation (allo-HSCT) in the treatment of adult and adolescent hemophagocytic lymphohistiocytosis (HLH) is rarely reported. We conducted a retrospective study of 30 adult and adolescent HLH transplanted for primary HLH (n = 4), tumor-HLH (n = 8), EBV-HLH (n = 14), and underlying disease-unknown (UDU)-HLH (n = 4). Peripheral blood stem cells (PBSCs) were the stem-cell source in all patients. Twenty-three patients were transplanted from HLA-haploidentical family donors, six from HLA-identical sibling donors, and one from a matched unrelated donor. Four patients appeared with mixed chimerism (MC), and no patient presented with graft failure. There was a high risk for EBV reactivation with an incidence of 47 %. Two patients developed post-transplant lymphoproliferative disorder (PTLD) and three were considered primary disease recurrent. With a median follow-up of 26 months, 19 patients survived and 11 patients died. The estimated 2-year overall survival (OS) was 63.3 ± 8.8 % in all patients, 100 % in primary HLH, 64.3 ± 12.8 % in EBV-HLH, 50.0 ± 17.7 % in tumor-HLH, and 50.0 ± 25.0 % in UDU-HLH. Myeloablative conditioning-based allo-HSCT is an effective treatment for adult and adolescent HLH to achieve complete remission and long-term survival.
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Murphy C, Nanthapisal S, Gilmour K, Laurent S, D'Arco F, Hemingway C, Brogan P, Eleftheriou D. Progressive neurologic disorder: Initial manifestation of hemophagocytic lymphohistiocytosis. Neurology 2016; 86:2109-11. [PMID: 27164702 PMCID: PMC4891214 DOI: 10.1212/wnl.0000000000002729] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2015] [Accepted: 02/24/2016] [Indexed: 11/15/2022] Open
Affiliation(s)
- Claire Murphy
- From the Infection, Immunity, Inflammation and Physiological Medicine Programme (C.M., S.N., P.B., D.E.), University College London Institute of Child Health, UK; Faculty of Medicine (S.N.), Thammasat University, Thailand; Immunology (K.G.), Neuroradiology Department (F.D.), and Neurology Department (C.H.), Great Ormond Street Hospital NHS Foundation Trust, London; and Paediatric Department (S.L.), Royal Free Hospital NHS Foundation Trust, London, UK.
| | - Sira Nanthapisal
- From the Infection, Immunity, Inflammation and Physiological Medicine Programme (C.M., S.N., P.B., D.E.), University College London Institute of Child Health, UK; Faculty of Medicine (S.N.), Thammasat University, Thailand; Immunology (K.G.), Neuroradiology Department (F.D.), and Neurology Department (C.H.), Great Ormond Street Hospital NHS Foundation Trust, London; and Paediatric Department (S.L.), Royal Free Hospital NHS Foundation Trust, London, UK
| | - Kimberly Gilmour
- From the Infection, Immunity, Inflammation and Physiological Medicine Programme (C.M., S.N., P.B., D.E.), University College London Institute of Child Health, UK; Faculty of Medicine (S.N.), Thammasat University, Thailand; Immunology (K.G.), Neuroradiology Department (F.D.), and Neurology Department (C.H.), Great Ormond Street Hospital NHS Foundation Trust, London; and Paediatric Department (S.L.), Royal Free Hospital NHS Foundation Trust, London, UK
| | - Sue Laurent
- From the Infection, Immunity, Inflammation and Physiological Medicine Programme (C.M., S.N., P.B., D.E.), University College London Institute of Child Health, UK; Faculty of Medicine (S.N.), Thammasat University, Thailand; Immunology (K.G.), Neuroradiology Department (F.D.), and Neurology Department (C.H.), Great Ormond Street Hospital NHS Foundation Trust, London; and Paediatric Department (S.L.), Royal Free Hospital NHS Foundation Trust, London, UK
| | - Felice D'Arco
- From the Infection, Immunity, Inflammation and Physiological Medicine Programme (C.M., S.N., P.B., D.E.), University College London Institute of Child Health, UK; Faculty of Medicine (S.N.), Thammasat University, Thailand; Immunology (K.G.), Neuroradiology Department (F.D.), and Neurology Department (C.H.), Great Ormond Street Hospital NHS Foundation Trust, London; and Paediatric Department (S.L.), Royal Free Hospital NHS Foundation Trust, London, UK
| | - Cheryl Hemingway
- From the Infection, Immunity, Inflammation and Physiological Medicine Programme (C.M., S.N., P.B., D.E.), University College London Institute of Child Health, UK; Faculty of Medicine (S.N.), Thammasat University, Thailand; Immunology (K.G.), Neuroradiology Department (F.D.), and Neurology Department (C.H.), Great Ormond Street Hospital NHS Foundation Trust, London; and Paediatric Department (S.L.), Royal Free Hospital NHS Foundation Trust, London, UK
| | - Paul Brogan
- From the Infection, Immunity, Inflammation and Physiological Medicine Programme (C.M., S.N., P.B., D.E.), University College London Institute of Child Health, UK; Faculty of Medicine (S.N.), Thammasat University, Thailand; Immunology (K.G.), Neuroradiology Department (F.D.), and Neurology Department (C.H.), Great Ormond Street Hospital NHS Foundation Trust, London; and Paediatric Department (S.L.), Royal Free Hospital NHS Foundation Trust, London, UK
| | - Despina Eleftheriou
- From the Infection, Immunity, Inflammation and Physiological Medicine Programme (C.M., S.N., P.B., D.E.), University College London Institute of Child Health, UK; Faculty of Medicine (S.N.), Thammasat University, Thailand; Immunology (K.G.), Neuroradiology Department (F.D.), and Neurology Department (C.H.), Great Ormond Street Hospital NHS Foundation Trust, London; and Paediatric Department (S.L.), Royal Free Hospital NHS Foundation Trust, London, UK
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68
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Jamy O, Nunnery S, Giri S, Wiedower E, Johnson B, Yaghmour G, Martin MG. Under-recognition of hemophagocytic syndrome in United States’ rural, non-teaching hospitals. Leuk Lymphoma 2016; 57:2911-2913. [DOI: 10.3109/10428194.2016.1169407] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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69
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Gao L, Dang X, Huang L, Zhu L, Fang M, Zhang J, Xu X, Zhu L, Li T, Zhao L, Wei J, Zhou J. Search for the potential "second-hit" mechanism underlying the onset of familial hemophagocytic lymphohistiocytosis type 2 by whole-exome sequencing analysis. Transl Res 2016; 170:26-39. [PMID: 26739415 DOI: 10.1016/j.trsl.2015.12.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2015] [Revised: 11/22/2015] [Accepted: 12/03/2015] [Indexed: 01/30/2023]
Abstract
Familial hemophagocytic lymphohistiocytosis type 2 (FHL2), caused by perforin 1 (PRF1), is a genetic disorder of lymphocyte cytotoxicity that usually presents in the first 2 years of life and has a poor prognosis. Late onset of FHL2 has been sporadically reported, and the mechanism is largely unknown. A newly diagnosed FHL2 patient was detected to have compound mutations in both PRF1 alleles and positive Epstein-Barr virus (EBV) infection. Her brother carried the same mutations and EBV infection status but kept healthy. To search the potential unknown mechanisms, we performed whole-exome sequencing analysis. The patient and her asymptomatic brother carried the same heterozygous missense (c.916G>A) and frameshift mutation (c.65delC) in PRF1. Germline mutation analysis demonstrated that only the proband was exclusively detected with a homozygous missense mutation (S1006L) in the PCDH18 gene, whereas others were found to have a heterozygous mutation (S1006L) of PCDH18. The calculated stability (free energy) changes showed that the mutation of PCDH18 mainly destabilized the protein structure. Furthermore, the mutation (S1006L) could lessen the PCDH18-induced inhibition of target cell activation and reduce the apoptosis of T lymphocytes. This study is the first to perform whole-exome sequencing analysis to search the potential "second-hit" mechanism that underlies the onset of FHL2. A novel type of compound heterozygous mutation has been found in PRF1. The detection of the homozygous germline mutation in PCDH18 strongly argues that the presence of a "second" germline mutation besides the PRF1 gene might be potentially an important mechanism for triggering the onset of FHL2.
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Affiliation(s)
- Lili Gao
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People's Republic of China
| | - Xiao Dang
- BGI Education Center, University of Chinese Academy of Sciences, Shenzhen, People's Republic of China; BGI-Shenzhen, Shenzhen, People's Republic of China
| | - Liang Huang
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People's Republic of China
| | - Li Zhu
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People's Republic of China
| | - Mingyan Fang
- BGI-Shenzhen, Shenzhen, People's Republic of China
| | | | - Xun Xu
- BGI-Shenzhen, Shenzhen, People's Republic of China
| | - Lijun Zhu
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People's Republic of China
| | - Tongjuan Li
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People's Republic of China
| | - Lei Zhao
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People's Republic of China
| | - Jia Wei
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People's Republic of China.
| | - Jianfeng Zhou
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People's Republic of China.
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Zhou XH, Luo JM, Bin Q, Huang XH. [Expression of porforin and granzyme B in familial hemophagocytic lymphohistiocytosis]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2016; 37:227-32. [PMID: 27033761 PMCID: PMC7342954 DOI: 10.3760/cma.j.issn.0253-2727.2016.03.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/21/2015] [Indexed: 12/28/2022]
Abstract
OBJECTIVE To analyze the correlation between genetic variants of PRF1 and expression level of perforin and granzyme B protein, and further determine the relationship between PRF1 gene variants and cytotoxic T lymphocyte/natural killer (CTL/NK) cell function in famililal hemophagocytic lymphohistiocytosis (FHL2). METHODS Eight children of FHL2 (P1-P8) after treatment, as well as parents and siblings of P1-P5 were included, and thirty healthy children came for physical examination were designated as controls. PRF1, Unc13D, STX11, STXBP2, RAB27A, LYST, SH2D1A, BIRC4 exons were amplified by PCR and followed by direct sequencing. Bioinformatics analysis of mutant PRF1 was performed by ExPASy online system. Perforin and granzyme B expression on cytotoxic lymphocyte was detected by flow cytometry. RESULTS ① Three of eight FHL2 children harbored heterozygous missense of PRF1 exons: P1 had compound heterozygous missense mutations (R4C and R33H) and P2 had heterozygous mutations (V50L), P3 had heterozygous mutations (R489W), which confirmed the diagnosis of FHL2. The father (F1) and younger brother (B1) of P1 also had compound heterozygous missense mutation (R4C/R33H), the mother (M2) and younger brother (B2) of P2 had V50L mutation, the father (F3) of P3 had no R489W mutation and the mother of P3 did not participate in this research, so mutation of R4C/R33H of P1 inherited from paternal line, and V50L mutation of P2 came from maternal line, R489W mutation of P3 came from maternal line. ② Comparing to control group, perforin expression of CD8(+) T cells and natural killer (NK) cells of P1, F1, B1, P2, M2 and B2 decreased significantly, but there was no significant difference between two groups in terms of granzyme B expression. CONCLUSIONS R4C/R33H compound heterozygous mutation and V50L heterozygous mutation all cause lower expression of perforin on CTL/NK cells, and may be causative mutations for familial hemophagocytic lymphohistiocytosis.
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Affiliation(s)
- X H Zhou
- Department of Pediatrics, Guangxi Medical University First Affiliated Hospital, Nanning 530021, China
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71
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Zhang M, Bracaglia C, Prencipe G, Bemrich-Stolz CJ, Beukelman T, Dimmitt RA, Chatham WW, Zhang K, Li H, Walter MR, De Benedetti F, Grom AA, Cron RQ. A Heterozygous RAB27A Mutation Associated with Delayed Cytolytic Granule Polarization and Hemophagocytic Lymphohistiocytosis. THE JOURNAL OF IMMUNOLOGY 2016; 196:2492-503. [PMID: 26880764 DOI: 10.4049/jimmunol.1501284] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 06/10/2015] [Accepted: 01/12/2016] [Indexed: 11/19/2022]
Abstract
Frequently fatal, primary hemophagocytic lymphohistiocytosis (HLH) occurs in infancy resulting from homozygous mutations in NK and CD8 T cell cytolytic pathway genes. Secondary HLH presents after infancy and may be associated with heterozygous mutations in HLH genes. We report two unrelated teenagers with HLH and an identical heterozygous RAB27A mutation (c.259G→C). We explore the contribution of this Rab27A missense (p.A87P) mutation on NK cell cytolytic function by cloning it into a lentiviral expression vector prior to introduction into the human NK-92 cell line. NK cell degranulation (CD107a expression), target cell conjugation, and K562 target cell lysis was compared between mutant- and wild-type-transduced NK-92 cells. Polarization of granzyme B to the immunologic synapse and interaction of mutant Rab27A (p.A87P) with Munc13-4 were explored by confocal microscopy and proximity ligation assay, respectively. Overexpression of the RAB27A mutation had no effect on cell conjugate formation between the NK and target cells but decreased NK cell cytolytic activity and degranulation. Moreover, the mutant Rab27A protein decreased binding to Munc13-4 and delayed granzyme B polarization toward the immunologic synapse. This heterozygous RAB27A mutation blurs the genetic distinction between primary and secondary HLH by contributing to HLH via a partial dominant-negative effect.
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Affiliation(s)
- Mingce Zhang
- Division of Pediatric Rheumatology, University of Alabama at Birmingham, Birmingham, AL 35233
| | - Claudia Bracaglia
- Divisione di Reumatologia Pediatrica, Ospedale Pediatrico Bambino Gesù, 00165 Rome, Italy
| | - Giusi Prencipe
- Divisione di Reumatologia Pediatrica, Ospedale Pediatrico Bambino Gesù, 00165 Rome, Italy
| | - Christina J Bemrich-Stolz
- Division of Pediatric Hematology-Oncology, University of Alabama at Birmingham, Birmingham, AL 35233
| | - Timothy Beukelman
- Division of Pediatric Rheumatology, University of Alabama at Birmingham, Birmingham, AL 35233; Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL 35294
| | - Reed A Dimmitt
- Division of Pediatric Gastroenterology, University of Alabama at Birmingham, Birmingham, AL 35233
| | - W Winn Chatham
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL 35294
| | - Kejian Zhang
- Human Genetics, University of Cincinnati, Cincinnati, OH 45229
| | - Hao Li
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL 35294
| | - Mark R Walter
- Department of Microbiology, University of Alabama at Birmingham, Birmingham, AL 35294; and
| | - Fabrizio De Benedetti
- Divisione di Reumatologia Pediatrica, Ospedale Pediatrico Bambino Gesù, 00165 Rome, Italy
| | - Alexei A Grom
- Division of Pediatric Rheumatology, University of Cincinnati, Cincinnati, OH 45229
| | - Randy Q Cron
- Division of Pediatric Rheumatology, University of Alabama at Birmingham, Birmingham, AL 35233; Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL 35294;
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72
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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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Sultanova AK, Kim SK, Lee JW, Jang PS, Chung NG, Cho B, Park J, Kim Y, Kim M. A Novel Syntaxin 11 Gene (STX11) Mutation c.650T>C, p.Leu217Pro, in a Korean Child With Familial Hemophagocytic Lymphohistiocytosis. Ann Lab Med 2015; 36:170-3. [PMID: 26709266 PMCID: PMC4713852 DOI: 10.3343/alm.2016.36.2.170] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2014] [Revised: 11/08/2015] [Accepted: 11/27/2015] [Indexed: 01/09/2023] Open
Abstract
We report the first Far Eastern case of a Korean child with familial hemophagocytic lymphohistiocytosis (HLH) caused by a novel syntaxin 11 (STX11) mutation. A 33-month-old boy born to non-consanguineous Korean parents was admitted for intermittent fever lasting one week, pancytopenia, hepatosplenomegaly, and HLH in the bone marrow. Under the impression of HLH, genetic study revealed a novel homozygous missense mutation of STX11: c.650T>C, p.Leu217Pro. Although no large deletion or allele drop was identified, genotype analysis demonstrated that the homozygous c.650T>C may have resulted from the duplication of a maternal (unimaternal) chromosomal region and concurrent loss of the other paternal allele, likely caused by meiotic errors such as two crossover events. A cumulative study of such novel mutations and their effects on specific protein interactions may deepen the understanding of how abnormal STX1 expression results in deficient cytotoxic function.
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Affiliation(s)
- Ardak K Sultanova
- Department of Pediatrics, National Research Center for Maternal and Child Health, Astana, Kazakhstan
| | - Seong-koo Kim
- Department of Pediatrics, The Catholic University of Korea, Seoul, Korea
| | - Jae Wook Lee
- Department of Pediatrics, The Catholic University of Korea, Seoul, Korea
| | - Pil-Sang Jang
- Department of Pediatrics, The Catholic University of Korea, Seoul, Korea
| | - Nack-Gyun Chung
- Department of Pediatrics, The Catholic University of Korea, Seoul, Korea
| | - Bin Cho
- Department of Pediatrics, The Catholic University of Korea, Seoul, Korea
| | - Joonhong Park
- Department of Laboratory Medicine, The Catholic University of Korea, Seoul, Korea.,Catholic Genetic Laboratory Center, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Korea
| | - Yonggoo Kim
- Department of Laboratory Medicine, The Catholic University of Korea, Seoul, Korea.,Catholic Genetic Laboratory Center, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Korea
| | - Myungshin Kim
- Department of Laboratory Medicine, The Catholic University of Korea, Seoul, Korea.,Catholic Genetic Laboratory Center, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Korea.
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Tesi B, Lagerstedt-Robinson K, Chiang SCC, Ben Bdira E, Abboud M, Belen B, Devecioglu O, Fadoo Z, Yeoh AEJ, Erichsen HC, Möttönen M, Akar HH, Hästbacka J, Kaya Z, Nunes S, Patiroglu T, Sabel M, Saribeyoglu ET, Tvedt TH, Unal E, Unal S, Unuvar A, Meeths M, Henter JI, Nordenskjöld M, Bryceson YT. Targeted high-throughput sequencing for genetic diagnostics of hemophagocytic lymphohistiocytosis. Genome Med 2015; 7:130. [PMID: 26684649 PMCID: PMC4684627 DOI: 10.1186/s13073-015-0244-1] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2015] [Accepted: 11/11/2015] [Indexed: 01/06/2023] Open
Abstract
Background Hemophagocytic lymphohistiocytosis (HLH) is a rapid-onset, potentially fatal hyperinflammatory syndrome. A prompt molecular diagnosis is crucial for appropriate clinical management. Here, we validated and prospectively evaluated a targeted high-throughput sequencing approach for HLH diagnostics. Methods A high-throughput sequencing strategy of 12 genes linked to HLH was validated in 13 patients with previously identified HLH-associated mutations and prospectively evaluated in 58 HLH patients. Moreover, 2504 healthy individuals from the 1000 Genomes project were analyzed in silico for variants in the same genes. Results Analyses revealed a mutation detection sensitivity of 97.3 %, an average coverage per gene of 98.0 %, and adequate coverage over 98.6 % of sites previously reported as mutated in these genes. In the prospective cohort, we achieved a diagnosis in 22 out of 58 patients (38 %). Genetically undiagnosed HLH patients had a later age at onset and manifested higher frequencies of known secondary HLH triggers. Rare, putatively pathogenic monoallelic variants were identified in nine patients. However, such monoallelic variants were not enriched compared with healthy individuals. Conclusions We have established a comprehensive high-throughput platform for genetic screening of patients with HLH. Almost all cases with reduced natural killer cell function received a diagnosis, but the majority of the prospective cases remain genetically unexplained, highlighting genetic heterogeneity and environmental impact within HLH. Moreover, in silico analyses of the genetic variation affecting HLH-related genes in the general population suggest caution with respect to interpreting causality between monoallelic mutations and HLH. A complete understanding of the genetic susceptibility to HLH thus requires further in-depth investigations, including genome sequencing and detailed immunological characterization. Electronic supplementary material The online version of this article (doi:10.1186/s13073-015-0244-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Bianca Tesi
- Childhood Cancer Research Unit, Department of Women's and Children's Health, Karolinska Institutet, Karolinska University Hospital Solna, SE-17176, Stockholm, Sweden. .,Clinical Genetics Unit, Department of Molecular Medicine and Surgery, and Center for Molecular Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden.
| | - Kristina Lagerstedt-Robinson
- Clinical Genetics Unit, Department of Molecular Medicine and Surgery, and Center for Molecular Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden.,Clinical Genetics, Karolinska University Hospital, Stockholm, Sweden
| | - Samuel C C Chiang
- Centre for Infectious Medicine, Department of Medicine, Karolinska Institutet, Karolinska University Hospital Huddinge, SE-14186, Stockholm, Sweden
| | - Eya Ben Bdira
- Childhood Cancer Research Unit, Department of Women's and Children's Health, Karolinska Institutet, Karolinska University Hospital Solna, SE-17176, Stockholm, Sweden.,Clinical Genetics Unit, Department of Molecular Medicine and Surgery, and Center for Molecular Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Miguel Abboud
- Department of Pediatrics and Adolescent Medicine, American University of Beirut, Beirut, Lebanon
| | - Burcu Belen
- Department of Pediatric Hematology, Izmir Katip Celebi University Medical Faculty, Tepecik Training and Research Hospital, Izmir, Turkey
| | - Omer Devecioglu
- Department of Pediatric Hematology Oncology, Istanbul Medical School, Istanbul, Turkey
| | - Zehra Fadoo
- Department of Oncology and Pediatrics, Aga Khan University, Karachi, Pakistan
| | - Allen E J Yeoh
- Viva-University Children's Cancer Centre, Department of Paediatric, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | | | - Merja Möttönen
- Department of Pediatrics and Adolescence, PEDEGO Research Unit, Oulu University Hospital, Oulu, Finland
| | - Himmet Haluk Akar
- Department of Pediatric Immunology, Erciyes University Medical Faculty, Kayseri, Turkey
| | - Johanna Hästbacka
- Department of Perioperative and Intensive Care, Children's Hospital, Helsinki University Central Hospital, Helsinki, Finland
| | - Zuhre Kaya
- Pediatric Hematology Unit of the Department of Pediatrics, Medical School of Gazi University, Ankara, Turkey
| | - Susana Nunes
- Hematology-Oncology Unit, Department of Pediatrics, São João Hospital Center, Oporto, Portugal
| | - Turkan Patiroglu
- Department of Pediatric Immunology, Erciyes University Medical Faculty, Kayseri, Turkey
| | - Magnus Sabel
- Institute of Clinical Sciences, Department of Pediatrics, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Queen Silvia Children's Hospital, Gothenburg, Sweden
| | - Ebru Tugrul Saribeyoglu
- Department of Pediatric Hematology and Oncology and Bone Marrow Transplantation Unit, Medipol School of Medicine, Medipol University, Istanbul, Turkey
| | - Tor Henrik Tvedt
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | - Ekrem Unal
- Department of Pediatrics, Division of Pediatric Hematology and Oncology, Faculty of Medicine, Erciyes University, Kayseri, Turkey
| | - Sule Unal
- Department of Pediatrics, Division of Pediatric Hematology, Ankara, Turkey
| | - Aysegul Unuvar
- Division of Pediatric Hematology and Oncology, Istanbul School of Medicine, Istanbul University, Istanbul, Turkey
| | - Marie Meeths
- Childhood Cancer Research Unit, Department of Women's and Children's Health, Karolinska Institutet, Karolinska University Hospital Solna, SE-17176, Stockholm, Sweden.,Clinical Genetics Unit, Department of Molecular Medicine and Surgery, and Center for Molecular Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Jan-Inge Henter
- Childhood Cancer Research Unit, Department of Women's and Children's Health, Karolinska Institutet, Karolinska University Hospital Solna, SE-17176, Stockholm, Sweden
| | - Magnus Nordenskjöld
- Clinical Genetics Unit, Department of Molecular Medicine and Surgery, and Center for Molecular Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden.,Clinical Genetics, Karolinska University Hospital, Stockholm, Sweden
| | - Yenan T Bryceson
- Centre for Infectious Medicine, Department of Medicine, Karolinska Institutet, Karolinska University Hospital Huddinge, SE-14186, Stockholm, Sweden. .,Broegelmann Research Laboratory, The Gades Institute, University of Bergen, Bergen, Norway.
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Role of Munc13-4 as a Ca2+-dependent tether during platelet secretion. Biochem J 2015; 473:627-39. [PMID: 26637270 DOI: 10.1042/bj20151150] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2015] [Accepted: 12/04/2015] [Indexed: 11/17/2022]
Abstract
The Munc13 family of exocytosis regulators has multiple Ca(2+)-binding, C2 domains. Here, we probed the mechanism by which Munc13-4 regulates in vitro membrane fusion and platelet exocytosis. We show that Munc13-4 enhances in vitro soluble NSF attachment protein receptor (SNARE)-dependent, proteoliposome fusion in a Ca(2+)- and phosphatidylserine (PS)-dependent manner that was independent of SNARE concentrations. Munc13-4-SNARE interactions, under the conditions used, were minimal in the absence or presence of Ca(2+). However, Munc13-4 was able to bind and cluster liposomes harbouring PS in response to Ca(2+). Interestingly, Ca(2+)-dependent liposome binding/clustering and enhancement of proteoliposome fusion required both Munc13-4 C2 domains, but only the Ca(2+)-liganding aspartate residues of the C2B domain. Analytical ultracentrifugation (AUC) measurements indicated that, in solution, Munc13-4 was a monomeric prolate ellipsoid with dimensions consistent with a molecule that could bridge two fusing membranes. To address the potential role of Munc13-4 as a tethering protein in platelets, we examined mepacrine-stained, dense granule mobility and secretion in platelets from wild-type and Munc13-4 null (Unc13d(Jinx)) mice. In the absence of Munc13-4, dense granules were highly mobile in both resting and stimulated platelets, and stimulation-dependent granule release was absent. These observations suggest that dense granules are stably docked in resting platelets awaiting stimulation and that Munc13-4 plays a vesicle-stabilizing or tethering role in resting platelets and also in activated platelets in response to Ca(2+). In summary, we show that Munc13-4 conveys Ca(2+) sensitivity to platelet SNARE-mediated membrane fusion and reveal a potential mechanism by which Munc13-4 bridges and stabilizes apposing membranes destined for fusion.
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Prognostic Factors and Long-Term Outcome in 52 Turkish Children With Hemophagocytic Lymphohistiocytosis. Pediatr Crit Care Med 2015; 16:e165-73. [PMID: 25901543 DOI: 10.1097/pcc.0000000000000449] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
OBJECTIVES Hemophagocytic lymphohistiocytosis is a syndrome of pathologic immune activation that shares similar clinical and laboratory phenotypes with severe sepsis. Recent studies led to better recognition of hemophagocytic lymphohistiocytosis by clinicians, but no consensus exists on the criteria for high-risk patients. DESIGN We retrospectively reviewed the medical records of patients diagnosed with hemophagocytic lymphohistiocytosis to analyze the risk factors associated with poor outcome. SETTING Pediatric intensive care and hematology units of three tertiary hospitals in Turkey. PARTICIPANTS Fifty-two children with hemophagocytic lymphohistiocytosis. INTERVENTIONS None. MEASUREMENT AND MAIN RESULTS There were a total of 52 children meeting the diagnostic criteria of Histiocytic Society. Of them, 28 (54%) had a primary hemophagocytic lymphohistiocytosis. Mutation studies were performed in 18 of 28 patients (65%). Fourteen of them had PRF1, STX11, STXBP2, and UNC13D mutations, and four had Rab27a and LYST mutations. The remaining 24 patients (46%) were defined as having secondary hemophagocytic lymphohistiocytosis. Twenty-one of them had infection-associated hemophagocytic lymphohistiocytosis, and three had lysinuric protein intolerance. The mortality rate was significantly higher in primary hemophagocytic lymphohistiocytosis (64%) than in secondary hemophagocytic lymphohistiocytosis (16%) (p < 0.05). There were no significant differences for survival rate between hemophagocytic lymphohistiocytosis 94 (44%) and hemophagocytic lymphohistiocytosis 2004 (64%) protocols (p > 0.05). Age below 2 years, hyperferritinemia, thrombocytopenia, high disseminated intravascular coagulation score at diagnosis, and no clinical response at 2 weeks of treatment were independent prognostic factors for poor prognosis. CONCLUSIONS Our data suggest that disseminated intravascular coagulation score greater than or equal to 5 can be used in the definition of high-risk patients. Early recognition of poor risk factors has important prognostic and therapeutic implications.
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Zhang L, Zhou J, Sokol L. Hereditary and acquired hemophagocytic lymphohistiocytosis. Cancer Control 2015; 21:301-12. [PMID: 25310211 DOI: 10.1177/107327481402100406] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Hemophagocytic lymphohistiocytosis (HLH) is a rare but life-threatening hyperinflammatory/hypercytokinemia syndrome clinicopathologically manifested by fever, hepatosplenomegaly, cytopenias, liver dysfunction, and hemophagocytosis. METHODS We searched the medical literature for English-written articles and analyzed data regarding the diagnosis, pathoetiology, prognosis, and management of HLH. RESULTS HLH can be subcategorized into primary/genetic (PHLH) or secondary/acquired (SHLH) according to etiology. PHLH, including familial HLH and inherited immune deficiency syndromes, typically occurs in children harboring underlying genetic defects, whereas SHLH frequently manifests in adults and is associated with infection, autoimmunity, immune suppression, or malignancy. The pathogenesis of HLH is still elusive. Its known mechanisms include somatic mutations in gene coding for proteins implicated in the cytotoxic pathways of cytotoxic T or natural killer cells. The impaired ability of these cells to kill target cells leads to an uncontrolled hypercytokinemia and hyperinflammatory process, triggering hemophagocytosis and multiorgan failure. Corticosteroids, chemotherapy, and immunotherapy are the mainstay therapeutic strategies. The consolidation with allogeneic hematopoietic stem cell transplantation is a potentially curative option for PHLH and refractory or relapsed SHLH. CONCLUSIONS Understanding of the pathophysiology of HLH has improved in the last decade. The establishment of diagnostic and treatment guidelines for PHLH and SHLH has resulted in earlier diagnoses and the rapid initiation of therapy, both of which are associated with favorable outcomes.
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Affiliation(s)
- Ling Zhang
- Department of Hematopathology and Laboratory Medicine, Moffitt Cancer Center, Tampa, FL 33612, USA.
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78
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Lehmberg K, Sprekels B, Nichols KE, Woessmann W, Müller I, Suttorp M, Bernig T, Beutel K, Bode SFN, Kentouche K, Kolb R, Längler A, Minkov M, Schilling FH, Schmid I, Vieth S, Ehl S, Zur Stadt U, Janka GE. Malignancy-associated haemophagocytic lymphohistiocytosis in children and adolescents. Br J Haematol 2015; 170:539-49. [PMID: 25940575 DOI: 10.1111/bjh.13462] [Citation(s) in RCA: 94] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2014] [Accepted: 03/09/2015] [Indexed: 11/29/2022]
Abstract
Haemophagocytic lymphohistiocytosis (HLH) in the context of malignancy is mainly considered a challenge of adult haematology. While this association is also observed in children, little is known regarding inciting factors, appropriate treatment and prognosis. We retrospectively analysed 29 paediatric and adolescent patients for presenting features, type of neoplasm or preceding chemotherapy, treatment and outcome. Haemophagocytic lymphohistiocytosis was considered triggered by the malignancy (M-HLH) in 21 patients, most of whom had T- (n = 12) or B-cell neoplasms (n = 7), with Epstein-Barr virus as a co-trigger in five patients. In eight patients, HLH occurred during chemotherapy (Ch-HLH) for malignancy, mainly acute leukaemias (n = 7); an infectious trigger was found in seven. In M- and Ch-HLH, median overall survival was 1·2 and 0·9 years, and the 6 month survival rates were 67% and 63%, respectively. Seven of 11 deceased M-HLH patients exhibited active malignancy and HLH at the time of death, while only two out of five deceased Ch-HLH patients had evidence of active HLH. To overcome HLH, malignancy- and HLH-directed treatments were administered in the M-HLH cohort; however, it was not possible to determine superiority of one approach over the other. For Ch-HLH, treatment ranged from postponement of chemotherapy to the use of etoposide-containing regimens.
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Affiliation(s)
- Kai Lehmberg
- Paediatric Haematology and Oncology, University Medical Centre Hamburg Eppendorf, Hamburg, Germany
| | - Björn Sprekels
- Paediatric Haematology and Oncology, University Medical Centre Hamburg Eppendorf, Hamburg, Germany
| | - Kim E Nichols
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Wilhelm Woessmann
- Paediatric Haematology and Oncology, University Hospital Giessen, Giessen, Germany
| | - Ingo Müller
- Paediatric Haematology and Oncology, University Medical Centre Hamburg Eppendorf, Hamburg, Germany
| | - Meinolf Suttorp
- Paediatric Haematology and Oncology, University Hospital Dresden, Dresden, Germany
| | - Toralf Bernig
- Paediatric Haematology and Oncology, University Hospital Halle, Halle, Germany
| | - Karin Beutel
- Paediatric Haematology and Oncology, Clinical Centre Schwabing and München Rechts der Isar, Technical University Munich, Munich, Germany
| | - Sebastian F N Bode
- Centre of Chronic Immunodeficiency, University of Freiburg, Freiburg, Germany
| | - Karim Kentouche
- Paediatric Haematology and Oncology, University Hospital Jena, Jena, Germany
| | - Reinhard Kolb
- Paediatric Haematology and Oncology, Elisabeth-Hospital Oldenburg, Oldenburg, Germany
| | - Alfred Längler
- Gemeinschaftskrankenhaus Herdecke, University of Witten/Herdecke, Herdecke, Germany
| | - Milen Minkov
- Paediatric Haematology and Oncology, Rudolfstiftung Hospital Vienna, Vienna, Austria
| | - Freimut H Schilling
- Paediatric Oncology and Haematology, Olgahospital, Klinikum Stuttgart, Stuttgart, Germany
| | - Irene Schmid
- Dr. von Hauner Children's Hospital, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Simon Vieth
- Paediatric Haematology and Oncology, University Hospital Kiel, Kiel, Germany
| | - Stephan Ehl
- Centre of Chronic Immunodeficiency, University of Freiburg, Freiburg, Germany
| | - Udo Zur Stadt
- Paediatric Haematology and Oncology, University Medical Centre Hamburg Eppendorf, Hamburg, Germany
| | - Gritta E Janka
- Paediatric Haematology and Oncology, University Medical Centre Hamburg Eppendorf, Hamburg, Germany
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Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a disease caused by dysregulation and hyperactivation of the immune system, and can be familial or acquired. HLH presenting in infancy can be rapidly fatal if not promptly recognized and treated. Congenital HLH can be caused by various genetic mutations or part of immunodeficiency syndromes. We present an infant with Griscelli syndrome and familial HLH with atypical genetic mutations, presenting as thrombocytopenia on the first day of life, cured with chemotherapy and unrelated cord blood transplant.
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80
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La actividad citotóxica de las células natural killer como herramienta diagnóstica en pacientes pediátricos críticos con sospecha de síndrome hemofagocítico. Med Intensiva 2015; 39:213-21. [DOI: 10.1016/j.medin.2014.05.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2014] [Revised: 05/28/2014] [Accepted: 05/29/2014] [Indexed: 11/19/2022]
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81
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Allen CE, McClain KL. Pathophysiology and epidemiology of hemophagocytic lymphohistiocytosis. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2015; 2015:177-182. [PMID: 26637718 DOI: 10.1182/asheducation-2015.1.177] [Citation(s) in RCA: 84] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a syndrome characterized by extreme immune activation, resulting in pathologic inflammation. The diagnosis includes a spectrum of inherited or acquired defects in cytotoxic lymphocyte function, often with uncontrolled infections. HLH may also arise as the result of persistent antigen stimulation due to autoimmune disease or malignancy. HLH is often described in binary terms as "primary," indicating Mendelian inheritance of gene mutations resulting in cytotoxic lymphocyte dysfunction, or "secondary" indicating an acquired reactive disorder. Increasing evidence describes HLH as more complex phenomenon, resulting from specific immune challenges in patients with a susceptible genetic background. Early recognition of HLH and evaluation of potential causes is critically important, as survival generally requires urgent treatment with immune suppression and resolution of the activating antigen. However, the diagnosis of HLH is challenged by the myriad of pathways that lead to pathologic inflammation and the clinical overlap with other conditions. Further improvements in therapy will require prospective trials to define optimal strategies for each patient based on the individual paths that lead to pathologic inflammation.
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Affiliation(s)
- Carl E Allen
- Texas Children's Cancer Center, Texas Children's Hospital, Houston, TX; and Department of Pediatrics, Graduate Program in Translational Biology and Molecular Medicine, Dan L. Duncan Cancer Center, Baylor College of Medicine, Houston, TX
| | - Kenneth L McClain
- Texas Children's Cancer Center, Texas Children's Hospital, Houston, TX; and Department of Pediatrics, Graduate Program in Translational Biology and Molecular Medicine, Dan L. Duncan Cancer Center, Baylor College of Medicine, Houston, TX
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82
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Henkes M, Finke J, Warnatz K, Ammann S, Stadt UZ, Janka G, Brugger W. Late-onset hemophagocytic lymphohistiocytosis (HLH) in an adult female with Griscelli syndrome type 2 (GS2). Ann Hematol 2014; 94:1057-60. [PMID: 25544030 DOI: 10.1007/s00277-014-2284-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2014] [Accepted: 12/14/2014] [Indexed: 01/15/2023]
Affiliation(s)
- Martin Henkes
- Department of Hematology and Oncology, Schwarzwald-Baar Clinic, Academic Teaching Hospital University of Freiburg, Klinikstr. 11, 78052, Villingen-Schwenningen, Germany,
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83
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Mhatre S, Madkaikar M, Desai M, Ghosh K. Spectrum of perforin gene mutations in familial hemophagocytic lymphohistiocytosis (FHL) patients in India. Blood Cells Mol Dis 2014; 54:250-7. [PMID: 25577959 DOI: 10.1016/j.bcmd.2014.11.023] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2014] [Accepted: 11/13/2014] [Indexed: 11/19/2022]
Abstract
BACKGROUND Inherited perforin deficiency is a rare autosomal recessive disorder that causes severe form of hemophagocytic lymphohistiocytosis (FHL2). The main aim of this study was to analyze the nature of gene mutations in a cohort of Indian patients with FHL2 and to utilize this knowledge for genetic counseling and prenatal diagnosis. METHODS 13 HLH patients with abnormal perforin expression on NK cells by flow cytometry were included in the study. The entire coding region and intronic splice sites of the PRF1 gene were sequenced from the genomic DNA of these patients. RESULTS 10 patients from the present series had an early presentation with severe clinical manifestations, while 3 had a delayed onset with unusual presenting features viz Hodgkin's lymphoma, tuberculosis and acute lymphoblastic leukemia. Sequence analysis revealed 11 different mutations (8 novel and 3 previously reported) spread over the entire coding region of PRF1 gene. Missense mutation Trp129Ser in heterozygous state was present in all the 3 patients with a delayed onset of the disease. CONCLUSION A wide heterogeneity was observed in the nature of mutations in Indian FHL2 patients. Molecular characterization of PRF1 gene was not only used in the confirmation of diagnosis but also in genetic counseling and pre-natal diagnosis in affected families.
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Affiliation(s)
- Snehal Mhatre
- National Institute of Immunohaematology, 13th floor KEM Hospital, Parel, Mumbai 400012, India
| | - Manisha Madkaikar
- National Institute of Immunohaematology, 13th floor KEM Hospital, Parel, Mumbai 400012, India.
| | - Mukesh Desai
- Department of Immunology, Bai Jerbai Wadia Hospital for Children, Parel, Mumbai 400012, India
| | - Kanjaksha Ghosh
- National Institute of Immunohaematology, 13th floor KEM Hospital, Parel, Mumbai 400012, India
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84
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Genetic features of late onset primary hemophagocytic lymphohistiocytosis in adolescence or adulthood. PLoS One 2014; 9:e107386. [PMID: 25233452 PMCID: PMC4169386 DOI: 10.1371/journal.pone.0107386] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2013] [Accepted: 09/28/2013] [Indexed: 11/25/2022] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening condition of uncontrolled immune activation leading to extreme inflammation. Primary HLH was once believed to be a disease that occurred only in infancy or young children, and was rarely diagnosed in adults. It is now understood that patients can develop primary HLH in their adolescence or adulthood. This study included 252 adolescent and adult patients with a clinical diagnosis of HLH from 35 general medical institutions across mainland China. All exons and 50 bp of flanking intronic sequence of six HLH-related genes (PRF1, UNC13D, STX11, STXBP2, SH2D1A, and BIRC4) were sequenced in these patients. We identified mutations in 18/252 (7.1%) of the patients, with changes in PRF1 being most common. Late-onset HLH often features viral infection and other predisposing factors. We conclude that late-onset primary HLH is not as rare as previously thought. Older patients should not be delayed to receive HLH-related genes testing when they are suspected with HLH.
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85
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Koh KN, Im HJ, Chung NG, Cho B, Kang HJ, Shin HY, Lyu CJ, Yoo KH, Koo HH, Kim HJ, Baek HJ, Kook H, Yoon HS, Lim YT, Kim HS, Ryu KH, Seo JJ. Clinical features, genetics, and outcome of pediatric patients with hemophagocytic lymphohistiocytosis in Korea: report of a nationwide survey from Korea Histiocytosis Working Party. Eur J Haematol 2014; 94:51-9. [PMID: 24935083 PMCID: PMC7163615 DOI: 10.1111/ejh.12399] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/06/2014] [Indexed: 12/27/2022]
Abstract
Background We analyzed a nationwide registry of pediatric patients with hemophagocytic lymphohistiocytosis (HLH) in Korea to assess the clinical and genetic features and treatment outcomes in pediatric HLH. Methods The Korea Histiocytosis Working Party retrospectively analyzed data on 251 pediatric patients diagnosed with HLH between 1996 and 2011. Results In the study cohort, 25 cases were categorized with familial HLH, 64 with presumed secondary HLH, and 162 with unspecified HLH. Of 217 evaluable patients, 91 (42%) had concomitant Epstein–Barr virus infection. Of 238 evaluable patients, central nervous system (CNS) involvement, which was more frequent in the familial group, was evident in 81 cases (34%). Genetic tests revealed a predominant UNC13D mutation with a high incidence of two recurrent splicing mutations (c.118‐308C>T and c.754‐1G>C). The 5‐yr overall survival rate was 68% (38% in the familial group and 81% in the presumed secondary group). The 5‐yr overall survival rate among 32 patients who underwent allogeneic hematopoietic stem cell transplantation was 64%. In multivariate analysis, a younger age at diagnosis, severe transaminasemia, and a coagulation abnormality were independent prognostic factors for survival. Responses during initial treatments were also significant indicators of outcome. Conclusion Our study showed the unique predominance of a UNC13D mutation and vulnerability to Epstein–Barr virus infection in Korean children with HLH and emphasizes the prognostic significance of age, liver dysfunction, and treatment responses in this disease. A multicenter prospective trial that builds on the present results is warranted to identify subgroups of patients with a poor prognosis and identify optimal treatments.
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Affiliation(s)
- Kyung-Nam Koh
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Korea
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86
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Abstract
Hemophagocytic lymphohistiocytosis (HLH) covers a wide array of related life-threatening conditions featuring ineffective immunity characterized by an uncontrolled hyperinflammatory response. HLH is often triggered by infection. Familial forms result from genetic defects in natural killer cells and cytotoxic T-cells, typically affecting perforin and intracellular vesicles. HLH is likely under-recognized, which contributes to its high morbidity and mortality. Early recognition is crucial for any reasonable attempt at curative therapy to be made. Current treatment regimens include immunosuppression, immune modulation, chemotherapy, and biological response modification, followed by hematopoietic stem-cell transplant (bone marrow transplant). A number of recent studies have contributed to the understanding of HLH pathophysiology, leading to alternate treatment options; however, much work remains to raise awareness and improve the high morbidity and mortality of these complex conditions.
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Affiliation(s)
- Melissa R George
- Department of Pathology, Penn State Milton S Hershey Medical Center, Hershey, PA, USA
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87
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Mittal N, Kent PM. Insights into the genetic basis of familal hemophagocytic lymphohistiocytosis. Pediatr Blood Cancer 2014; 61:962-3. [PMID: 24616126 DOI: 10.1002/pbc.25006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2014] [Accepted: 02/04/2014] [Indexed: 11/06/2022]
Affiliation(s)
- Nupur Mittal
- Department of Pediatrics, Division of Pediatric Hematology Oncology, Rush University Medical Center, University of Illinois At Chicago and John. H. Stroger hospital (Tri- institutional fellowship), Chicago, Illinois
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Qian Y, Johnson JA, Connor JA, Valencia CA, Barasa N, Schubert J, Husami A, Kissell D, Zhang G, Weirauch MT, Filipovich AH, Zhang K. The 253-kb inversion and deep intronic mutations in UNC13D are present in North American patients with familial hemophagocytic lymphohistiocytosis 3. Pediatr Blood Cancer 2014; 61:1034-40. [PMID: 24470399 DOI: 10.1002/pbc.24955] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2013] [Accepted: 12/23/2013] [Indexed: 12/18/2022]
Abstract
BACKGROUND The mutations in UNC13D are responsible for familial hemophagocytic lymphohistiocytosis (FHL) type 3. A 253-kb inversion and two deep intronic mutations, c.118-308C > T and c.118-307G > A, in UNC13D were recently reported in European and Asian FHL3 patients. We sought to determine the prevalence of these three non-coding mutations in North American FHL patients and evaluate the significance of examining these new mutations in genetic testing. PROCEDURE We performed DNA sequencing of UNC13D and targeted analysis of these three mutations in 1,709 North American patients with a suspected clinical diagnosis of hemophagocytic lymphohistiocytosis (HLH). RESULTS The 253-kb inversion, intronic mutations c.118-308C > T and c.118-307G > A were found in 11, 15, and 4 patients, respectively, in which the genetic basis (bi-allelic mutations) explained 25 additional patients. Taken together with previously diagnosed FHL3 patients in our HLH patient registry, these three non-coding mutations were found in 31.6% (25/79) of the FHL3 patients. The 253-kb inversion, c.118-308C > T and c.118-307G > A accounted for 7.0%, 8.9%, and 1.3% of mutant alleles, respectively. Significantly, eight novel mutations in UNC13D are being reported in this study. To further evaluate the expression level of the newly reported intronic mutation c.118-307G > A, reverse transcription PCR and Western blot analysis revealed a significant reduction of both RNA and protein levels suggesting that the c.118-307G > A mutation affects transcription. CONCLUSIONS These specified non-coding mutations were found in a significant number of North American patients and inclusion of them in mutation analysis will improve the molecular diagnosis of FHL3.
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Affiliation(s)
- Yaping Qian
- Division of Human Genetics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati School of Medicine, Cincinnati, Ohio
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89
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Sieni E, Cetica V, Hackmann Y, Coniglio ML, Da Ros M, Ciambotti B, Pende D, Griffiths G, Aricò M. Familial hemophagocytic lymphohistiocytosis: when rare diseases shed light on immune system functioning. Front Immunol 2014; 5:167. [PMID: 24795715 PMCID: PMC3997030 DOI: 10.3389/fimmu.2014.00167] [Citation(s) in RCA: 72] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2013] [Accepted: 03/29/2014] [Indexed: 12/03/2022] Open
Abstract
The human immune system depends on the activity of cytotoxic T lymphocytes (CTL), natural killer (NK) cells, and NKT cells in order to fight off a viral infection. Understanding the molecular mechanisms during this process and the role of individual proteins was greatly improved by the study of familial hemophagocytic lymphohistiocytosis (FHL). Since 1999, genetic sequencing is the gold standard to classify patients into different subgroups of FHL. The diagnosis, once based on a clinical constellation of abnormalities, is now strongly supported by the results of a functional flow-cytometry screening, which directs the genetic study. A few additional congenital immune deficiencies can also cause a resembling or even identical clinical picture to FHL. As in many other rare human disorders, the collection and analysis of a relatively large number of cases in registries is crucial to draw a complete picture of the disease. The conduction of prospective therapeutic trials allows investigators to increase the awareness of the disease and to speed up the diagnostic process, but also provides important functional and genetic confirmations. Children with confirmed diagnosis may undergo hematopoietic stem cell transplantation, which is the only cure known to date. Moreover, detailed characterization of these rare patients helped to understand the function of individual proteins within the exocytic machinery of CTL, NK, and NKT cells. Moreover, identification of these genotypes also provides valuable information on variant phenotypes, other than FHL, associated with biallelic and monoallelic mutations in the FHL-related genes. In this review, we describe how detailed characterization of patients with genetic hemophagocytic lymphohistiocytosis has resulted in improvement in knowledge regarding contribution of individual proteins to the functional machinery of cytotoxic T- and NK-cells. The review also details how identification of these genotypes has provided valuable information on variant phenotypes.
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Affiliation(s)
- Elena Sieni
- Department Pediatric Hematology Oncology, Azienda Ospedaliero-Universitaria Meyer Children Hospital , Florence , Italy
| | - Valentina Cetica
- Department Pediatric Hematology Oncology, Azienda Ospedaliero-Universitaria Meyer Children Hospital , Florence , Italy ; Pediatric Hematology Oncology Network, Istituto Toscano Tumori (I.T.T.) , Florence , Italy
| | - Yvonne Hackmann
- Cambridge Institute for Medical Research, University of Cambridge Biomedical Campus , Cambridge , UK
| | - Maria Luisa Coniglio
- Department Pediatric Hematology Oncology, Azienda Ospedaliero-Universitaria Meyer Children Hospital , Florence , Italy
| | - Martina Da Ros
- Department Pediatric Hematology Oncology, Azienda Ospedaliero-Universitaria Meyer Children Hospital , Florence , Italy
| | - Benedetta Ciambotti
- 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
| | - Gillian Griffiths
- Cambridge Institute for Medical Research, University of Cambridge Biomedical Campus , Cambridge , UK
| | - Maurizio Aricò
- Pediatric Hematology Oncology Network, Istituto Toscano Tumori (I.T.T.) , Florence , Italy
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90
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Janka GE, Lehmberg K. Hemophagocytic syndromes--an update. Blood Rev 2014; 28:135-42. [PMID: 24792320 DOI: 10.1016/j.blre.2014.03.002] [Citation(s) in RCA: 296] [Impact Index Per Article: 29.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2014] [Accepted: 03/11/2014] [Indexed: 12/12/2022]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening hyperinflammatory syndrome and not an independent disease. HLH represents the extreme end of a severe uncontrolled hyperinflammatory reaction that can occur in many underlying conditions. Genetic forms of HLHs are due to defects in transport, processing and function of cytotoxic granules in natural killer cells and cytotoxic T lymphocytes, and are not restricted to manifestation in childhood. Acquired forms of HLH are encountered in infections, autoinflammatory and autoimmune diseases, malignancies, acquired immune deficiency. Functional tests allow for differentiation between genetic and acquired HLH. Treatment aims at suppressing hypercytokinemia and eliminating activated and infected cells. It includes immunomodulatory and immunosuppressive agents, cytostatics, T-cell and cytokine antibodies. In genetic HLH cure can only be achieved with hematopoietic stem cell transplantation. Reduced-intensity conditioning regimens have considerably improved survival.
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Affiliation(s)
- Gritta E Janka
- Pediatric Hematology and Oncology, University Medical Center Eppendorf, Hamburg, Germany.
| | - Kai Lehmberg
- Pediatric Hematology and Oncology, University Medical Center Eppendorf, Hamburg, Germany
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91
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Gupta S, Weitzman S. Primary and secondary hemophagocytic lymphohistiocytosis: clinical features, pathogenesis and therapy. Expert Rev Clin Immunol 2014; 6:137-54. [PMID: 20383897 DOI: 10.1586/eci.09.58] [Citation(s) in RCA: 118] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Sumit Gupta
- Division of Haematology/Oncology, The Hospital for Sick Children, 555 University Avenue, Toronto, ON M5G 1X8, Canada.
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92
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An O, Gursoy A, Gurgey A, Keskin O. Structural and functional analysis of perforin mutations in association with clinical data of familial hemophagocytic lymphohistiocytosis type 2 (FHL2) patients. Protein Sci 2013; 22:823-39. [PMID: 23592409 DOI: 10.1002/pro.2265] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2012] [Revised: 03/28/2013] [Accepted: 04/03/2013] [Indexed: 11/07/2022]
Abstract
Perforin plays a key role in the immune system via pore formation at the target cell membrane in the elimination of virus-infected and transformed cells. A vast number of observed mutations in perforin impair this mechanism resulting in a rare but fatal disease, familial hemophagocytic lymphohistiocytosis type 2 (FHL2). Here we report a comprehensive in silico structural analysis of a collection of 76 missense perforin mutations based on a proposed pore model. In our model, perforin monomers oligomerize having cyclic symmetry in consistent with previously found experimental constraints yet having flexibility in the size of the pore and the number of monomers involved. Clusters of the mutations on the model map to three distinct functional regions of the perforin. Calculated stability (free energy) changes show that the mutations mainly destabilize the protein structure, interestingly however, A91V polymorphism, leads to a more stable one. Structural characteristics of mutations help explain the severe functional consequences on perforin deficient patients. Our study provides a structural approach to the mutation effects on the perforin oligomerization and impaired cytotoxic function in FHL2 patients.
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Affiliation(s)
- Omer An
- Center for Computational Biology and Bioinformatics, College of Engineering, Koc University, Rumelifeneri Yolu, Sariyer, Istanbul, Turkey
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93
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Galandrini R, Capuano C, Santoni A. Activation of Lymphocyte Cytolytic Machinery: Where are We? Front Immunol 2013; 4:390. [PMID: 24312097 PMCID: PMC3832890 DOI: 10.3389/fimmu.2013.00390] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2013] [Accepted: 11/06/2013] [Indexed: 11/13/2022] Open
Abstract
Target cell recognition by cytotoxic lymphocytes implies the simultaneous engagement and clustering of adhesion and activating receptors followed by the activation of an array of signal transduction pathways. The cytotoxic immune synapse represents the highly specialized dynamic interface formed between the cytolytic effector and its target that allows temporal and spatial integration of signals responsible for a defined sequence of processes culminating with the polarized secretion of lytic granules. Over the last decades, much attention has been given to the molecular signals coupling receptor ligation to the activation of cytolytic machinery. Moreover, in the last 10 years the discovery of genetic defects affecting cytotoxic responses greatly boosted our knowledge on the molecular effectors involved in the regulation of discrete phases of cytotoxic process at post-receptor levels. More recently, the use of super resolution and total internal reflection fluorescence imaging technologies added new insights on the dynamic reorganization of receptor and signaling molecules at lytic synapse as well as on the relationship between granule dynamics and cytoskeleton remodeling. To date we have a solid knowledge of the molecular mechanisms governing granule movement and secretion, being not yet fully unraveled the machinery that couples early receptor signaling to the late stage of synapse remodeling and granule dynamics. Here we highlight recent advances in our understanding of the molecular mechanisms acting in the activation of cytolytic machinery, also discussing similarities and differences between Natural killer cells and cytotoxic CD8+ T cells.
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Affiliation(s)
- Ricciarda Galandrini
- Department of Experimental Medicine, Istituto Pasteur-Fondazione Cenci-Bolognetti, Fondazione Eleonora Lorillard Spencer Cenci, Sapienza University , Rome , Italy
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94
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Chandrakasan S, Filipovich AH. Hemophagocytic lymphohistiocytosis: advances in pathophysiology, diagnosis, and treatment. J Pediatr 2013; 163:1253-9. [PMID: 23953723 DOI: 10.1016/j.jpeds.2013.06.053] [Citation(s) in RCA: 166] [Impact Index Per Article: 15.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2012] [Revised: 06/10/2013] [Accepted: 06/24/2013] [Indexed: 12/27/2022]
Affiliation(s)
- Shanmuganathan Chandrakasan
- Division of Bone Marrow Transplantation and Immune Deficiency Cincinnati Children's Hospital Medical Center, Cincinnati, OH.
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95
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96
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Bas AY, Demirel N, Zenciroglu A, Yarali N, Metin A. Familial haemophagocytic lymphohistiocytosis in two newborn siblings: a good mimicker of newborn sepsis. ACTA ACUST UNITED AC 2013; 27:231-5. [PMID: 17716452 DOI: 10.1179/146532807x220352] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
Familial haemophagocytic lymphohistiocytosis (FHL) is a rare, autosomal recessive disorder. We report two newborn siblings diagnosed as FHL.
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Affiliation(s)
- Ahmet Yagmur Bas
- Department of Neonatology, Dr Sami Ulus Children's Hospital, Ankara, Turkey.
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97
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98
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HUASONG ZENG, PING WEI, XIANGYUAN CHEN, YANDAN WEI. Clinical Features and Perforin A91V Gene Analysis in 31 Patients with Macrophage Activation Syndrome and Systemic Juvenile Idiopathic Arthritis in China. J Rheumatol 2013; 40:1238-9. [DOI: 10.3899/jrheum.121040] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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99
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Abstract
Haemophagocytic lymphohistiocytosis (HLH) is a hyperinflammatory disorder resulting from immune dysfunction reflecting either primary immune deficiency or acquired failure of normal immune homeostasis. Familial HLH includes autosomal recessive and X-linked disorders characterized by uncontrolled activation of T cells and macrophages and overproduction of inflammatory cytokines, secondary to defects in genes encoding proteins involved in granule-dependent cytolytic pathways. In older children and adults, HLH is associated more often with infections, malignancies, autoimmune diseases, and acquired immune deficiencies. HLH, macrophage activation syndrome, sepsis, and systemic inflammatory response syndrome are different clinical entities that probably represent a common immunopathological state, termed cytokine storm. These conditions may be clinically indistinguishable; all include massive inflammatory response, elevated serum cytokine levels, multi-organ involvement, haemophagocytic macrophages, and often death. Tissues of haematopoietic and lymphoid function are directly involved; other organs are secondarily damaged by circulating cytokines and chemokines. Haemophagocytic disorders are now increasingly diagnosed in the context of severe inflammatory reactions to viruses, malignancies and systemic connective tissue diseases. Many of these cases may reflect underlying genetic predispositions to HLH. The detection of gene defects has contributed considerably to our understanding of HLH, but the mechanisms leading to acquired HLH have yet to be fully determined.
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Affiliation(s)
- G Naheed Usmani
- Division of Pediatric Hematology and Oncology, University of Massachusetts Medical Center, Worcester, MA, USA
| | - Bruce A Woda
- Department of Pathology, UMass Memorial Medical Center, Worcester, MA, USA
| | - Peter E Newburger
- Department of Pediatrics, University of Massachusetts Medical School, Worcester, MA, USA
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100
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X-linked agammaglobulinemia presenting with secondary hemophagocytic syndrome: a case report. Case Rep Med 2013; 2013:742795. [PMID: 23424595 PMCID: PMC3568855 DOI: 10.1155/2013/742795] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2012] [Accepted: 12/21/2012] [Indexed: 11/18/2022] Open
Abstract
Introduction. Coincidence of X-linked agammaglobulinemia (XLA) and secondary hemophagocytic syndrome (sHS) is atypical. Both diseases are rare and pathogenesis of the latter one is not clearly known. Case Presentation. A 5-year-old boy was diagnosed both with XLA and sHS. However, in his history, he did not have severe and recurrent infections. Bruton tyrosine kinase (BTK) gene mutation was present (c.1581_1584delTTTG). To the best of the authors' knowledge, coincidence of XLA and sHS had not been reported in the literature before. Conclusion. Patients with XLA are extremely vulnerable to recurrent bacterial infections. The diagnosis of XLA with sHS at any time of life is both an interesting and challenging situation without history of recurrent bacterial infections.
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