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Daver N, McClain K, Allen CE, Parikh SA, Otrock Z, Rojas-Hernandez C, Blechacz B, Wang S, Minkov M, Jordan MB, La Rosée P, Kantarjian HM. A consensus review on malignancy-associated hemophagocytic lymphohistiocytosis in adults. Cancer 2017. [PMID: 28621800 DOI: 10.1002/cncr.30826] [Citation(s) in RCA: 133] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a syndrome of severe immune activation and dysregulation resulting in extreme and often life-threatening inflammation. HLH has been well recognized in pediatric populations, and most current diagnostic and therapeutic guidelines are based on pediatric HLH. Recently there has been recognition of HLH in adults, especially secondary to immune deregulation by an underlying rheumatologic, infectious, or malignant condition. This review is focused on malignancy-associated HLH (M-HLH), in which possible mechanisms of pathogenesis include severe inflammation, persistent antigen stimulation by the tumor cells, and loss of immune homeostasis because of chemotherapy, hematopoietic stem cell transplantation, or infection. Previously considered rare, M-HLH may occur in up to 1% of patients with hematologic malignancies. M-HLH is often missed or diagnosed late in most published studies, and it has been associated with a poor median survival of less than 2 months. Identification of the clinical and laboratory features specific to M-HLH in adults may allow early detection, consultation with HLH experts, and intervention. Improved management of adult M-HLH with optimal combinations of T-lympholytic and immunosuppressive agents and the incorporation of novel agents based on the pediatric experience hopefully will improve outcomes in adults with M-HLH. Cancer 2017;123:3229-40. © 2017 American Cancer Society.
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Affiliation(s)
- Naval Daver
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Kenneth McClain
- Histiocytosis Program, Texas Children's Cancer Center, Texas Children's Hospital, Houston, Texas
| | - Carl E Allen
- Histiocytosis Program, Texas Children's Cancer Center, Texas Children's Hospital, Houston, Texas
| | | | - Zaher Otrock
- Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, Missouri
| | | | - Boris Blechacz
- Department of Gastroenterology, Hepatology, and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Sa Wang
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Milen Minkov
- University Clinic of Pediatrics, St. Anna Children's Hospital, Medical University of Vienna, Vienna, Austria
| | - Michael B Jordan
- Langerhans Cell Histiocytosis Center, Cincinnati Children's Hospital, Cincinnati, Ohio
| | - Paul La Rosée
- Department of Internal Medicine, Schwarzwald-Baar Clinic, Villingen-Schwenningen, Germany
| | - Hagop M Kantarjian
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
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Clinical utility of soluble interleukin-2 receptor in hemophagocytic syndromes: a systematic scoping review. Ann Hematol 2017; 96:1241-1251. [PMID: 28497365 DOI: 10.1007/s00277-017-2993-y] [Citation(s) in RCA: 91] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2017] [Accepted: 04/11/2017] [Indexed: 12/22/2022]
Abstract
The serum-soluble interleukin-2 receptor (sIL-2r) level is considered an important diagnostic test and disease marker in hemophagocytic syndromes/hemophagocytic lymphohistiocytosis (HPS/HLH). However, this cytokine receptor is rarely measured in clinical practice and has been excluded from recent diagnostic/classification criteria such as the HScore and macrophage activation syndrome (MAS) 16. We performed a systematic scoping review of 64 articles (1975-2016) examining the clinical utility of sIL-2r in HPS/HLH. Twenty-two articles describe sIL-2r as a sensitive diagnostic marker for HLH, but only three distinct datasets actually address sensitivity. The original HLH-2004 Guidelines reported sensitivity of 93% and specificity of 100% for sIL-2r ≥ 2400, based on a pediatric dataset (n = 152) which is published for the first time in this review. Two pediatric studies reported sensitivity of 89% for sIL-2r ≥ 2400 in diagnosis of MAS complicating juvenile idiopathic arthritis (JIA) (n = 27) and 88% for secondary HLH in acute liver failure (n = 9). Twenty articles described sIL-2r as a dynamic marker of disease activity that falls with response to treatment, and 15 described high initial sIL-2r levels >10,000 U/mL as a poor prognostic marker. The ability of sIL-2r to distinguish between subtypes of HPS/HLH was inconsistent. This review confirms the importance of soluble IL-2r as a diagnostic and disease marker in HPS/HLH, but also reveals the need for more primary data about its performance characteristics, particularly in adults. More emphasis should be made in including this simple, inexpensive test in clinical practice and studies of HPS/HLH.
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Viswanath DI, Mace EM, Hsu HT, Orange JS. Quantification of natural killer cell polarization and visualization of synaptic granule externalization by imaging flow cytometry. Clin Immunol 2017; 177:70-75. [PMID: 26948929 PMCID: PMC5010793 DOI: 10.1016/j.clim.2016.03.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2015] [Revised: 10/18/2015] [Accepted: 03/02/2016] [Indexed: 01/07/2023]
Abstract
Defining immunological mechanisms underlying NK cell biology is crucial for the treatment and prevention of immune deficiency and malignancy. The limited availability of human biological specimens presents a challenge to the study of human immunobiology. The use of high throughput, multi-parametric assays will not only aid in the definition and diagnosis of complex human immune disorders affecting NK cell function but also advance NK cell biology through population-based assessment of molecular signaling. In an effort to garner the most information from limited numbers of human cells, we designed a quantitative method to study NK cell function using imaging flow cytometry (IFC), which combines multiparametric flow cytometry and fluorescence microscopy. Specifically, we developed IFC as a tool to measure polarization and secretion of lytic granules at the immunological synapse formed between an NK cell and a susceptible target. We have further validated our approach through quantitative comparison with high-resolution confocal microscopy. We show that IFC can be used as a quantitative, high throughput measure of NK cell biological function possessing greater dimensionality than standard flow cytometry.
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Affiliation(s)
- Dixita I. Viswanath
- Rice University, Houston, TX 77005, USA
- Center for Human Immunobiology, Texas Children's Hospital and Baylor College of Medicine, Houston, TX 77030, USA
| | - Emily M. Mace
- Center for Human Immunobiology, Texas Children's Hospital and Baylor College of Medicine, Houston, TX 77030, USA
| | - Hsiang-Ting Hsu
- Center for Human Immunobiology, Texas Children's Hospital and Baylor College of Medicine, Houston, TX 77030, USA
| | - Jordan S. Orange
- Rice University, Houston, TX 77005, USA
- Center for Human Immunobiology, Texas Children's Hospital and Baylor College of Medicine, Houston, TX 77030, USA
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Wu XL, Zhao XQ, Zhang BX, Xuan F, Guo HM, Ma FT. A novel frameshift mutation of Chediak-Higashi syndrome and treatment in the accelerated phase. ACTA ACUST UNITED AC 2017; 50:e5727. [PMID: 28355352 PMCID: PMC5423745 DOI: 10.1590/1414-431x20165727] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2017] [Accepted: 10/14/2017] [Indexed: 11/30/2022]
Abstract
Chediak-Higashi syndrome (CHS) is a rare autosomal recessive immunodeficiency disease characterized by frequent infections, hypopigmentation, progressive neurologic deterioration and hemophagocytic lymphohistiocytosis (HLH), known as the accelerated phase. There is little experience in the accelerated phase of CHS treatment worldwide. Here, we present a case of a 9-month-old boy with continuous high fever, hypopigmentation of the skin, enlarged lymph nodes, hepatosplenomegaly and lung infection. He was diagnosed with CHS by gene sequencing, and had entered the accelerated phase. After 8 weeks of therapy, the boy had remission and was prepared for allogenic stem cell transplantation.
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Affiliation(s)
- X L Wu
- Department of Pediatric Hematology-Oncology, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - X Q Zhao
- Department of Pediatric Hematology-Oncology, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - B X Zhang
- Department of Pediatric Hematology-Oncology, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - F Xuan
- Department of Pediatric Hematology-Oncology, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - H M Guo
- Department of Pediatric Hematology-Oncology, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - F T Ma
- Department of Pediatric Hematology-Oncology, The Second Hospital of Hebei Medical University, Shijiazhuang, China
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Abstract
BACKGROUND Hemophagocytic lymphohistiocytosis (HLH) has well been studied as a genetic disorder in children (primary HLH). Mutations in the regulatory complex of the cellular immune synapse lead to a loss of function of cytotoxic T‑cells and natural killer cells with excessive inflammation based on a cytokine storm. During the last decade, an increasing number of adult HLH patients without a family history of HLH (secondary or acquired HLH) have been reported. Various triggers - infections, malignancies or autoimmune diseases - result in an acquired loss of function of these cells and a sepsis-like disease. Missed or late diagnosis is believed to be a major cause of the high mortality. OBJECTIVES To describe the current knowledge on HLH and to raise awareness. MATERIALS AND METHODS Analysis of case reports, current studies, and expert recommendations. RESULTS Increased vigilance in identifying the adult form of HLH resulted in an increasing number of case reports over the past few years. HLH patients typically present with a clinical phenotype resembling severe sepsis or septic shock with fever, cytopenia, and organomegaly, which do not or insufficiently respond to anti-infective treatment. Early recognition of HLH distinction from sepsis, and prompt initiation of treatment - which is fundamentally different from sepsis - are crucial for improved outcome. A promising diagnostic parameter is ferritin, which has gained sufficient specificity, but only in the context of the triad of fever, cytopenia, and organomegaly. Treatment of adult HLH patients requires immunosuppression, with strict therapeutic guidance derived from the triggering disease. CONCLUSIONS Because of the similar clinical presentation to that of sepsis, HLH is often not recognized, resulting in a fatal outcome. In "sepsis" patients on the ICU with deterioration despite a standard of care, HLH needs to be considered by testing for ferritin when considering differential diagnoses. The complexity of the illness requires interdisciplinary patient care with specific integration of the hematologist in the diagnostic workup and therapeutic management, because of the frequent use of chemotherapy-based immunosuppression.
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Perforin and CD107a testing is superior to NK cell function testing for screening patients for genetic HLH. Blood 2017; 129:2993-2999. [PMID: 28270454 DOI: 10.1182/blood-2016-12-753830] [Citation(s) in RCA: 89] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2016] [Accepted: 02/19/2017] [Indexed: 01/12/2023] Open
Abstract
Primary hemophagocytic lymphohistiocytosis (HLH) can be caused by biallelic mutations in PRF1, encoding perforin, or UNC13D, STXBP2, STX11, RAB27A, LYST, and AP3B1, encoding proteins involved in cytotoxic lymphocyte degranulation. Natural killer (NK)-cell cytotoxicity assays can quickly screen for all of these genetic diseases, facilitating treatment, but combining NK-cell perforin expression and CD107a upregulation tests can as well. To determine the relative diagnostic accuracies for each approach, we retrospectively reviewed screening test performance in 1614 patients referred for HLH evaluation. For each test, we generated a receiver operating characteristic (ROC) curve, and calculated area under the curve (AUC) and diagnostic parameters at optimal threshold. We generated an AUC for combining perforin and CD107a tests by creating a logistic regression model and applying model-generated coefficients to patient values. Sensitivities of NK-cell function, perforin mean channel fluorescence (MCF), and CD107a MCF to detect biallelic mutations were 59.5%, 96.6%, and 93.8%, with specificities of 72.0%, 99.5%, and 73%. AUCs for NK-cell cytotoxicity, perforin MCF, CD107a MCF, and combined perforin and CD107a MCFs were 0.690, 0.971, 0.860, and 0.838. Perforin and CD107a tests are more sensitive and no less specific compared with NK cytotoxicity testing for screening for genetic HLH and should be considered for addition to current HLH criteria.
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Sen ES, Steward CG, Ramanan AV. Diagnosing haemophagocytic syndrome. Arch Dis Child 2017; 102:279-284. [PMID: 27831908 DOI: 10.1136/archdischild-2016-310772] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2016] [Revised: 09/22/2016] [Accepted: 09/27/2016] [Indexed: 02/06/2023]
Abstract
Haemophagocytic syndrome, or haemophagocytic lymphohistiocytosis (HLH), is a hyperinflammatory disorder characterised by uncontrolled activation of the immune system. It can result from mutations in multiple genes involved in cytotoxicity or occur secondary to a range of infections, malignancies or autoimmune rheumatic diseases. In the latter case, it is also known as macrophage activation syndrome (MAS). Characteristic features are persistent fever, hepatosplenomegaly, petechial/purpuric rash, progressive cytopenias, coagulopathy, transaminitis, raised C reactive protein, falling erythrocyte sedimentation rate, hypertriglyceridaemia, hypofibrinogenaemia and extreme hyperferritinaemia often associated with multi-organ impairment. Distinguishing HLH from systemic sepsis can present a major challenge. Criteria for diagnosis and classification of HLH and MAS are available and a serum ferritin >10 000 µg/L is strongly supportive of HLH. Without early recognition and appropriate treatment, HLH is almost universally fatal. However, with prompt referral and advancements in treatment over the past two decades, outcomes have greatly improved.
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Affiliation(s)
- Ethan S Sen
- Department of Paediatric Rheumatology, Bristol Royal Hospital for Children, Bristol, UK
| | - Colin G Steward
- Department of Paediatric Haematology, Oncology and Bone Marrow Transplantation, Bristol Royal Hospital for Children, Bristol, UK
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Zhang J, Wang YN, Wang JS, Wu L, Wei N, Fu L, Gao Z, Chen JH, Pei RJ, Wang Z. [The significance of pedigree genetic screening and rapid immunological parameters in the diagnosis of primary hemophagocytic lymphohistiocytosis]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2017; 37:565-70. [PMID: 27535855 PMCID: PMC7365012 DOI: 10.3760/cma.j.issn.0253-2727.2016.07.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
目的 探讨家系基因筛查及快速免疫学指标检测在原发性噬血细胞综合征(HLH)诊断中的意义。 方法 通过对伴有PRF1、UNC13D及SH2D1A基因突变的4例原发性HLH患者展开家系调查,分别完成基因筛查及各项免疫学指标检测(包括NK细胞活性、CD107a检测及HLH相关缺陷蛋白表达测定),评价各项检测指标在原发性HLH诊断中的意义并探讨各项指标间的相关性。 结果 4个家系基因突变分别为PRF1基因错义突变c.T172C(p.S58P)和非框架移码突变c.1083_1094del (p.361_365del);PRF1基因错义突变c.C1349T(p.T450M)和框架移码突变c.1090_1091delCT (p.T364fsX93);UNC13D基因错义突变c.G2588A(p.G863D);SH2D1A基因半合子错义突变c.32T>G (p.I11S)。先证者及家系成员分别存在不同程度的NK细胞活性降低,其中PRF1基因及SH2D1A基因突变家系HLH相关基因编码穿孔素蛋白、信号淋巴细胞活化分子相关蛋白(SAP)表达水平下降,UNC13D基因突变先证者及与其存在完全相同突变位点的家系成员细胞毒脱颗粒功能(CD107a表达)显著减低。 结论 开展家系基因筛查及快速免疫学指标检测对诊断原发性HLH具有重要意义,两者具有较好的一致性,其中快速免疫学指标检测作为一种高效的检测手段,可为原发性HLH的早期诊断提供可靠依据。
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Affiliation(s)
- J Zhang
- Department of Hematology, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
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Filippone EJ, Singh P, Frank AM, Gupta A, Farber JL. Rapidly Fatal Hemophagocytic Lymphohistiocytosis Developing Within Six Days Following Deceased-Donor Renal Transplantation: Case Report. Transplant Proc 2016; 48:3123-3127. [PMID: 27932162 DOI: 10.1016/j.transproceed.2016.03.031] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2016] [Accepted: 03/30/2016] [Indexed: 12/12/2022]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is an often fatal hyperinflammatory syndrome that may complicate malignancy, infection, rheumatic disease, or immunosuppression. HLH after kidney transplantation is most often triggered by infection, usually Herpes viruses such as cytomegalovirus and Epstein-Barr virus (EBV). It usually occurs early after transplantation. We present a case of HLH triggered by reactivation of EBV that pursued a rapidly fatal course within 6 days of receiving a deceased-donor kidney transplant. This case serves to remind transplant clinicians to consider HLH when cytopenias and hyperinflammation are atypical for the usual post-transplantation course. We discuss pitfalls in diagnosis and suggestions for treatment in this setting.
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Affiliation(s)
- E J Filippone
- Division of Nephrology, Department of Medicine, Sydney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania.
| | - P Singh
- Division of Nephrology, Department of Medicine, Sydney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - A M Frank
- Department of Surgery, Sydney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - A Gupta
- Department of Medicine, Albert Einstein Medical Center, Philadelphia, Pennsylvania
| | - J L Farber
- Department of Pathology, Sydney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania
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Lin S, Li Y, Long J, Liu Q, Yang F, He Y. Acute liver failure caused by hemophagocytic lymphohistiocytosis in adults: A case report and review of the literature. Medicine (Baltimore) 2016; 95:e5431. [PMID: 27893685 PMCID: PMC5134878 DOI: 10.1097/md.0000000000005431] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Hemophagocytic lymphohistiocytosis (HLH) is a rare condition that can be caused by a primary or acquired disorder of uncontrolled immune response. Liver injury is a common complication of HLH; however, HLH presenting as acute liver failure (ALF) has rarely been reported in adults. CASE SUMMARY A 34-year-old man was admitted to our hospital with nausea and fatigue persisting for 2 weeks and jaundice for 1 week. He had hyperthermia at the onset of disease. At admission, he had severe liver injury with unknown etiology. The laboratory data showed that he had hyperferritinemia, thrombocytopenia, anemia, hypertriglyceridemia, and hypofibrinogenemia. Finally, a bone marrow biopsy revealed hemophagocytic cells, and he was diagnosed with HLH. The patient was treated with prednisone and plasma exchange. However, the liver function of the patient deteriorated, and he finally died of multiorgan failure. CONCLUSIONS Reports of adult patients with ALF caused by HLH have increased, and HLH should be suspected in patients with ALF of indeterminate cause. Although the efficacy of the treatment strategy recommended by the HLH 2004 remains to be confirmed in adult patients with ALF caused by HLH, early diagnosis and prompt combined treatment with steroids and cyclosporin A or etoposide should be emphasized.
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The Unexpected Evolution of an Expected Complication: Hemophagocytic Lymphohistiocytosis. Obes Surg 2016; 27:205-207. [PMID: 27798794 DOI: 10.1007/s11695-016-2430-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Abstract
Haemophagocytic lymphohistiocytosis is a rare inflammatory condition. It can present in adult general medical patients and is a challenging diagnostic conundrum. This article provides an overview of the pathophysiology and clinical presentation of the syndrome for the general physician who will be rarely confronted with this problem but will have to act promptly when the situation arises. Treatment is also briefly discussed, although this usually occurs in a specialist setting after the diagnosis has been established.
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63
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Zheng Y, Hu G, Liu Y, Ma Y, Dang Y, Li F, Xing H, Wang T, Huo L. The role of 18F-FDG PET/CT in the management of patients with secondary haemophagocytic lymphohistiocytosis. Clin Radiol 2016; 71:1248-1254. [PMID: 27387105 DOI: 10.1016/j.crad.2016.05.011] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2016] [Revised: 05/13/2016] [Accepted: 05/19/2016] [Indexed: 01/12/2023]
Abstract
AIM To investigate the ability of combined 2-[18F]-fluoro-2-deoxy-d-glucose (18F-FDG) positron-emission tomography (PET)/computed tomography (CT) to determine potential causes of secondary haemophagocytic lymphohistiocytosis (sHLH) and to predict prognosis. MATERIAL AND METHODS Forty-three patients (male/female 20/23, median age 48.5 years), who were diagnosed with sHLH and underwent FDG-PET/CT before treatment, were retrospectively reviewed. The clinical characteristics were compared to identify the predictors of high-yield FDG-PET/CT. Univariate and multivariate analyses were conducted to identify factors associated with survival. Statistical analysis was performed using SPSS version 19.0. RESULTS PET results were helpful in 65.1% (28/43), whilst non-contributory in 34.9% (15/43) of patients with regard to the final diagnosis. Lymphoma was the most common (25/43) reason for sHLH, and patients with focal FDG uptake were more likely to be diagnosed with underlying diseases. C-reactive protein (CRP) was found to be a good indicator for the usefulness of PET/CT in HLH patients. Multivariate analysis showed that therapy regimen (hazard ratio [HR]=4.99, p=0.026), fibrinogen (FBG) <1.5 g/l (HR=3.87, p=0.049) and spleen:mediastinum ratio (SP/M) (HR=7.44, p=0.006) were independent prognostic factors for survival. CONCLUSION FDG-PET/CT could be a useful technique for detecting underlying diseases causing sHLH. CRP was a useful predictor of FDG-PET/CT effectiveness. Therapy regimen, FBG level, and SP/M were independent prognostic factors for HLH survival.
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Affiliation(s)
- Y Zheng
- Department of Nuclear Medicine, China-Japan Friendship Hospital, Beijing, PR China
| | - G Hu
- Department of Nuclear Medicine, Chinese Academy of Medical Sciences, Peking Union Medical College Hospital, Beijing, PR China
| | - Y Liu
- Department of Nuclear Medicine, Chinese Academy of Medical Sciences, Peking Union Medical College Hospital, Beijing, PR China
| | - Y Ma
- Department of Nuclear Medicine, Chinese Academy of Medical Sciences, Peking Union Medical College Hospital, Beijing, PR China
| | - Y Dang
- Department of Nuclear Medicine, Chinese Academy of Medical Sciences, Peking Union Medical College Hospital, Beijing, PR China
| | - F Li
- Department of Nuclear Medicine, Chinese Academy of Medical Sciences, Peking Union Medical College Hospital, Beijing, PR China
| | - H Xing
- Department of Nuclear Medicine, Chinese Academy of Medical Sciences, Peking Union Medical College Hospital, Beijing, PR China
| | - T Wang
- Department of Nuclear Medicine, Chinese Academy of Medical Sciences, Peking Union Medical College Hospital, Beijing, PR China
| | - L Huo
- Department of Nuclear Medicine, Chinese Academy of Medical Sciences, Peking Union Medical College Hospital, Beijing, PR China.
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Nosratian-Baskovic M, Tan B, Folkins A, Chisholm KM, Dorigo O. Hemophagocytic lymphohistiocytosis as a paraneoplastic syndrome associated with ovarian dysgerminoma. Gynecol Oncol Rep 2016; 17:38-41. [PMID: 27354999 PMCID: PMC4909829 DOI: 10.1016/j.gore.2016.05.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2016] [Revised: 05/25/2016] [Accepted: 05/30/2016] [Indexed: 12/03/2022] Open
Abstract
Ovarian dysgerminoma associated with paraneoplastic fever, cytopenia and splenomegaly Complete symptom resolution resulted from tumor resection and medical management Non-hematolymphoid neoplasms are part of differential diagnosis in secondary HLH.
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Affiliation(s)
- Mana Nosratian-Baskovic
- Stanford University, Department Obstetrics and Gynecology, Division of Gynecologic Oncology, Stanford, CA, United States
| | - Brent Tan
- Stanford University, Department Obstetrics and Gynecology, Division of Gynecologic Oncology, Stanford, CA, United States
| | - Ann Folkins
- Stanford University, Department of Pathology, Stanford, CA, United States
| | - Karen M Chisholm
- Stanford University, Department of Pathology, Stanford, CA, United States; Department of Laboratories, Seattle Children's Hospital, Department of Laboratories, Seattle, WA, United States
| | - Oliver Dorigo
- Stanford University, Department Obstetrics and Gynecology, Division of Gynecologic Oncology, Stanford, CA, United States
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Debaugnies F, Mahadeb B, Ferster A, Meuleman N, Rozen L, Demulder A, Corazza F. Performances of the H-Score for Diagnosis of Hemophagocytic Lymphohistiocytosis in Adult and Pediatric Patients. Am J Clin Pathol 2016; 145:862-70. [PMID: 27298397 DOI: 10.1093/ajcp/aqw076] [Citation(s) in RCA: 144] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVES In this study, we compared the performances of adapted hemophagocytic lymphohistiocytosis (HLH)-2004 guidelines with those of the new diagnostic H-score to identify patients with HLH in a multicenter cohort consisting of adult and pediatric cases of suspected HLH. METHODS The study sample consisted of 147 cases, including 20 adults and 16 children with HLH. Two sets of biological data were evaluated: at presentation and the maximal values reached during the episode. RESULTS At presentation, for both children and adults, the H-score was more efficient than adapted HLH-2004 guidelines to identify HLH. The diagnostic sensitivity and specificity were respectively 100% and 80% for children and 90% and 79% for adults. However, for adults, performances became comparable between adapted HLH-2004 guidelines and H-score as patient clinical status worsened. The specificity decreased to 73% for the same sensitivity. CONCLUSIONS The adapted HLH-2004 guidelines seem less powerful and H-score seems to be more appropriate for children, which may be due to less significantly marked biological features. For adults, H-score performances are better when determined at presentation. The cutoff value of the H-score should be adapted depending on the target population to obtain optimal specificity.
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Affiliation(s)
- France Debaugnies
- From the Laboratory of Immunology Laboratory of Biochemistry, Laboratoire National de Santé, Dudelange, Luxembourg.
| | | | - Alina Ferster
- Department of Hematology and Oncology, Hôpital Universitaire des Enfants Reine Fabiola, Brussels, Belgium
| | | | - Laurence Rozen
- Laboratory of Hematology and Hemostasis, Université Libre de Bruxelles, CHU Brugmann, Brussels, Belgium
| | - Anne Demulder
- Laboratory of Hematology and Hemostasis, Université Libre de Bruxelles, CHU Brugmann, Brussels, Belgium
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Tamamyan GN, Kantarjian HM, Ning J, Jain P, Sasaki K, McClain KL, Allen CE, Pierce SA, Cortes JE, Ravandi F, Konopleva MY, Garcia-Manero G, Benton CB, Chihara D, Rytting ME, Wang S, Abdelall W, Konoplev SN, Daver NG. Malignancy-associated hemophagocytic lymphohistiocytosis in adults: Relation to hemophagocytosis, characteristics, and outcomes. Cancer 2016; 122:2857-66. [PMID: 27244347 DOI: 10.1002/cncr.30084] [Citation(s) in RCA: 80] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Revised: 04/02/2016] [Accepted: 04/19/2016] [Indexed: 12/24/2022]
Abstract
BACKGROUND Malignancy-associated hemophagocytic lymphohistiocytosis (HLH) in adults is a highly lethal disorder. Knowledge gaps have resulted in under diagnosis or delayed diagnosis. METHODS The University of Texas MD Anderson Cancer Center pathology database (1991-2014) was retrospectively interrogated for the keywords "hemophagocytosis" and/or "lymphohistiocytosis." Seventy-seven adult patients were identified. All had an underlying malignancy. Sixteen patients who had insufficient documentation were excluded. RESULTS The majority of patients who had pathologic evidence of hemophagocytosis/lymphohistiocytosis had an incomplete workup to confirm or refute HLH using the 2004 HLH criteria (HLH-2004; n = 8 variables), which is a common problem in adult HLH. Only 13 of 61 patients (21%) met the HLH-2004 diagnostic criteria based on available retrospective data. To identify potentially missed cases of HLH, the published literature was reviewed, and selected additional variables known to be associated with adult HLH were selected, resulting in extended diagnostic criteria of 18 variables. Thirty-five patients met the extended criteria, and 33 had follow-up data available. The median overall survival of the 13 patients who met both the extended criteria and the HLH-2004 criteria was similar to that of the 20 patients who met the extended criteria but NOT the HLH-2004 criteria (1.43 vs 1.76 months, respectively; P = .34) indicating a similar underlying, aggressive, systemic process. Twenty-six patients did not meet either criteria, and 17 had follow-up data available. The median overall survival of the 17 patients who had pathologic hemophagocytosis or lymphohistiocytosis but met neither criteria was significantly superior to the survival of those who met both the extended criteria and the HLH-2004 criteria and those who met the extended criteria but not the HLH-2004 criteria (17.27 vs 1.43 vs 1.76, respectively; P = .002). CONCLUSIONS The addition of diagnostic laboratory variables that are more easily and rapidly available in smaller institutions and primary care settings than the HLH-2004 variables may be a good surrogate to raise early suspicion of malignancy-associated HLH. Prospective validation is warranted. Cancer 2016. © 2016 American Cancer Society. Cancer 2016;122:2857-2866. © 2016 American Cancer Society.
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Affiliation(s)
- Gevorg N Tamamyan
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas.,Department of Oncology, Yerevan State Medical University, Yerevan, Armenia
| | - Hagop M Kantarjian
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jing Ning
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Preetesh Jain
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Koji Sasaki
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Kenneth L McClain
- Histiocytosis Program, Texas Children's Cancer Center, Texas Children's Hospital, Houston, Texas
| | - Carl E Allen
- Histiocytosis Program, Texas Children's Cancer Center, Texas Children's Hospital, Houston, Texas
| | - Sherry A Pierce
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jorge E Cortes
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Farhad Ravandi
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Marina Y Konopleva
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | | | - Christopher B Benton
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Dai Chihara
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Michael E Rytting
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Sa Wang
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Waleed Abdelall
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Sergej N Konoplev
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Naval G Daver
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
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Filippone EJ, Farber JL. Hemophagocytic lymphohistiocytosis: an update for nephrologists. Int Urol Nephrol 2016; 48:1291-1304. [DOI: 10.1007/s11255-016-1294-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Accepted: 04/11/2016] [Indexed: 12/11/2022]
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Johnson B, Giri S, Nunnery SE, Wiedower E, Jamy O, Yaghmour G, Chandler JC, Martin MG. Comorbidities Drive Outcomes for Both Malignancy-Associated and Non–Malignancy-Associated Hemophagocytic Syndrome. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2016; 16:230-6. [DOI: 10.1016/j.clml.2016.01.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/11/2015] [Revised: 12/30/2015] [Accepted: 01/07/2016] [Indexed: 12/13/2022]
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69
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Cesarine J, Filippone LM, Filippone EJ. Hemophagocytic lymphohistiocytosis in the ED. Am J Emerg Med 2016; 34:2057.e5-2057.e8. [PMID: 27066745 DOI: 10.1016/j.ajem.2016.03.034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Accepted: 03/11/2016] [Indexed: 12/17/2022] Open
Affiliation(s)
- Joseph Cesarine
- Department of Emergency Medicine, Cooper Medical School of Rowan University, Camden, NJ
| | - Lisa M Filippone
- Department of Emergency Medicine, Cooper Medical School of Rowan University, Camden, NJ
| | - Edward J Filippone
- Division of Nephrology, Department of Medicine, Sydney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA 19107.
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Lehmberg K, Nichols KE, Henter JI, Girschikofsky M, Greenwood T, Jordan M, Kumar A, Minkov M, La Rosée P, Weitzman S. Consensus recommendations for the diagnosis and management of hemophagocytic lymphohistiocytosis associated with malignancies. Haematologica 2016; 100:997-1004. [PMID: 26314082 DOI: 10.3324/haematol.2015.123562] [Citation(s) in RCA: 69] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
The hyperinflammatory syndrome hemophagocytic lymphohistiocytosis can occur in the context of malignancies. Malignancy-triggered hemophagocytic lymphohistiocytosis should be regarded separately from hemophagocytic lymphohistiocytosis during chemotherapeutic treatment, which is frequently associated with an infectious trigger. The substantial overlap between the features of hemophagocytic lymphohistiocytosis with features of neoplasms makes its identification difficult when it occurs in malignant conditions. To facilitate recognition and diagnostic workup, and provide guidance regarding the treatment of malignancy-associated hemophagocytic lymphohistiocytosis, consensus recommendations were developed by the Study Group on Hemophagocytic Lymphohistiocytosis Subtypes of the Histiocyte Society, an interdisciplinary group consisting of pediatric and adult hemato-oncologists and immunologists.
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Affiliation(s)
- Kai Lehmberg
- Department of Pediatric Hematology and Oncology, University Medical Center Eppendorf, Hamburg, Germany
| | - Kim E Nichols
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Jan-Inge Henter
- Childhood Cancer Research Unit, Department of Women's and Children's Health, Karolinska Institutet, Karolinska University Hospital Solna, Stockholm, Sweden
| | - Michael Girschikofsky
- Department of Medicine I, Hematology and Stem Cell Transplantation, Hemostasis and Medical Oncology, Elisabethinen Hospital, Linz, Austria
| | - Tatiana Greenwood
- Childhood Cancer Research Unit, Department of Women's and Children's Health, Karolinska Institutet, Karolinska University Hospital Solna, Stockholm, Sweden
| | - Michael Jordan
- Department of Immunology, Cincinnati Children's Hospital, OH, USA
| | - Ashish Kumar
- Department of Immunology, Cincinnati Children's Hospital, OH, USA
| | - Milen Minkov
- Department of Pediatric Hematology and Oncology, St. Anna Children's Hospital, Vienna, Austria
| | - Paul La Rosée
- Klinik für Innere Medizin II, Abt. Hämatologie und internistische Onkologie, Universitätsklinikum Jena, Germany
| | - Sheila Weitzman
- Department of Hematology and Oncology, Sick Kids Hospital, Toronto, Canada
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71
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Santoriello D, Hogan J, D'Agati VD. Hemophagocytic Syndrome With Histiocytic Glomerulopathy and Intraglomerular Hemophagocytosis. Am J Kidney Dis 2016; 67:978-83. [PMID: 26774467 DOI: 10.1053/j.ajkd.2015.11.017] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Accepted: 11/29/2015] [Indexed: 12/12/2022]
Abstract
Hemophagocytic syndrome (HPS), a rare and life-threatening disease, is characterized by hyperactivation of the immune system that causes hypercytokinemia and potential multiorgan failure. Acute kidney injury is the most common kidney manifestation of HPS and is generally considered a poor prognostic factor. Glomerular involvement is uncommon and usually manifests as either podocytopathy with collapsing glomerulopathy or thrombotic microangiopathy. We report a rare case of severe histiocytic glomerulopathy in a patient with HPS who presented with acute kidney injury and proteinuria. Kidney biopsy revealed massive glomerular infiltration by macrophages resembling proliferative glomerulonephritis accompanied by intraglomerular hemophagocytosis and mild features of glomerular thrombotic microangiopathy. The patient's kidney failure and proteinuria responded rapidly to high-dose pulse methylprednisolone followed by a tapering course of oral prednisone. Our case expands the renal pathologic spectrum of HPS to include histiocyte-rich glomerular infiltration and intraglomerular hemophagocytosis. Greater awareness of this entity is needed to ensure prompt recognition and appropriate therapy.
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Affiliation(s)
- Dominick Santoriello
- Department of Pathology & Cell Biology, Columbia University Medical Center, New York, NY.
| | - Jonathan Hogan
- Department of Medicine, Division of Nephrology, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Vivette D D'Agati
- Department of Pathology & Cell Biology, Columbia University Medical Center, New York, NY
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Mutations in AP3D1 associated with immunodeficiency and seizures define a new type of Hermansky-Pudlak syndrome. Blood 2016; 127:997-1006. [PMID: 26744459 DOI: 10.1182/blood-2015-09-671636] [Citation(s) in RCA: 108] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2015] [Accepted: 12/26/2015] [Indexed: 01/07/2023] Open
Abstract
Genetic disorders affecting biogenesis and transport of lysosome-related organelles are heterogeneous diseases frequently associated with albinism. We studied a patient with albinism, neutropenia, immunodeficiency, neurodevelopmental delay, generalized seizures, and impaired hearing but with no mutation in genes so far associated with albinism and immunodeficiency. Whole exome sequencing identified a homozygous mutation in AP3D1 that leads to destabilization of the adaptor protein 3 (AP3) complex. AP3 complex formation and the degranulation defect in patient T cells were restored by retroviral reconstitution. A previously described hypopigmented mouse mutant with an Ap3d1 null mutation (mocha strain) shares the neurologic phenotype with our patient and shows a platelet storage pool deficiency characteristic of Hermansky-Pudlak syndrome (HPS) that was not studied in our patient because of a lack of bleeding. HPS2 caused by mutations in AP3B1A leads to a highly overlapping phenotype without the neurologic symptoms. The AP3 complex exists in a ubiquitous and a neuronal form. AP3D1 codes for the AP3δ subunit of the complex, which is essential for both forms. In contrast, the AP3β3A subunit, affected in HPS2 patients, is substituted by AP3β3B in the neuron-specific heterotetramer. AP3δ deficiency thus causes a severe neurologic disorder with immunodeficiency and albinism that we propose to classify as HPS10.
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73
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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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74
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de Asua I, Ciliberti E. Haemophagocytic syndrome in intensive care: The great pretender. J Intensive Care Soc 2015; 16:316-319. [PMID: 28979438 DOI: 10.1177/1751143715584383] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
The haemophagocytic syndrome is a unique disease process in which the dysregulation of the patient's immune system leads to an inflammatory storm which rapidly ravages through multiple organ systems, generating life-threatening end-organ dysfunction. Since it usually mimics other conditions frequently encountered in the critical care population - most notably septic shock - its diagnosis is elusive and the condition remains under-recognized and under-reported. We present a concise review of the pathophysiology and clinical features of the heamophagocytic syndrome and discuss the main diagnostic and therapeutic issues relevant to the management of this condition in the critically ill patient. Increasing awareness about the haemophagocytic syndrome amongst intensive care physicians will facilitate earlier recognition and timely management.
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Affiliation(s)
- Ignacio de Asua
- Department of Anaesthetics and Intensive Care, Royal Brompton and Harefield NHS Trust, Harefield, Middlesex, UK
| | - Esteban Ciliberti
- Department of Anaesthetics and Intensive Care, Royal Brompton and Harefield NHS Trust, Harefield, Middlesex, UK
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75
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Dalal BI, Vakil AP, Khare NS, Wang SY, Richards MJ, Chen LYC. Abnormalities of the lymphocyte subsets and their immunophenotype, and their prognostic significance in adult patients with hemophagocytic lymphohistiocytosis. Ann Hematol 2015; 94:1111-7. [DOI: 10.1007/s00277-015-2350-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2014] [Accepted: 03/04/2015] [Indexed: 10/23/2022]
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76
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Oschlies I, Simonitsch-Klupp I, Maldyk J, Konovalov D, Abramov D, Myakova N, Lisfeld J, Attarbaschi A, Kontny U, Woessmann W, Klapper W. Subcutaneous panniculitis-like T-cell lymphoma in children: a detailed clinicopathological description of 11 multifocal cases with a high frequency of haemophagocytic syndrome. Br J Dermatol 2015; 172:793-7. [PMID: 25456748 DOI: 10.1111/bjd.13440] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Affiliation(s)
- I Oschlies
- Department of Pathology, Hematopathology Section and Lymph Node Registry, Christian-Albrecht University Kiel and University Hospital Schleswig-Holstein, Campus Kiel, Michaelisstr. 11, 24105, Kiel, Germany.
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77
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Kumakura S. Validity in the Diagnosis of Reactive Hemophagocytic Syndrome: Comment on the Article by Fardet et al. Arthritis Rheumatol 2015; 67:587-8. [DOI: 10.1002/art.38935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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78
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Götze T, Blessing H, Grillhösl C, Gerner P, Hoerning A. Neonatal Cholestasis - Differential Diagnoses, Current Diagnostic Procedures, and Treatment. Front Pediatr 2015; 3:43. [PMID: 26137452 PMCID: PMC4470262 DOI: 10.3389/fped.2015.00043] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2014] [Accepted: 04/29/2015] [Indexed: 12/18/2022] Open
Abstract
Cholestatic jaundice in early infancy is a complex diagnostic problem. Misdiagnosis of cholestasis as physiologic jaundice delays the identification of severe liver diseases. In the majority of infants, prolonged physiologic jaundice represent benign cases of breast milk jaundice, but few among them are masked and caused by neonatal cholestasis (NC) that requires a prompt diagnosis and treatment. Therefore, a prolonged neonatal jaundice, longer than 2 weeks after birth, must always be investigated because an early diagnosis is essential for appropriate management. To rapidly identify the cases with cholestatic jaundice, the conjugated bilirubin needs to be determined in any infant presenting with prolonged jaundice at 14 days of age with or without depigmented stool. Once NC is confirmed, a systematic approach is the key to reliably achieve the diagnosis in order to promptly initiate the specific, and in many cases, life-saving therapy. This strategy is most important to promptly identify and treat infants with biliary atresia, the most common cause of NC, as this requires a hepatoportoenterostomy as soon as possible. Here, we provide a detailed work-up approach including initial treatment recommendations and a clinically oriented overview of possible differential diagnoses in order to facilitate the early recognition and a timely diagnosis of cholestasis. This approach warrants a broad spectrum of diagnostic procedures and investigations including new methods that are described in this review.
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Affiliation(s)
- Thomas Götze
- Department for Pediatric and Adolescent Medicine, Friedrich-Alexander University of Erlangen-Nuremberg , Erlangen , Germany
| | - Holger Blessing
- Department for Pediatric and Adolescent Medicine, Friedrich-Alexander University of Erlangen-Nuremberg , Erlangen , Germany
| | - Christian Grillhösl
- Department for Pediatric and Adolescent Medicine, Friedrich-Alexander University of Erlangen-Nuremberg , Erlangen , Germany
| | - Patrick Gerner
- Department for Pediatric and Adolescent Medicine, Albert-Ludwigs-University Freiburg , Freiburg , Germany
| | - André Hoerning
- Department for Pediatric and Adolescent Medicine, Friedrich-Alexander University of Erlangen-Nuremberg , Erlangen , Germany
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Abstract
Peripheral blood cytopenia in children can be due to a variety of acquired or inherited diseases. Genetic disorders affecting a single hematopoietic lineage are frequently characterized by typical bone marrow findings, such as lack of progenitors or maturation arrest in congenital neutropenia or a lack of megakaryocytes in congenital amegakaryocytic thrombocytopenia, whereas antibody-mediated diseases such as autoimmune neutropenia are associated with a rather unremarkable bone marrow morphology. By contrast, pancytopenia is frequently associated with a hypocellular bone marrow, and the differential diagnosis includes acquired aplastic anemia, myelodysplastic syndrome, inherited bone marrow failure syndromes such as Fanconi anemia and dyskeratosis congenita, and a variety of immunological disorders including hemophagocytic lymphohistiocytosis. Thorough bone marrow analysis is of special importance for the diagnostic work-up of most patients. Cellularity, cellular composition, and dysplastic signs are the cornerstones of the differential diagnosis. Pancytopenia in the presence of a normo- or hypercellular marrow with dysplastic changes may indicate myelodysplastic syndrome. More challenging for the hematologist is the evaluation of the hypocellular bone marrow. Although aplastic anemia and hypocellular refractory cytopenia of childhood (RCC) can reliably be differentiated on a morphological level, the overlapping pathophysiology remains a significant challenge for the choice of the therapeutic strategy. Furthermore, inherited bone marrow failure syndromes are usually associated with the morphological picture of RCC, and the recognition of these entities is essential as they often present a multisystem disease requiring different diagnostic and therapeutic approaches. This paper gives an overview over the different disease entities presenting with (pan)cytopenia, their pathophysiology, characteristic bone marrow findings, and therapeutic approaches.
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Affiliation(s)
- Miriam Erlacher
- Division of Pediatric Hematology and Oncology, Department of Pediatrics and Adolescent Medicine, University Medical Center of Freiburg , Freiburg , Germany ; Freiburg Institute for Advanced Studies, University of Freiburg , Freiburg , Germany
| | - Brigitte Strahm
- Division of Pediatric Hematology and Oncology, Department of Pediatrics and Adolescent Medicine, University Medical Center of Freiburg , Freiburg , Germany
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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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81
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Lang S, Kansy B. Cervical lymph node diseases in children. GMS CURRENT TOPICS IN OTORHINOLARYNGOLOGY, HEAD AND NECK SURGERY 2014; 13:Doc08. [PMID: 25587368 PMCID: PMC4273169 DOI: 10.3205/cto000111] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
The lymph nodes are an essential part of the body’s immune system and as such are affected in many infectious, autoimmune, metabolic and malignant diseases. The cervical lymph nodes are particularly important because they are the first drainage stations for key points of contact with the outside world (mouth/throat/nose/eyes/ears/respiratory system) – a critical aspect especially among children – and can represent an early clinical sign in their exposed position on a child’s slim neck. Involvement of the lymph nodes in multiple conditions is accompanied by a correspondingly large number of available diagnostic procedures. In the interests of time, patient wellbeing and cost, a careful choice of these must be made to permit appropriate treatment. The basis of diagnostic decisions is a detailed anamnesis and clinical examination. Sonography also plays an important role in differential diagnosis of lymph node swelling in children and is useful in answering one of the critical diagnostic questions: is there a suspicion of malignancy? If so, full dissection of the most conspicuous lymph node may be necessary to obtain histological confirmation. Diagnosis and treatment of childhood cervical lymph node disorders present the attending pediatric and ENT physicians with some particular challenges. The spectrum of differential diagnoses and the varying degrees of clinical relevance – from banal infections to malignant diseases – demand a clear and considered approach to the child’s individual clinical presentation. Such an approach is described in the following paper.
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Affiliation(s)
- Stephan Lang
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Benjamin Kansy
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Essen, University Duisburg-Essen, Essen, Germany
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82
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Ozen S, Dai A, Coskun E, Oztuzcu S, Ergun S, Aktekin E, Yavuz S, Bay A. Importance of hyperbilirubinemia in differentiation of primary and secondary hemophagocytic lymphohistiocytosis in pediatric cases. Mediterr J Hematol Infect Dis 2014; 6:e2014067. [PMID: 25408853 PMCID: PMC4235485 DOI: 10.4084/mjhid.2014.067] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2014] [Accepted: 10/03/2014] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND AND OBJECTIVE Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening hyper-inflammatory disease. It is difficult to differentiate between primary and secondary HLH based on clinical findings at the onset of disease. We aimed to find parameters that can help to differentiate primary and secondary HLH at initial diagnosis especially for physicians working in developing countries. PATIENT AND METHOD We retrospectively analyzed data of 38 HLH patients who were admitted to the Pediatric Hematology Department of Gaziantep University between January 2009 and December 2013. RESULTS Of 38 patients, 20 were defined as primary, and 18 were secondary HLH. The average age of primary and secondary HLH patients was 31±9 and 81±14 months, respectively (p=0.03). We found consanguinity rates significantly higher in primary HLH patients compared to secondary HLH patients (p=0.03). We found that total and direct bilirubin levels significantly increased in primary HLH patients compared to secondary HLH patients (p=0.006, p=0.044). Also, CRP levels were found markedly increased in secondary HLH patients compared to primary ones (p=0.017). CONCLUSION We showed that cholestasis and hyperbilirubinemia findings of HLH patients at the initial diagnosis should be considered in favor of primary HLH, and an increased level of CRP should be considered in favor of secondary HLH.
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Affiliation(s)
- Seval Ozen
- Gaziantep University Department of Pediatrics, Gaziantep, Turkey
| | - Alper Dai
- Gaziantep University Department of Pediatrics, Gaziantep, Turkey
| | - Enes Coskun
- Gaziantep University Department of Pediatrics, Gaziantep, Turkey
| | - Serdar Oztuzcu
- Gaziantep University Department of Medical Biology, Gaziantep, Turkey
| | - Sercan Ergun
- Gaziantep University Department of Medical Biology, Gaziantep, Turkey
| | - Elif Aktekin
- Gaziantep University Department of Pediatrics, Gaziantep, Turkey
| | - Sibel Yavuz
- Gaziantep University Department of Pediatrics, Gaziantep, Turkey
| | - Ali Bay
- Gaziantep University Department of Pediatrics, Gaziantep, Turkey
- Gaziantep University Division of Pediatric Hematology Gaziantep, Turkey
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83
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Kumakura S, Murakawa Y. Clinical characteristics and treatment outcomes of autoimmune-associated hemophagocytic syndrome in adults. Arthritis Rheumatol 2014; 66:2297-307. [PMID: 24756912 PMCID: PMC4271677 DOI: 10.1002/art.38672] [Citation(s) in RCA: 87] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2013] [Accepted: 04/11/2014] [Indexed: 12/13/2022]
Abstract
Objective To better define the clinical characteristics and treatment outcomes of autoimmune-associated hemophagocytic syndrome (AAHS) in adults. Methods Adults with AAHS (defined as pathologic evidence of hemophagocytosis without any obvious cause other than an autoimmune disease) were identified through a review of the literature. Results Among 116 patients identified, underlying diseases included systemic lupus erythematosus (SLE) in 52.3%, adult-onset Still's disease (AOSD) in 26.7%, and dermatomyositis in 6.9%. Fever, lymphadenopathy, hepatomegaly, and splenomegaly were found in 86.8%, 41.0%, 41.8%, and 45.5% of patients, respectively. Cytopenia, liver dysfunction, and hyperferritinemia developed frequently, and coagulopathy was seen in 50.6% of patients. Normal or low C-reactive protein levels were characteristic of patients with underlying SLE. The most commonly used therapy was corticosteroids, which were initially administered in 95.7% of patients, with 57.7% responding. Patients with corticosteroid-refractory disease were usually treated with cyclosporine, intravenous cyclophosphamide (IV CYC), or intravenous immunoglobulin (IVIG), with IV CYC being highly effective. Treatment with biologic agents resulted in favorable effects in the majority of patients. The mortality rate was 12.9%. Male sex (odds ratio [OR] 6.47, 95% confidence interval [95% CI] 2.06–30.39, P < 0.01), dermatomyositis (OR 5.57, 95% CI 1.08–28.65, P < 0.05), and anemia (hemoglobin <8 gm/dl; OR 3.74, 95% CI 1.02–13.8, P < 0.05) were identified as factors associated with mortality. Conclusion AAHS is potentially fatal. Corticosteroids are a mainstay of initial treatment. For corticosteroid-refractory disease, IV CYC may be beneficial as compared with cyclosporine or IVIG. Treatment that proceeds directly from corticosteroids to biologic agents is promising.
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84
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Lozano ML, Rivera J, Sánchez-Guiu I, Vicente V. Towards the targeted management of Chediak-Higashi syndrome. Orphanet J Rare Dis 2014; 9:132. [PMID: 25129365 PMCID: PMC4243965 DOI: 10.1186/s13023-014-0132-6] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2014] [Accepted: 08/05/2014] [Indexed: 12/15/2022] Open
Abstract
Chediak-Higashi syndrome (CHS) is a rare, autosomal recessive congenital immunodeficiency caused by mutations in CHS1, a gene encoding a putative lysosomal trafficking protein. In the majority of patients, this disorder is typically characterized by infantile-onset hemophagocytic lymphohistiocytosis (HLH), which is lethal unless allogeneic transplantation is performed. A small number of individuals have the attenuated form of the disease and do not benefit from transplant. Improved outcomes of transplantation have been reported when performed before the development of HLH, thus it is important to quickly differentiate patients that present with the childhood form of disease and to prematurely enroll them into a transplantation protocol. In addition, this would also preclude those that exhibit clinical phenotypes of adolescent and adult CHS from this treatment. Patients with an absence of cytotoxic T lymphocyte (CTL) function have a high risk for developing HLH, and could therefore benefit the most from early hematopoietic stem cell transplantation (HSCT). However, although normal CTL cytotoxicity or bi-allelic missense mutations do not exclude the occurrence of HLH in childhood, a more conservative approach is justified. This article summarizes recent advances in the clinical characterization of CHS patients, provides updates on promising new testing methods, and focuses on specific therapeutic approaches.
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Affiliation(s)
- Maria L Lozano
- Centro Regional de Hemodonación, Hospital JM Morales Meseguer, University of Murcia, IMIB-Arrixaca, C/Ronda de Garay s/n, Murcia 30003, Spain.
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85
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Imashuku S. Hemophagocytic lymphohistiocytosis: Recent progress in the pathogenesis, diagnosis and treatment. World J Hematol 2014; 3:71-84. [DOI: 10.5315/wjh.v3.i3.71] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2014] [Revised: 05/09/2014] [Accepted: 06/18/2014] [Indexed: 02/05/2023] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a hyperinflammatory syndrome that develops as a primary (familial/hereditary) or secondary (non-familial/hereditary) disease characterized in the majority of the cases by hereditary or acquired impaired cytotoxic T-cell (CTL) and natural killer responses. The molecular mechanisms underlying impaired immune homeostasis have been clarified, particularly for primary diseases. Familial HLH (familial hemophagocytic lymphohistiocytosis type 2-5, Chediak-Higashi syndrome, Griscelli syndrome type 2, Hermansky-Pudlak syndrome type 2) develops due to a defect in lytic granule exocytosis, impairment of (signaling lymphocytic activation molecule)-associated protein, which plays a key role in CTL activity [e.g., X-linked lymphoproliferative syndrome (XLP) 1], or impairment of X-linked inhibitor of apoptosis, a potent regulator of lymphocyte homeostasis (e.g., XLP2). The development of primary HLH is often triggered by infections, but not in all. Secondary HLH develops in association with infection, autoimmune diseases/rheumatological conditions and malignancy. The molecular mechanisms involved in secondary HLH cases remain unknown and the pathophysiology is not the same as primary HLH. For either primary or secondary HLH cases, immunosuppressive therapy should be given to control the hypercytokinemia with steroids, cyclosporine A, or intravenous immune globulin, and if primary HLH is diagnosed, immunochemotherapy with a regimen containing etoposide or anti-thymocyte globulin should be started. Thereafter, allogeneic hematopoietic stem-cell transplantation is recommended for primary HLH or secondary refractory disease (especially EBV-HLH).
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86
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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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87
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Janka G. Hemophagocytic lymphohistiocytosis: A serious challenge for every physician. Rev Clin Esp 2014; 214:318-9. [PMID: 24954295 DOI: 10.1016/j.rce.2014.05.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2014] [Accepted: 05/12/2014] [Indexed: 12/12/2022]
Affiliation(s)
- G Janka
- Pediatric Hematology and Oncology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
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88
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Koduri PR. Comment on Pregnancy-Induced Hemophagocytic Syndrome. J Obstet Gynaecol India 2014; 64:228. [DOI: 10.1007/s13224-014-0569-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2013] [Accepted: 05/08/2014] [Indexed: 11/30/2022] Open
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89
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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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90
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Brunt EM, Gouw ASH, Hubscher SG, Tiniakos DG, Bedossa P, Burt AD, Callea F, Clouston AD, Dienes HP, Goodman ZD, Roberts EA, Roskams T, Terracciano L, Torbenson MS, Wanless IR. Pathology of the liver sinusoids. Histopathology 2014; 64:907-20. [PMID: 24393125 DOI: 10.1111/his.12364] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The hepatic sinusoids comprise a complex of vascular conduits to transport blood from the porta hepatis to the inferior vena cava through the liver. Under normal conditions, portal venous and hepatic artery pressures are equalized within the sinusoids, oxygen and nutrients from the systemic circulation are delivered to the parenchymal cells and differentially distributed throughout the liver acini, and proteins of liver derivation are carried into the cardiac/systemic circulation. Liver sinusoid structures are lined by endothelial cells unique to their location, and Kupffer cells. Multifunctional hepatic stellate cells and various immune active cells are localized within the space of Disse between the sinusoid and the adjacent hepatocytes. Flow within the sinusoids can be compromised by physical or pressure blockage in their lumina as well as obstructive processes within the space of Disse. The intimate relationship of the liver sinusoids to neighbouring hepatocytes is a significant factor affecting the health of hepatocytes, or transmission of the effects of injury within the sinusoidal space. Pathologists should recognize several patterns of injury involving the sinusoids and surrounding hepatocytes. In this review, injury, alterations and accumulations within the liver sinusoids are illustrated and discussed.
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Affiliation(s)
- Elizabeth M Brunt
- Department of Pathology and Immunology, Washington University, School of Medicine, St Louis, MO, USA
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91
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Jovanovic A, Kuzmanovic M, Kravljanac R, Micic D, Jovic M, Gazikalovic S, Pasic S. Central nervous system involvement in hemophagocytic lymphohistiocytosis: a single-center experience. Pediatr Neurol 2014; 50:233-7. [PMID: 24332871 DOI: 10.1016/j.pediatrneurol.2013.10.014] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2013] [Revised: 10/10/2013] [Accepted: 10/28/2013] [Indexed: 12/01/2022]
Abstract
BACKGROUND Hemophagocytic lymphohistiocytosis is a rare multisystem disorder characterized by proliferation and diffuse infiltration multiple organs with histiocytes, including the central nervous system. PATIENTS AND METHODS Thirty children diagnosed with hemophagocytic lymphohistiocytosis between 1997 and 2010 were reviewed and analyzed. Central nervous system disease involvement was defined as the presence of neurological symptoms and signs or elevated values of cerebrospinal fluid cells and/or proteins. RESULTS Among the 30 patients, 17 (56%) had central nervous system involvement. Fourteen patients (46%) presented with neurological symptoms including seizures, irritability, bulging fontanelle, cranial nerve palsy, or disturbance of consciousness, whereas the remaining three patients developed central nervous system symptoms during the course of the disease. Seventeen patients (56%) had cerebrospinal fluid abnormalities. Neuroradiological studies were performed in nine patients. The most common findings were edema, atrophy, subcortical necrosis, and high signal intensity on T2-weighted magnetic resonance imaging. All patients were treated according to the Hemophagocytic Lymphohistiocytosis-94 and Hemophagocytic Lymphohistiocytosis-2004 protocols. Patients with central nervous system involvement had greater mortality. In prediction of the outcome, the cutoff value for cerebrospinal fluid protein was 470 mg/L. The most common neurological sequela was psychomotor delay. CONCLUSION Central nervous system involvement in hemophagocytic lymphohistiocytosis is common and is associated with poor outcome.
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Affiliation(s)
- Ankica Jovanovic
- Department of Pediatric Hematology, Mother and Child Health Institute, Medical Faculty, University of Belgrade, Serbia; Department of Neurology, Mother and Child Health Institute, Medical Faculty, University of Belgrade, Serbia; Department of Radiology, Mother and Child Health Institute, Medical Faculty, University of Belgrade, Serbia; Department of Immunology, Mother and Child Health Institute, Medical Faculty, University of Belgrade, Serbia
| | - Milos Kuzmanovic
- Department of Pediatric Hematology, Mother and Child Health Institute, Medical Faculty, University of Belgrade, Serbia; Department of Neurology, Mother and Child Health Institute, Medical Faculty, University of Belgrade, Serbia; Department of Radiology, Mother and Child Health Institute, Medical Faculty, University of Belgrade, Serbia; Department of Immunology, Mother and Child Health Institute, Medical Faculty, University of Belgrade, Serbia
| | - Ruzica Kravljanac
- Department of Pediatric Hematology, Mother and Child Health Institute, Medical Faculty, University of Belgrade, Serbia; Department of Radiology, Mother and Child Health Institute, Medical Faculty, University of Belgrade, Serbia; Department of Immunology, Mother and Child Health Institute, Medical Faculty, University of Belgrade, Serbia
| | - Dragan Micic
- Department of Pediatric Hematology, Mother and Child Health Institute, Medical Faculty, University of Belgrade, Serbia; Department of Neurology, Mother and Child Health Institute, Medical Faculty, University of Belgrade, Serbia; Department of Radiology, Mother and Child Health Institute, Medical Faculty, University of Belgrade, Serbia; Department of Immunology, Mother and Child Health Institute, Medical Faculty, University of Belgrade, Serbia
| | - Milena Jovic
- Department of Neurology, Mother and Child Health Institute, Medical Faculty, University of Belgrade, Serbia; Department of Radiology, Mother and Child Health Institute, Medical Faculty, University of Belgrade, Serbia; Department of Immunology, Mother and Child Health Institute, Medical Faculty, University of Belgrade, Serbia
| | - Slobodan Gazikalovic
- Department of Pediatric Hematology, Mother and Child Health Institute, Medical Faculty, University of Belgrade, Serbia; Department of Neurology, Mother and Child Health Institute, Medical Faculty, University of Belgrade, Serbia; Department of Immunology, Mother and Child Health Institute, Medical Faculty, University of Belgrade, Serbia
| | - Srdjan Pasic
- Department of Pediatric Hematology, Mother and Child Health Institute, Medical Faculty, University of Belgrade, Serbia; Department of Neurology, Mother and Child Health Institute, Medical Faculty, University of Belgrade, Serbia; Department of Radiology, Mother and Child Health Institute, Medical Faculty, University of Belgrade, Serbia.
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92
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Hibino M, Sato S, Shimizu T, Yamamoto S, Ohe M, Kondo T. Hemophagocytic lymphohistiocytosis secondary to Mycoplasma pneumoniae infection without pneumonia. Intern Med 2014; 53:1679-83. [PMID: 25088886 DOI: 10.2169/internalmedicine.53.2089] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Mycoplasma pneumoniae typically causes respiratory tract infections, including pneumonia. We herein report the case of a 30-year-old Japanese woman with hemophagocytic lymphohistiocytosis (HLH), which is rarely caused by bacteria, secondary to Mycoplasma pneumoniae infection and ensuing hypercytokinemia without pneumonia who was successfully treated with a combination of antibiotics and corticosteroids. Therefore, Mycoplasma pneumoniae infection, which is treatable with antibiotics, should be considered a possible trigger of HLH in patients who present with a viral-like illness without pneumonia.
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Affiliation(s)
- Makoto Hibino
- Department of Respiratory Medicine, Shonan Fujisawa Tokushukai Hospital, Japan
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93
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Hara S, Kawada JI, Kawano Y, Yamashita T, Minagawa H, Okumura N, Ito Y. Hyperferritinemia in neonatal and infantile human parechovirus-3 infection in comparison with other infectious diseases. J Infect Chemother 2013; 20:15-9. [PMID: 24462418 DOI: 10.1016/j.jiac.2013.11.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2013] [Revised: 07/01/2013] [Accepted: 07/08/2013] [Indexed: 10/25/2022]
Abstract
Human parechovirus-3 (HPeV-3) has been associated with severe clinical manifestations in neonates and infants in the form of sepsis or hemophagocytic lymphohistiocytosis (HLH)-like illness. To clarify the clinical features of HPeV-3 infection, we compared clinical signs and laboratory findings among enteroviruses (EVs), HPeV-3, and other infections. Participants were 26 febrile infants in whom EVs (n = 20) or HPeV-3 (n = 6) were isolated from throat swab or fecal specimens. Clinical and laboratory data were compared among EVs, HPeV-3, respiratory syncytial virus (RSV) infection (n = 15), and bacterial meningitis (n = 8) groups. Apnea was frequently seen in the HPeV-3 group although there were no significant differences in other clinical symptoms. Leukocyte count was significantly lower in the HPeV-3 group than in the EV and RSV group. Platelet count was significantly lower in the HPeV-3 group than in the RSV group. Serum ferritin levels in the HPeV-3 group (mean, 2437 ng/ml) and EV group (mean, 552 ng/ml) were significantly higher than in the RSV group (mean 237 ng/ml; P = 0.008 and P = 0.002, respectively). The frequency of patients with clearly high ferritin levels ≥1000 ng/ml was comparatively higher in the HPeV-3 group (4/6) than the EV group (3/20) (P = 0.03). In the HPeV-3 group, ferritin levels were high on Days 4-5. Elevated ferritin levels, decreased leukocyte and platelet counts could offer diagnostic clues to HPeV-3 infection in infant. These laboratory findings might be associated with aberrant immune response to HPeV-3, which could contribute to the development of sepsis or HLH-like illness in neonates.
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Affiliation(s)
- Shinya Hara
- Department of Pediatrics, Toyota Memorial Hospital, Toyota, Japan
| | - Jun-ichi Kawada
- Department of Pediatrics, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yoshihiko Kawano
- Department of Pediatrics, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Teruo Yamashita
- Laboratory of Virology, Aichi Prefectural Institute of Public Health, Nagoya, Japan
| | - Hiroko Minagawa
- Laboratory of Virology, Aichi Prefectural Institute of Public Health, Nagoya, Japan
| | - Naoya Okumura
- Department of Pediatrics, Toyota Memorial Hospital, Toyota, Japan
| | - Yoshinori Ito
- Department of Pediatrics, Nagoya University Graduate School of Medicine, Nagoya, Japan.
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94
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Janka GE, Lehmberg K. Hemophagocytic lymphohistiocytosis: pathogenesis and treatment. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2013; 2013:605-611. [PMID: 24319239 DOI: 10.1182/asheducation-2013.1.605] [Citation(s) in RCA: 190] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is not an independent disease but rather a life-threatening clinical syndrome that occurs in many underlying conditions and in all age groups. HLH is the consequence of a severe, uncontrolled hyperinflammatory reaction that in most cases is triggered by an infectious agent. Persistent stimulation of lymphocytes and histiocytes results in hypercytokinemia, leading to the characteristic symptoms of HLH. Genetic defects in familial HLH and in immunodeficiency syndromes associated with albinism affect the transport, processing, and function of cytotoxic granules in natural killer cells and cytotoxic T lymphocytes. This leads to defective killing of target cells and a failure to contract the immune response. The defects are increasingly found also in adolescents and adults. Acquired HLH occurs in autoinflammatory and autoimmune diseases (macrophage activation syndrome) and in patients with iatrogenic immunosuppression or with malignancies, but also in otherwise healthy persons with infections. Treatment of HLH aims at suppressing hypercytokinemia and eliminating the activated and infected cells. In genetic HLH, hematopoietic stem cell transplantation (HSCT) is needed for the correction of the immune defect. Treatment modalities include immunosuppressive, immunomodulatory, and cytostatic drugs; T-cell antibodies; and anticytokine agents. Using immunochemotherapy, familial HLH, which had been invariably fatal, has become a curable disease with more than 50% survivors. Reduced intensity conditioning for HSCT, which is associated with less transplantation-related mortality, will further improve cure rates.
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