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Chen X, Wang S, Yang J, Wang X, Yang L, Zhou J. The predictive value of hematological inflammatory markers for acute kidney injury and mortality in adults with hemophagocytic Lymphohistiocytosis: A retrospective analysis of 585 patients. Int Immunopharmacol 2023; 122:110564. [PMID: 37451019 DOI: 10.1016/j.intimp.2023.110564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 06/22/2023] [Accepted: 06/22/2023] [Indexed: 07/18/2023]
Abstract
BACKGROUND Hemophagocytic lymphohistiocytosis (HLH) is a rare immunological hyperactivation-related disease with a high mortality rate. The purpose of this study was to examine the relationship between complete blood count parameters and the occurrence of acute kidney injury (AKI) and mortality in patients with HLH. METHODS We included 585 adult patients with HLH. Logistic regression models for AKI and 28-day mortality were developed. RESULTS Multivariate logistic regression models revealed that hemoglobin (HB) ≤ 7.3 g/dl (adjusted OR, 1.651; 95% CI, 1.044-2.612), hemoglobin-to-red blood cell distribution width ratio (HRR) < 0.49 (adjusted OR, 1.692), neutrophil-to-lymphocyte ratio (NLR) ≥ 3.15 (adjusted OR, 1.697), and neutrophil-to-lymphocyte-platelet ratio (NLPR) ≥ 11.0 (adjusted OR, 1.608) were independent risk factors for the development of AKI. Moreover, lower platelet levels (31 × 109/L < platelets < 84 × 109/L, adjusted OR, 2.133; platelets ≤ 31 × 109/L, adjusted OR, 3.545) and higher red blood cell distribution width-to-platelet ratio (RPR) levels (0.20 < RPR < 0.54, adjusted OR, 2.595; RPR ≥ 0.54, adjusted OR, 4.307), lymphocytes ≤ 0.34 × 109/L (adjusted OR, 1.793), NLPR ≥ 11.0 (adjusted OR, 2.898), and the aggregate index of systemic inflammation (AISI) ≤ 7 (adjusted OR,1.778) were also independent risk factors for 28-day mortality. Furthermore, patients with AKI had a worse prognosis than those without AKI (P < 0.05). CONCLUSION In patients with HLH, hematological parameters are of great value for the early identification of patients at high risk of AKI and 28-day mortality.
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Affiliation(s)
- Xuelian Chen
- Department of Nephrology, West China Hospital, Sichuan University, Chengdu, China
| | - Siwen Wang
- Department of Occupational Disease and Toxicosis/Nephrology, West China Fourth Hospital, Sichuan University, Chengdu, China
| | - Jia Yang
- Department of Nephrology, West China Hospital, Sichuan University, Chengdu, China
| | - Xin Wang
- Department of Pediatric Nephrology, West China Second Hospital, Sichuan University, Chengdu, China
| | - Lichuan Yang
- Department of Nephrology, West China Hospital, Sichuan University, Chengdu, China
| | - Jiaojiao Zhou
- Department of Medical Ultrasound, West China Hospital, Sichuan University, Chengdu, China.
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102
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Zhang Q, Zhu L, Zhou D, Li L, Xie W, Tan Y, Ye X. Risk factors and prognosis of early death in secondary hemophagocytic lymphohistiocytosis. Ann Hematol 2023; 102:2301-2308. [PMID: 37266671 DOI: 10.1007/s00277-023-05153-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 02/24/2023] [Indexed: 06/03/2023]
Abstract
The aim of our study was to summarize the clinical characteristics of early death patients with newly diagnosed secondary hemophagocytic lymphohistiocytosis (sHLH), analyze the risk factors of early death, and analyze the survival of patients. The clinical characteristics of 324 newly diagnosed sHLH patients admitted to the First Affiliated Hospital of Zhejiang University Medical College and Zhejiang Provincial Cancer Hospital from January 2014 to February 2021 were analyzed retrospectively. Analyze the independent risk factors of early death, compare the secondary diseases and treatment methods of patients with early death group and non early death group, and analyze the survival of all patients with sHLH. Among the 324 newly diagnosed patients with sHLH, 134 died early, with an early mortality rate of 41.4%. Comparing the clinical characteristics of patients with early death group and patients with non early death group, logistic regression model was used to conduct multifactor analysis. Age > 60 years, Plt ≤ 20.0 × 109/L, APTT > 36.0 s and LDH > 1000.0 U/L were independent risk factors for early death of newly diagnosed sHLH patients (P < 0.05). Comparing the secondary diseases and treatment methods between early death group and non early death group, the proportion of sHLH patients secondary to lymphoma was higher in early death group than that in non early death group (P < 0.05). The proportion of sHLH patients secondary to connective tissue disease and infection was lower in early death group than that in non early death group (P < 0.05), and the proportion of sHLH patients used hormone combined chemotherapy was lower in early death group than that in non early death group (P < 0.05). The median follow-up time of all patients was 12.0 (1-65) months. The 5-year OS rates of patients with age > 60 years and age ≤ 60 years were 25.8% and 49.6% respectively (P < 0.001); The 5-year OS rates of patients with Plt > 20.0 × 109/L and Plt ≤ 20.0 × 109/L were 52.5% and 25.5% respectively (P < 0.001); The 5-year OS rates of patients with APTT > 36.0 s and APTT ≤ 36.0 s were 34.5% and 57.4% respectively (P < 0.001); The 5-year OS rates of patients with LDH > 1000.0 U/L and LDH ≤ 1000.0 U/L were 23.3% and 56.3% respectively (P < 0.001). Age > 60 years, Plt ≤ 20.0 × 109/L, APTT > 36.0 s and LDH > 1000.0 U/L are independent risk factors for early death of sHLH patients. The early mortality of lymphoma associated HLH (LA-HLH) patients is high, and early use of hormone combined chemotherapy can reduce the early mortality.
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Affiliation(s)
- Qiaolei Zhang
- Department of Hematology, Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), No.38 Guangji Road, banshanqiao, Gongshu District, Hangzhou, 310003, Zhejiang, China
- Institute of Cancer and Basic Medicine(IBMC), Chinese Academy of Sciences, Hangzhou, China
| | - Lixia Zhu
- Department of Hematology, The First Affiliated Hospital of Medical School of Zhejiang University, No.79 Qingchun Road Hangzhou, Hangzhou, 310003, Zhejiang, China
| | - De Zhou
- Department of Hematology, The First Affiliated Hospital of Medical School of Zhejiang University, No.79 Qingchun Road Hangzhou, Hangzhou, 310003, Zhejiang, China
| | - Li Li
- Department of Hematology, The First Affiliated Hospital of Medical School of Zhejiang University, No.79 Qingchun Road Hangzhou, Hangzhou, 310003, Zhejiang, China
| | - Wanzhuo Xie
- Department of Hematology, The First Affiliated Hospital of Medical School of Zhejiang University, No.79 Qingchun Road Hangzhou, Hangzhou, 310003, Zhejiang, China
| | - Yamin Tan
- Department of Hematology, Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), No.38 Guangji Road, banshanqiao, Gongshu District, Hangzhou, 310003, Zhejiang, China.
- Institute of Cancer and Basic Medicine(IBMC), Chinese Academy of Sciences, Hangzhou, China.
| | - Xiujin Ye
- Department of Hematology, The First Affiliated Hospital of Medical School of Zhejiang University, No.79 Qingchun Road Hangzhou, Hangzhou, 310003, Zhejiang, China.
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103
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de Fritsch E, Louis-Sidney F, Felix A, Moinet F, Bagoée C, Henry K, Wolff S, Polomat K, Dramé M, Deligny C, Suzon B. Epidemiology, characteristics, treatments, and outcomes of adult-onset Still's disease in Afro-Caribbeans: Results from a population-based study in Martinique, French West Indies. J Autoimmun 2023; 139:103086. [PMID: 37356346 DOI: 10.1016/j.jaut.2023.103086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 06/14/2023] [Accepted: 06/19/2023] [Indexed: 06/27/2023]
Abstract
OBJECTIVES To describe the epidemiology, characteristics, response to initial treatment, and outcomes of Adult-Onset Still's disease (AOSD) in the Afro-Caribbean population of Martinique with free and easy access to specialised care. METHODS We conducted a retrospective study from 2004 to 2022 in the island of Martinique, French West-Indies which total population was 354 800 in 2021. Patients were identified from multiple sources including standardised databases. To be included, patients had to be residents of the island and fulfilled Yamaguchi and/or Fautrel's criteria for AOSD, or have a compatible disease course, without a diagnosis of cancer, auto-immune disease or another auto-inflammatory disorder. Date of diagnosis, clinical and biological characteristics, treatments, and outcomes were collected. RESULTS The prevalence was 7.6/100 000 inhabitants in 2021. The mean incidence was 0.4/100 000 during study period. Thirty-three patients (70.6% females) with a median follow-up of 35 months [7.5 to 119] were included. Twenty-six patients (78.8%) had a systemic pattern. Patients with a systemic monocyclic pattern had significantly more polyarticular involvement than patients with systemic polycyclic pattern (p = 0.016). Pulmonary involvement occurred in 51.5% of patients at diagnosis and systemic Pouchot score has been identified as an independent predictive factor for pulmonary involvement; OR of 3.29 [CI 95% 1.20; 9.01]. At first flare, all patients but one received oral glucocorticoids, 11 patients (32.4%) received intravenous glucocorticoids pulse and 12 patients (33%) received anti-IL1 therapy. Nineteen patients (57%) relapsed in a median time of 9 months [6 to 12] Three patients (9%) developed hemophagocytosis lymphohistiocytosis, fatal in 1 case. All deceased patients (n = 4, 11.76%) belonged to the systemic polycyclic pattern, with an event-free survival of 13.6 months [IQR 5.7; 29.5] CONCLUSION: AOSD in the Afro-Caribbean population of Martinique shares some similarities with other ethnic groups, but exhibit differences, such as a high proportion of lung involvement. Comparative studies are needed to confirm these results.
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Affiliation(s)
- Eleonore de Fritsch
- Department of Internal Medicine, Martinique University Hospital, Fort-de France, France
| | - Fabienne Louis-Sidney
- Department of Rheumatology, Martinique University Hospital, Fort-de-France, France; EpiCliV Research Unit, University of French West Indies, Martinique, France
| | - Arthur Felix
- Department of General Pediatrics, Competence Centre for Rare Pediatric Inflammatory Rheumatisms and Systemic Autoimmune Diseases (RAISE) Antilles-Guyane, Martinique University Hospital, Fort-de France, France
| | - Florence Moinet
- Department of Internal Medicine, Martinique University Hospital, Fort-de France, France
| | - Cécile Bagoée
- Department of Internal Medicine, Territorial Hospital Centre of New Caledonia, Nouméa, New Caledonia
| | - Kim Henry
- Department of Infectious Diseases, Cayenne Hospital, Guyane, France
| | - Sophie Wolff
- Department of Internal Medicine, Martinique University Hospital, Fort-de France, France
| | - Katlyne Polomat
- Department of Internal Medicine, Martinique University Hospital, Fort-de France, France
| | - Moustapha Dramé
- EpiCliV Research Unit, University of French West Indies, Martinique, France; Department of Clinical Research and Innovation, Martinique University Hospital, Fort-de-France, France
| | - Christophe Deligny
- Department of Internal Medicine, Martinique University Hospital, Fort-de France, France; EpiCliV Research Unit, University of French West Indies, Martinique, France
| | - Benoit Suzon
- Department of Internal Medicine, Martinique University Hospital, Fort-de France, France; EpiCliV Research Unit, University of French West Indies, Martinique, France.
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104
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Lim AM, Ghazaleh JR, Cacdac RM, Oberndorf JK, Quizon MRL, Thomas JM. Sepsis as the Grand Mimic of Secondary Hemophagocytic Lymphohistiocytosis: Serratia marcescens Bacteremia with Concomitant Decompensated Cirrhotic Liver Disease. Case Rep Crit Care 2023; 2023:9916937. [PMID: 37675083 PMCID: PMC10480021 DOI: 10.1155/2023/9916937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 07/29/2023] [Accepted: 08/17/2023] [Indexed: 09/08/2023] Open
Abstract
Secondary hemophagocytic lymphohistiocytosis (HLH) is an elusive entity with sequelae that may be confused with sepsis. We discuss a 45-year-old man with decompensated liver cirrhosis with sepsis treated with broad-spectrum intravenous antibiotics. Further work-up initially supported sepsis-HLH overlap syndrome (SHLHOS) and corticosteroids were added. Ongoing refractory hypotension ensued, and the patient passed within 31 hours of presentation. Based on the patient's overwhelming immune activation and clinical course likely unsalvageable by cytotoxic immunosuppressive agents, the patient was diagnosed with sepsis with acute end organ dysfunction. This case report illustrates both the diagnostic challenge of sepsis versus HLH, which both require very different treatments, and the potential for rapid clinical decline without swift recognition and management of the true pathology.
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Affiliation(s)
- Anthony M. Lim
- Eisenhower Medical Center, 39000 Bob Hope Drive, Rancho Mirage, CA 92270, USA
| | | | - Robert M. Cacdac
- Eisenhower Medical Center, 39000 Bob Hope Drive, Rancho Mirage, CA 92270, USA
| | - Julia K. Oberndorf
- Eisenhower Medical Center, 39000 Bob Hope Drive, Rancho Mirage, CA 92270, USA
| | | | - Justin M. Thomas
- Eisenhower Medical Center, 39000 Bob Hope Drive, Rancho Mirage, CA 92270, USA
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105
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Ichimura H, Ichikawa S, Ono K, Inokura K, Hoshi Y, Shirai T, Fukuhara N, Yokoyama H, Fujii H, Harigae H. Severe Bone Marrow Aplasia Following Macrophage Activation Syndrome in Systemic Lupus Erythematosus. TOHOKU J EXP MED 2023; 260:301-304. [PMID: 37164698 DOI: 10.1620/tjem.2023.j037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
Abstract
Macrophage activation syndrome (MAS) is a potentially fatal complication of rheumatic diseases, characterized by activated macrophages with hemophagocytosis and multiple organ damage. We report a case of MAS associated with systemic lupus erythematosus that initially presented with severe liver dysfunction. Although it was improved with steroids and plasmapheresis, severe pancytopenia was subsequently experienced, and the bone marrow showed severe aplasia similar to aplastic anemia. Nevertheless, the administration of immunosuppressants resulted in the recovery of blood counts within two weeks. When severe MAS results in cytokine overproduction, bone marrow aplasia may occur, for which immunosuppressive therapy may be highly effective.
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Affiliation(s)
| | | | - Koya Ono
- Department of Hematology, Tohoku University Hospital
| | - Kyoko Inokura
- Department of Hematology, Tohoku University Hospital
| | - Yosuke Hoshi
- Department of Rheumatology, Tohoku University Hospital
| | | | | | | | - Hiroshi Fujii
- Department of Rheumatology, Tohoku University Hospital
| | - Hideo Harigae
- Department of Hematology, Tohoku University Hospital
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106
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Premec H, Živko M, Mijić M, Jelić-Puškarić B, Lalovac M, Filipec Kanižaj T, Sobočan N. Acute Liver Failure Caused by Secondary Hemophagocytic Lymphohistiocytosis After COVID-19 Vaccination - Case Report and Literature Review. Int Med Case Rep J 2023; 16:449-455. [PMID: 37577009 PMCID: PMC10416787 DOI: 10.2147/imcrj.s417347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 07/22/2023] [Indexed: 08/15/2023] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a congenital or acquired hyperinflammatory syndrome, in some cases accompanied by acute liver failure. We present a case report of acute liver failure associated with HLH after COVID-19 vaccination and bring a literature review of the connection between HLH and COVID-19 vaccination. HLH has significant mortality rate, and liver transplantation is not a therapeutic option. Therefore, early recognition and timely conservative treatment are corner stones in reducing HLH-related morbidity and mortality.
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Affiliation(s)
- Hrvoje Premec
- Department of Gastroenterology, University Hospital Merkur, Zagreb, Croatia
| | - Matea Živko
- School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Maja Mijić
- Department of Gastroenterology, University Hospital Merkur, Zagreb, Croatia
| | - Biljana Jelić-Puškarić
- Department of Pathology and Cytology, University Hospital Merkur, Zagreb, Croatia
- School of Medicine, Catholic University of Croatia, Zagreb, Croatia
| | - Miloš Lalovac
- Department of Gastroenterology, University Hospital Merkur, Zagreb, Croatia
- University of Dubrovnik, Dubrovnik, Croatia
| | - Tajana Filipec Kanižaj
- Department of Gastroenterology, University Hospital Merkur, Zagreb, Croatia
- School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Nikola Sobočan
- Department of Gastroenterology, University Hospital Merkur, Zagreb, Croatia
- School of Medicine, University of Zagreb, Zagreb, Croatia
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107
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Zeng Z, Tu W, Ji B, Liu J, Huang K, Nie D, Yang L. IFN-α induced systemic lupus erythematosus complicated with hemophagocytic lymphohistiocytosis: a case report and literature review. Front Immunol 2023; 14:1223062. [PMID: 37600795 PMCID: PMC10436618 DOI: 10.3389/fimmu.2023.1223062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 07/21/2023] [Indexed: 08/22/2023] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a severe and life-threatening hyperinflammatory condition characterized by excessive activation of macrophages and T cells and resulted in multi-organ dysfunction. HLH can be a primary disease or secondary to infections, malignancy, and some autoimmune diseases, including adult-onset Still's disease (AOSD) and systemic lupus erythematosus (SLE). However, it is rare for HLH to occur as a secondary condition to drug-induced lupus erythematosus (DILE). In this report, we present a case of HLH as an unusual complication during SLE treatment in a 31-year-old male patient. The patient initially suffered from active chronic hepatitis B (CHB) and was treated with pegylated INFα-2b (Peg-INFα-2b), tenofovir disoproxil and lamivudine. After 19 months, CHB obtained biochemical and virological response with HBsAg positive to HBsAb. The patient developed fever, headache, and cytopenia after Peg-INFα-2b treatment for 33 months, and laboratory studies revealed that ANA and anti dsDNA were positive. He displayed 5 features meeting the HLH-2004 criteria for diagnosis including fever, pancytopenia, hyperferritinemia, high levels of soluble CD25, and hemophagocytosis on bone marrow biopsy. The patient was initiated with a combination treatment of intravenous methylprednisolone pulse therapy, oral cyclosporine, and etoposide (VP-16), which was followed by a course of oral prednisolone, intravenous cyclophosphamide pulse therapy, and entecavir with complete response. To our knowledge, this is the first report of IFN-α induced SLE complicating with HLH. Physicians should consider the potential autoimmune side effects of IFN-α therapy and be alert to insidious HLH in patients diagnosed with SLE.
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Affiliation(s)
- Zhipeng Zeng
- Department of Rheumatology and Immunology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Wei Tu
- Department of Rheumatology and Immunology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Bai Ji
- Department of Internal Medicine, the People Hospital of Tongshan, Xianning, China
| | - Jie Liu
- Department of Cardiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Kecheng Huang
- Department of Obstetrics and Gynecology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Daan Nie
- Department of Cardiology, the Affiliated Hospital of Guizhou Medical University, Guiyang, China
| | - Liu Yang
- Department of Reproductive Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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108
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Abdelhay A, Mahmoud AA, Al Ali O, Hashem A, Orakzai A, Jamshed S. Epidemiology, characteristics, and outcomes of adult haemophagocytic lymphohistiocytosis in the USA, 2006-19: a national, retrospective cohort study. EClinicalMedicine 2023; 62:102143. [PMID: 37599909 PMCID: PMC10432999 DOI: 10.1016/j.eclinm.2023.102143] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 07/20/2023] [Accepted: 07/24/2023] [Indexed: 08/22/2023] Open
Abstract
Background Haemophagocytic lymphohistiocytosis (HLH) is a rare and life-threatening syndrome characterized by an excessive inflammatory response. Limited data exist on adult HLH. Methods In this national, retrospective cohort study, we analysed data from the US National Inpatient Sample database collected between October 1, 2006 and December 31, 2019. Using the International Classification of Diseases (ICD) codes, we identified all adult patients who were admitted non-electively with the diagnosis of HLH. We described demographic characteristics, triggers, and associated conditions. Trends of diagnosis, treatment, and in-hospital mortality were analysed using joinpoint models. In-hospital mortality rates were compared using multivariable logistic regression models that adjusted for demographic characteristics and associated conditions. Finally, we described resource utilization outcomes including cost of hospitalization and length of stay. Findings We identified 16,136 non-elective adult HLH admissions. The population pyramid showed a bimodal distribution, with peaks in young adults (16-30 years) and older adults (56-70 years). Joinpoint regression analysis revealed a significant increase in HLH incidence per 100,000 admissions over the study period (Average Annual Percent Change [APC] = 25.3%, p < 0.0001), and no significant change in rates of in-hospital mortality (slope = -0.01; p = 0.95) or administration of in-hospital HLH treatment (slope = 0.46, p = 0.20). The most common associated conditions were malignancy (4953 admissions [30.7%]), infections (3913 admissions [24.3%]), autoimmune conditions (3362 admissions [20.8%]), organ transplant status (639 admissions [4%]), and congenital immunodeficiency syndromes (399 admissions [2.5%]). In-hospital mortality was higher in older adults and males. Furthermore, Congenital immunodeficiency syndromes had the worst in-hospital mortality rate (mortality rate 31.1%, adjusted OR 2.36 [1.56-3.59]), followed by malignancies (mortality rate 28.4%, adjusted OR 1.80 [1.46-2.22]), infections (mortality rate 21.4%, adjusted OR 1.33 [1.10-1.62]), other/no trigger (mortality rate 13.6%, adjusted OR 0.73 [0.58-0.92]), autoimmune (mortality rate 13%, adjusted OR 0.72 [0.57-0.92]), and post-organ transplant status (mortality rate 14.1%, adjusted OR 0.64 [0.43-0.97]). The overall mean length of stay was 14.3 ± 13.9 days, and the mean cost of hospitalization was $54,900 ± 59,800. Interpretation We provide insight into the burden of adult HLH in the USA. The incidence has been increasing and the outcomes remain dismal. This signifies the growing need for the development of updated diagnosis and treatment protocols that are specific to adult HLH. Funding None.
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Affiliation(s)
- Ali Abdelhay
- Department of Internal Medicine, Rochester General Hospital, Rochester, NY, USA
| | - Amir A. Mahmoud
- Department of Internal Medicine, Rochester General Hospital, Rochester, NY, USA
| | - Omar Al Ali
- Department of Internal Medicine, Rochester General Hospital, Rochester, NY, USA
| | - Anas Hashem
- Department of Internal Medicine, Rochester General Hospital, Rochester, NY, USA
| | - Abdullah Orakzai
- Department of Internal Medicine, Rochester General Hospital, Rochester, NY, USA
| | - Saad Jamshed
- Division of Hematology and Oncology, Rochester Regional Health, Rochester, NY, USA
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109
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Ali S, Choo S, Hosking L, Smith A, Hughes T. A case of T-cell-Epstein-Barr virus-haemophagocytic lymphohistiocytosis and sustained remission following ruxolitinib therapy. Clin Transl Immunology 2023; 12:e1459. [PMID: 37497193 PMCID: PMC10368518 DOI: 10.1002/cti2.1459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Revised: 05/31/2023] [Accepted: 07/15/2023] [Indexed: 07/28/2023] Open
Abstract
Objectives Epstein-Barr virus (EBV) is a common cause of secondary haemophagocytic lymphohistiocytosis (HLH). While B cells are reservoirs for EBV, infection within T cells and NK cells in this disease can be difficult to treat. Methods A 19-year-old female presented with a 6-week history of coryzal symptoms on a background of Crohn's disease. On examination, she was febrile and tachycardic with mild tonsillar enlargement and splenomegaly. New trilineage cytopenias and elevation in liver enzymes were detected, with acute EBV subsequently confirmed on whole blood PCR. A diagnosis of EBV-associated HLH was supported further with elevated serum ferritin, triglycerides and soluble CD25, low fibrinogen and the presence of haemophagocytosis in the bone marrow. Results Corticosteroids, IVIG and rituximab were given, and anakinra was subsequently added due to ongoing fevers. EBV infection was then demonstrated within CD8+ T cells on EBER Flow-FISH assay. Ruxolitinib was commenced and her fevers abated on day 5, with improvement in other HLH parameters. She was discharged after a 39-day hospital admission. To date, she has remained in remission of HLH, despite developing COVID-19 infection during the convalescence phase of HLH. Conclusion EBV viraemia requires adequate treatment to control EBV-associated HLH as rituximab may be insufficient, and corticosteroid resistance can result in continued EBV infection in CD8+ T cells. This entity is known as T-cell-EBV-HLH. Ruxolitinib is a novel treatment strategy in this specific context and has several advantages, including inhibition of corticosteroid resistance to promote apoptosis of EBV-infected T cells.
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Affiliation(s)
- Syed Ali
- Department of Clinical Immunology and AllergyFlinders Medical CentreBedford ParkSAAustralia
- School of Medicine and Public HealthFlinders UniversityBedford ParkSAAustralia
| | - Sharon Choo
- Department of Allergy and ImmunologyRoyal Children's HospitalParkvilleVICAustralia
- Immunology LaboratoryRoyal Children's HospitalParkvilleVICAustralia
| | - Laine Hosking
- Department of Allergy and ImmunologyRoyal Children's HospitalParkvilleVICAustralia
- Immunology LaboratoryRoyal Children's HospitalParkvilleVICAustralia
| | - Anthony Smith
- Department of Clinical Immunology and AllergyFlinders Medical CentreBedford ParkSAAustralia
- School of Medicine and Public HealthFlinders UniversityBedford ParkSAAustralia
| | - Tiffany Hughes
- Department of Clinical Immunology and AllergyFlinders Medical CentreBedford ParkSAAustralia
- School of Medicine and Public HealthFlinders UniversityBedford ParkSAAustralia
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110
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Lopez-Garcia A, Solan L, Alvarez B, Caballero JC, Cornago J, Pardo L, Diaz de la Pinta FJ, Cordoba R, Rodriguez-Pinilla M. Hemophagocytic Lymphohistiocytosis Secondary to Hodgkin's Lymphoma with Isolated Bone Marrow Involvement in a Newly Diagnosed HIV Patient. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1274. [PMID: 37512086 PMCID: PMC10383783 DOI: 10.3390/medicina59071274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/10/2023] [Revised: 07/01/2023] [Accepted: 07/06/2023] [Indexed: 07/30/2023]
Abstract
Human immunodeficiency virus (HIV) infection is known to be associated with the development of Hodgkin's lymphoma (HL). Exclusive extranodal bone marrow involvement is less common. Co-infection by other viruses, such as the Epstein-Barr virus (EBV), increases the incidence of a frequent complication denominated by hemophagocytic lymphohistocytosis (HLH). We present the case of a 50-year-old patient with the above clinical spectrum who develops several serious complications during treatment.
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Affiliation(s)
- Alberto Lopez-Garcia
- Department of Hematology, Fundación Jiménez Díaz University Hospital, 28040 Madrid, Spain
- Instituto de Investigacion Sanitaria, Fundación Jiménez Díaz University Hospital, 28040 Madrid, Spain
| | - Laura Solan
- Department of Hematology, Fundación Jiménez Díaz University Hospital, 28040 Madrid, Spain
- Instituto de Investigacion Sanitaria, Fundación Jiménez Díaz University Hospital, 28040 Madrid, Spain
| | - Beatriz Alvarez
- Department of Infectious Diseases, Fundación Jiménez Díaz University Hospital, 28040 Madrid, Spain
| | - Juan Carlos Caballero
- Department of Hematology, Fundación Jiménez Díaz University Hospital, 28040 Madrid, Spain
| | - Javier Cornago
- Department of Hematology, Fundación Jiménez Díaz University Hospital, 28040 Madrid, Spain
| | - Laura Pardo
- Department of Hematology, Fundación Jiménez Díaz University Hospital, 28040 Madrid, Spain
| | | | - Raul Cordoba
- Department of Hematology, Fundación Jiménez Díaz University Hospital, 28040 Madrid, Spain
- Instituto de Investigacion Sanitaria, Fundación Jiménez Díaz University Hospital, 28040 Madrid, Spain
| | - Maria Rodriguez-Pinilla
- Instituto de Investigacion Sanitaria, Fundación Jiménez Díaz University Hospital, 28040 Madrid, Spain
- Department of Pathology, Fundación Jiménez Díaz University Hospital, 28040 Madrid, Spain
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111
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He L, Yang C, Wang Y. Biological therapies for hemophagocytic lymphohistiocytosis: current knowledge and future perspectives. Expert Opin Biol Ther 2023; 23:1005-1013. [PMID: 37614018 DOI: 10.1080/14712598.2023.2251885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Revised: 08/20/2023] [Accepted: 08/22/2023] [Indexed: 08/25/2023]
Abstract
INTRODUCTION Hemophagocytic lymphohistiocytosis (HLH) is a hyperinflammatory syndrome with a dismal prognosis. The underlying causes of HLH are diverse. However, the overabundance of cytokines was shared by all forms of HLH. Cytokine-targeted biotherapies have been increasingly used in HLH treatment. AREAS COVERED In this review, we aim to provide an overview of biological treatment options for HLH. EXPERT OPINION Biological therapies offer alternative treatment options for patients with refractory/relapsed HLH or who are intolerant to conventional chemotherapies. As a complement to traditional treatment, biological agents improve response rates, maintain more protracted periods of remission, and reduce treatment related toxicity. A combination of biological agents may be a promising direction for HLH treatment. However, they may induce HLH to deteriorate and even trigger HLH.
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Affiliation(s)
- Lingbo He
- Department of General Practice, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Chun Yang
- Department of General Practice, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Yini Wang
- Department of General Practice, Beijing Friendship Hospital, Capital Medical University, Beijing, China
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112
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Sun FY, Ouyang BQ, Li XX, Zhang T, Feng WT, Han YG. Epstein-Barr virus-induced infection-associated hemophagocytic lymphohistiocytosis with acute liver injury: A case report. World J Clin Cases 2023; 11:4090-4097. [PMID: 37388783 PMCID: PMC10303618 DOI: 10.12998/wjcc.v11.i17.4090] [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: 03/11/2023] [Revised: 04/25/2023] [Accepted: 05/19/2023] [Indexed: 06/12/2023] Open
Abstract
BACKGROUND Hemophagocytic lymphohistiocytosis (HLH) is a severe hyperinflammatory reaction, which is rare and life-threatening. According to the pathogen, HLH is divided into genetic and acquired. The most common form of acquired HLH is infection-associated HLH, of which Herpes viruses, particularly Epstein-Barr virus (EBV), are the leading infectious triggers. However, it is difficult to distinguish between simple infection with EBV and EBV-induced infection-associated HLH since both can destroy the whole-body system, particularly the liver, thereby increasing the difficulty of diagnosis and treatment.
CASE SUMMARY This paper elaborates a case about EBV-induced infection-associated HLH and acute liver injury, aiming to propose clinical guides for the early detection and treatment of patients with EBV-induced infection-associated HLH. The patient was categorized as acquired hemophagocytic syndrome in adults. After the ganciclovir antiviral treatment combined with meropenem antibacterial therapy and methylprednisolone inhibition to inflammatory response, gamma globulin enhanced immunotherapy, the patient recovered.
CONCLUSION From the diagnosis and treatment of this patient, attention should be paid to routine EBV detection and a further comprehensive understanding of the disease as well as early recognition and early initiation are keys to patients’ survival.
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Affiliation(s)
- Fang-Yuan Sun
- Trauma Emergency Center, The Seventh People’s Hospital of Shanghai University of Traditional Chinese Medicine, Shanghai 200137, China
| | - Bing-Qing Ouyang
- Trauma Emergency Center, The Seventh People’s Hospital of Shanghai University of Traditional Chinese Medicine, Shanghai 200137, China
| | - Xiao-Xiao Li
- Trauma Emergency Center, The Seventh People’s Hospital of Shanghai University of Traditional Chinese Medicine, Shanghai 200137, China
| | - Tao Zhang
- Trauma Emergency Center, The Seventh People’s Hospital of Shanghai University of Traditional Chinese Medicine, Shanghai 200137, China
| | - Wen-Tao Feng
- Trauma Emergency Center, The Seventh People’s Hospital of Shanghai University of Traditional Chinese Medicine, Shanghai 200137, China
| | - Yao-Guo Han
- Trauma Emergency Center, The Seventh People’s Hospital of Shanghai University of Traditional Chinese Medicine, Shanghai 200137, China
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Masood M, Siddique A, Kozarek RA. Adult Hemophagocytic Lymphohistiocytosis Mimicking Acute Viral Hepatitis. Dig Dis Sci 2023:10.1007/s10620-023-07985-3. [PMID: 37286930 DOI: 10.1007/s10620-023-07985-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 05/22/2023] [Indexed: 06/09/2023]
Abstract
Adult hemophagocytic lymphohistiocytosis is a lifethreatenning disease which has hepatic manifestations mimicking acute hepatitis or can present with fulminant hepatic failure. The undelying pathophysiology is immune dysregulation causing a hyperinflammatory state. Clues to diagnosis include extremely high ferritin levels, whereas definitive diagnosis is usually made by bone marrow, as opposed to liver biopsy. Even with early and appropriate treatment with weekly dexamethasone and etoposide, mortality remains high.
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Affiliation(s)
- Muaaz Masood
- Division of Gastroenterology and Hepatology, Center for Digestive Health, Virginia Mason Franciscan Health, 1201 Ninth Ave, Seattle, WA, 98101, USA
| | - Asma Siddique
- Division of Gastroenterology and Hepatology, Center for Digestive Health, Virginia Mason Franciscan Health, 1201 Ninth Ave, Seattle, WA, 98101, USA
| | - Richard A Kozarek
- Division of Gastroenterology and Hepatology, Center for Digestive Health, Virginia Mason Franciscan Health, 1201 Ninth Ave, Seattle, WA, 98101, USA.
- Center for Interventional Immunology, Benaroya Research Institute, Virginia Mason Franciscan Health, 1201 Ninth Ave, Seattle, WA, 98101, USA.
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Okobi TJ, Cautha S, Bhatt T, Atogwe ID, Schmidt P, Patel D, Khaja M. Hemophagocytic Lymphohistiocytosis and Hodgkin Lymphoma in a Newly Diagnosed HIV Patient: A Diagnostic Dilemma. Cureus 2023; 15:e41127. [PMID: 37519529 PMCID: PMC10385007 DOI: 10.7759/cureus.41127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/29/2023] [Indexed: 08/01/2023] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a severe hyperinflammatory syndrome that arises due to a dysregulated immune response caused by the aberrant activation of lymphocytes and macrophages. In this rare case report, we describe a newly diagnosed human immunodeficiency virus (HIV) patient who was found to have Epstein-Barr virus (EBV) provoked HLH and co-existing Hodgkin lymphoma (HL). Our patient was a 28-year-old newly diagnosed HIV patient who presented with nonspecific symptoms, including bilateral foot pain and tingling sensation. Laboratory findings were significant for pancytopenia. With a high index of suspicion, the patient had a bone marrow biopsy done which confirmed a diagnosis of both HLH and Hodgkin's lymphoma. The case highlighted the diagnostic dilemma of HLH in the setting of HIV infection. Identifying the major components of his disease process was pivotal to ensure that the patient was commenced on appropriate therapy for the EBV-driven HLH and HL. The diagnosis of HLH in newly diagnosed HIV remains challenging due to the diverse clinical presentations and the need to exclude other possible causes. The clinical features of HLH, HL, and HIV can be nonspecific and overlap, creating a diagnostic dilemma. Diagnosis requires a combination of clinical, laboratory, and histopathological features. The management in such cases requires prompt diagnosis through a multidisciplinary approach, a variety of chemotherapy, immunosuppression, supportive care, and treatment of the underlying triggers.
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Affiliation(s)
| | | | | | | | | | - Dhruv Patel
- Internal Medicine, Bronx Care Health System, Bronx, USA
| | - Misbahuddin Khaja
- Internal Medicine/Pulmonary Critical Care, Icahn School of Medicine at Mount Sinai/Bronx Care Health System, Bronx, USA
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115
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Wi W, Yoon KW, Kim HJ. Secondary hemophagocytic lymphohistiocytosis associated with heat stroke: A case report and review of literature. Medicine (Baltimore) 2023; 102:e33842. [PMID: 37233425 PMCID: PMC10219742 DOI: 10.1097/md.0000000000033842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 05/04/2023] [Indexed: 05/27/2023] Open
Abstract
RATIONALE Hemophagocytic lymphohistiocytosis (HLH) is a syndrome with potentially fatal consequences that results from an excessive immune response caused by malfunctioning natural killer cells and cytotoxic T lymphocytes. Secondary HLH, which is the predominant type in adults, is associated with various medical conditions, including infections, malignancies, and autoimmune diseases. Secondary HLH associated with heat stroke has not been reported. PATIENT CONCERNS A 74-year-old male was admitted to the emergency department after being unconscious in a 42°C hot public bath. The patient was witnessed to be in the water for more than 4 hours. The patient's condition was complicated by rhabdomyolysis and septic shock, which were managed with mechanical ventilation, vasoactive agents, and continuous renal replacement therapy. The patient also showed evidence of diffuse cerebral dysfunction. DIAGNOSES While the patient's condition initially improved, the patient developed a fever, anemia, thrombocytopenia, and an acute rise in total bilirubin, which, we suspected, was caused by HLH. Further investigations revealed elevated serum ferritin and soluble interleukin-2 receptor levels. INTERVENTIONS The patient received 2 cycles of serial therapeutic plasma exchange to lower the endotoxin burden. To manage HLH, high-dose glucocorticoid therapy was done. OUTCOMES Despite the best efforts, the patient did not recover and expired from progressive hepatic failure. LESSONS We report a novel case of secondary HLH associated with heat stroke. Diagnosing secondary HLH can be difficult since clinical manifestations of the underlying disease and HLH may present simultaneously. Early diagnosis and prompt initiation of treatment is required to improve the prognosis of the disease.
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Affiliation(s)
- Wongook Wi
- Department of Anesthesiology and Pain Medicine, Chung-Ang University Gwangmyeong Hospital, Gwangmyeong-si, Gyeonggi-do, Republic of Korea
| | - Kyoung Won Yoon
- Division of Critical Care, Department of Surgery, Chung-Ang University Gwangmyeong Hospital, Gwangmyeong-si, Gyeonggi-do, Republic of Korea
| | - Hyo Jin Kim
- Department of Anesthesiology and Pain Medicine, Chung-Ang University Gwangmyeong Hospital, Gwangmyeong-si, Gyeonggi-do, Republic of Korea
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116
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West J, Stilwell P, Liu H, Ban L, Bythell M, Card T, Lanyon P, Nanduri V, Rankin J, Bishton M, Crooks C. 1-year survival in haemophagocytic lymphohistiocytosis: a nationwide cohort study from England 2003-2018. J Hematol Oncol 2023; 16:56. [PMID: 37237311 DOI: 10.1186/s13045-023-01434-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 03/29/2023] [Indexed: 05/28/2023] Open
Abstract
Haemophagocytic lymphohistiocytosis (HLH) is a lethal syndrome of excessive immune activation. We undertook a nationwide study in England of all cases of HLH diagnosed between 2003 and 2018, using linked electronic health data from hospital admissions and death certification. We modelled interactions between demographics and comorbidities and estimated one-year survival by calendar year, age group, gender and comorbidity (haematological malignancy, auto-immune, other malignancy) using Cox regression. There were 1628 people with HLH identified. Overall, crude one-year survival was 50% (95% Confidence interval 48-53%) which varied substantially with age (0-4: 61%; 5-14: 76%; 15-54: 61%; > 55: 24% p < 0.01), sex (males, 46%, worse than females, 55% p < 0.01) and associated comorbidity (auto-immune, 69%, haematological malignancy 28%, any other malignancy, 37% p < 0.01). Those aged < 54 years had a threefold increased risk of death at 1-year amongst HLH associated with malignancy compared to auto-immune. However, predicted 1-year survival decreased markedly with age in those with auto-immune (age 0-14, 84%; 15-54, 73%; > 55, 27%) such that among those > 55 years, survival was as poor as for patients with haematological malignancy. One-year survival following a diagnosis of HLH varies considerably by age, gender and associated comorbidity. Survival was better in those with auto-immune diseases among the young and middle age groups compared to those with an underlying malignancy, whereas in older age groups survival was uniformly poor regardless of the underlying disease process.
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Affiliation(s)
- Joe West
- University of Nottingham, Nottingham, UK
- National Disease Registration Service, NHS Digital, Leeds, UK
- Nottingham University Hospitals NHS Trust, Nottingham, UK
- Aarhus University, Aarhus, Denmark
| | - Peter Stilwell
- National Disease Registration Service, NHS Digital, Leeds, UK
| | - Hanhua Liu
- National Disease Registration Service, NHS Digital, Leeds, UK
| | | | - Mary Bythell
- National Disease Registration Service, NHS Digital, Leeds, UK
| | - Tim Card
- University of Nottingham, Nottingham, UK
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Peter Lanyon
- University of Nottingham, Nottingham, UK
- National Disease Registration Service, NHS Digital, Leeds, UK
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | | | - Judith Rankin
- National Disease Registration Service, NHS Digital, Leeds, UK
- Newcastle University, Newcastle upon Tyne, UK
| | - Mark Bishton
- University of Nottingham, Nottingham, UK.
- National Disease Registration Service, NHS Digital, Leeds, UK.
- Nottingham University Hospitals NHS Trust, Nottingham, UK.
| | - Colin Crooks
- University of Nottingham, Nottingham, UK
- National Disease Registration Service, NHS Digital, Leeds, UK
- Nottingham University Hospitals NHS Trust, Nottingham, UK
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Shen J, Fan J, Zhao Y, Jiang D, Niu Z, Zhang Z, Cao G. Innate and adaptive immunity to SARS-CoV-2 and predisposing factors. Front Immunol 2023; 14:1159326. [PMID: 37228604 PMCID: PMC10203583 DOI: 10.3389/fimmu.2023.1159326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Accepted: 04/27/2023] [Indexed: 05/27/2023] Open
Abstract
The coronavirus disease 2019 (COVID-19) pandemic, caused by severe acute respiratory syndrome coronavirus (SARS-CoV-2), has affected all countries worldwide. Although some symptoms are relatively mild, others are still associated with severe and even fatal clinical outcomes. Innate and adaptive immunity are important for the control of SARS-CoV-2 infections, whereas a comprehensive characterization of the innate and adaptive immune response to COVID-19 is still lacking and the mechanisms underlying immune pathogenesis and host predisposing factors are still a matter of scientific debate. Here, the specific functions and kinetics of innate and adaptive immunity involved in SARS-CoV-2 recognition and resultant pathogenesis are discussed, as well as their immune memory for vaccinations, viral-mediated immune evasion, and the current and future immunotherapeutic agents. We also highlight host factors that contribute to infection, which may deepen the understanding of viral pathogenesis and help identify targeted therapies that attenuate severe disease and infection.
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Affiliation(s)
- Jiaying Shen
- Tongji University School of Medicine, Tongji University, Shanghai, China
| | - Junyan Fan
- Department of Epidemiology, Shanghai Key Laboratory of Medical Bioprotection, Key Laboratory of Biological Defense, Ministry of Education, Second Military Medical University, Shanghai, China
| | - Yue Zhao
- Department of Epidemiology, Shanghai Key Laboratory of Medical Bioprotection, Key Laboratory of Biological Defense, Ministry of Education, Second Military Medical University, Shanghai, China
| | - Doming Jiang
- Tongji University School of Medicine, Tongji University, Shanghai, China
| | - Zheyun Niu
- Tongji University School of Medicine, Tongji University, Shanghai, China
| | - Zihan Zhang
- Tongji University School of Medicine, Tongji University, Shanghai, China
| | - Guangwen Cao
- Tongji University School of Medicine, Tongji University, Shanghai, China
- Department of Epidemiology, Shanghai Key Laboratory of Medical Bioprotection, Key Laboratory of Biological Defense, Ministry of Education, Second Military Medical University, Shanghai, China
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118
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Wollina U, Fölster-Holst R, Karadağ AS. Miscellaneous annular diseases. Clin Dermatol 2023; 41:413-421. [PMID: 37453713 DOI: 10.1016/j.clindermatol.2023.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
Abstract
Annular lesions represent a unique macro-morphologic pattern in various skin disorders that may be found in pityriasis rotunda, elastosis perforans serpiginosa, subacute nodular migratory panniculitis, keratolysis exfoliativa, neutrophilic eccrine hidradenitis, hemophagocytic lymphohistiocytosis, and intentionally induced annular lesions. This group is highly heterogenous and variable in clinical presentation. Whereas some are benign self-limiting disorders like pityriasis rotunda, others such as hemophagocytic lymphohistiocytosis follow a chronic course or have a potential of being life-threatening. Epidemiology, pathogenesis, histopathology, clinical presentation and diagnosis, differential diagnosis, and treatment are discussed.
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Affiliation(s)
- Uwe Wollina
- Department of Dermatology and Allergology, Städtisches Klinikum Dresden, Academic Teaching Hospital, Dresden, Germany.
| | - Regina Fölster-Holst
- Department of Dermatology, Venereology and Allergology, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany
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119
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Javed F, Amr M, Abdelfattah AH. Hemophagocytic Lymphohistiocytosis in a Patient with Hodgkin Lymphoma, HIV, and Epstein-Barr Virus. Cureus 2023; 15:e38382. [PMID: 37265913 PMCID: PMC10231408 DOI: 10.7759/cureus.38382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/30/2023] [Indexed: 06/03/2023] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is an aggressive and life-threatening syndrome of excessive immune activation. It occurs in many underlying conditions and all age groups due to severe and uncontrolled inflammatory reactions, with the resultant overproduction of immune cells and cytokines. This leads to multi-organ damage (if not detected early and treated properly) with a mortality of more than 55%. We present a case of a 38-year-old male patient who presented with HLH with concurrent HIV/AIDS, and Epstein-Barr virus (EBV)-related Hodgkin lymphoma. We aim to emphasize the importance of considering HLH and cancer in patients with HIV/AIDS.
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Affiliation(s)
- Faiza Javed
- Hospital Medicine, University of Kentucky, Lexington, USA
| | - Mahmoud Amr
- Hospital Medicine, University of Kentucky, Lexington, USA
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120
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Conway Morris A, Smielewska A. Viral infections in critical care: a narrative review. Anaesthesia 2023; 78:626-635. [PMID: 36633460 PMCID: PMC10952373 DOI: 10.1111/anae.15946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/23/2022] [Indexed: 01/13/2023]
Abstract
Viral infections form a substantial part of the intensive care workload, even before the recent and ongoing COVID-19 pandemic. The growing availability of molecular diagnostics for viral infections has led to increased recognition of these pathogens. This additional information, however, provides new challenges for interpretation and management. As the SARS-CoV-2 pandemic has amply demonstrated, the emergence and global spread of novel viruses are likely to provide continued challenges for critical care physicians into the future. This article will provide an overview of viral infections relevant to the critical care physician, discussing the diagnosis and management of respiratory viral infections, blood borne and enteric viruses. We will also discuss herpesviridae complications, commonly seen due to reactivation of latent infections. Further, we explore some rarer and emerging viruses, including recognition of viral haemorrhagic fevers, and briefly discuss post-viral syndromes which may present to the intensive care unit. Finally, we will discuss infection control and its importance in preventing nosocomial viral transmission.
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Affiliation(s)
- A. Conway Morris
- Division of Anaesthesia, Department of MedicineUniversity of CambridgeUK
- John V Farman Intensive Care UnitAddenbrooke's HospitalCambridgeUK
| | - A. Smielewska
- Department of Clinical Virology, LCL, CSSBLiverpool University Hospitals NHS Foundation TrustLiverpoolUK
- School of Clinical MedicineUniversity of LiverpoolUK
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121
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Mahmoud AA, Abdelhay A, Khamis A, Mostafa M, Shehadah A, Mohamed MS, Eltaher B, Malik T. Hemophagocytic lymphohistiocytosis in inflammatory bowel disease: a nationwide analysis. Ann Hematol 2023:10.1007/s00277-023-05223-4. [PMID: 37093242 DOI: 10.1007/s00277-023-05223-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Accepted: 04/10/2023] [Indexed: 04/25/2023]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a rare but life-threatening immune dysregulation disease. Patients with inflammatory bowel disease (IBD) can become profoundly immunocompromised due to immunosuppressive therapy, hence increasing the risk of viral infections that can trigger HLH. However, data on the association between IBD and HLH remains limited. We used data from the National Inpatient Sample (2012-2019) utilizing International Classification of Diseases (ICD)-9 or ICD-10 codes to identify individuals with IBD, either Crohn's disease (CD) or ulcerative colitis (UC), and HLH. The primary outcome was to compare the prevalence of HLH among patients with IBD with those without IBD. Secondary outcomes included in-hospital mortality, mean hospital length of stay, and description of HLH-associated triggers in IBD patients. A total of 513,322 hospitalizations included a diagnosis of IBD, 188,297 had UC and 325,025 had CD. Compared to the general population, patients with IBD were older (median age of 52 vs. 49 years, p < 0.05), more likely to be male, and of Asian/Pacific Islander descent, and had a higher median household income. There was also a higher prevalence of liver disease, autoimmune diseases, tobacco abuse, and hypothyroidism (all had p-value of < 0.001) in IBD patients. There were 94 hospitalizations identified with a diagnosis of HLH in IBD patients. Compared to patients without IBD, patients with IBD had increased odds of developing HLH (0.02% vs 0.01%, p-value < 0.001). After adjusting for various demographic characteristics, co-morbidities, and HLH-related conditions, IBD was an independent predictor for developing HLH (adjusted OR, 2.3; 95% CI, 1.847-2.866, p-value of < 0.001). There was no statistical difference between CD and UC in the odds of developing HLH. Compared to IBD patients without HLH, patients with IBD and HLH had a lower mean age at diagnosis (38 vs 52, p-value of < 0.001), higher in-hospital mortality (14.9% vs 1.5%, p-value of < 0.001), and longer mean hospital length of stay (days) (17 vs 5.4, p-value of < 0.001). Prevalence of different HLH-associated illnesses was identified in HLH patient's discharge data. Lymphoma was the most common associated malignancy (18.1%) and cytomegalovirus infection was the most common associated infection (16.0%). Our population-based study suggests that IBD is independently associated with developing HLH. Early recognition of IBD patients presenting with features suggestive of HLH is warranted to aide early diagnosis and aggressive treatment.
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Affiliation(s)
- Amir A Mahmoud
- Department of Internal Medicine, Rochester General Hospital, 1425 Portland Ave, Rochester, NY, 14621, USA.
| | - Ali Abdelhay
- Department of Internal Medicine, Rochester General Hospital, 1425 Portland Ave, Rochester, NY, 14621, USA
| | - Alia Khamis
- Office of Scientific Affairs and Research, King Hussein Cancer Center, Amman, Jordan
| | - Mariam Mostafa
- Department of Internal Medicine, Rochester General Hospital, 1425 Portland Ave, Rochester, NY, 14621, USA
| | - Ahmed Shehadah
- Department of Internal Medicine, Rochester General Hospital, 1425 Portland Ave, Rochester, NY, 14621, USA
| | - Mohamed Salah Mohamed
- Department of Internal Medicine, Rochester General Hospital, 1425 Portland Ave, Rochester, NY, 14621, USA
| | - Basant Eltaher
- Department of Hematology and Bone Marrow Transplant, Ain Shams University Faculty of Medicine, Cairo, Egypt
| | - Talha Malik
- Department of Gastroenterology and Hepatology, Mayo Clinic, Phoenix, AZ, USA
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122
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Noboa MER, Lopez-Arevalo H, Patel AR, Arora S, Manadan AM. Nationwide analysis of adult hospitalizations with hemophagocytic lymphohistiocytosis and systemic lupus erythematosus. Clin Rheumatol 2023:10.1007/s10067-023-06594-9. [PMID: 37081184 DOI: 10.1007/s10067-023-06594-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Revised: 04/03/2023] [Accepted: 04/05/2023] [Indexed: 04/22/2023]
Abstract
INTRODUCTION Hemophagocytic lymphohistiocytosis (HLH) is a well-recognized complication of systemic lupus erythematosus (SLE). This study aims to characterize HLH with and without SLE in the US adult inpatient population. METHODS We performed a retrospective study of HLH with and without SLE from the 2016-2019 National Inpatient Sample (NIS) database. We described the demographic characteristics of HLH with and without SLE. Multivariable analysis was performed to calculate odds ratios (OR) for in-hospital death. RESULTS A total of 8690 hospitalizations had HLH. Of those 605 (7%) had SLE, and 8085 (93%) did not have SLE. Relative to the non-SLE group, the SLE group was younger, had more females, less whites, more African Americans, more Hispanics, and more Asian/Pacific Islanders. Over 60% of HLH with or without SLE had a concurrent infection. Sixty (9.9%) of HLH hospitalizations with SLE died compared to 1735 (21.5%) of those without SLE. Among HLH hospitalizations, multivariable analysis showed that age (OR 1.02; 95% C.I. 1.016-1.031), Charlson Comorbidity Index (OR 1.15; 95% C.I. 1.091-1.213), infections (OR 3.35; 95% C.I. 2.467-4.557), and leukemia/lymphoma (OR 1.46; 95% C.I. 1.112-1.905) had higher odds of in-hospital death. SLE did not increase the odds of death. CONCLUSIONS Inpatients with both HLH and SLE were younger, had a higher proportion of racial/ethnic minorities, and were predominately female. One out of every 10 hospitalizations for HLH ended in death but SLE itself was not an independent risk factor for death. Concurrent infection was the variable most associated with HLH death. Key Points • HLH and SLE group were younger and had higher proportions of female and racial/ethnic minorities. • SLE was not an independent risk factor for death in HLH patients.
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Affiliation(s)
| | - Hugo Lopez-Arevalo
- Department of Internal Medicine, Cook County Hospital, 1950 W. Polk, Chicago, IL, 60612, USA
| | - Axi R Patel
- Department of Internal Medicine, Cook County Hospital, 1950 W. Polk, Chicago, IL, 60612, USA
| | - Shilpa Arora
- Department of Internal Medicine, Cook County Hospital, 1950 W. Polk, Chicago, IL, 60612, USA
- Division of Rheumatology, Rush University Medical Center, 1611 West Harrison Street, Suite 510, Chicago, IL, 60612, USA
| | - Augustine M Manadan
- Department of Internal Medicine, Cook County Hospital, 1950 W. Polk, Chicago, IL, 60612, USA
- Division of Rheumatology, Rush University Medical Center, 1611 West Harrison Street, Suite 510, Chicago, IL, 60612, USA
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123
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Woźniak E, Owczarczyk-Saczonek A, Lange M, Czarny J, Wygonowska E, Placek W, Nedoszytko B. The Role of Mast Cells in the Induction and Maintenance of Inflammation in Selected Skin Diseases. Int J Mol Sci 2023; 24:ijms24087021. [PMID: 37108184 PMCID: PMC10139379 DOI: 10.3390/ijms24087021] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 03/23/2023] [Accepted: 04/07/2023] [Indexed: 04/29/2023] Open
Abstract
Under physiological conditions, skin mast cells play an important role as guardians that quickly react to stimuli that disturb homeostasis. These cells efficiently support, fight infection, and heal the injured tissue. The substances secreted by mast cells allow for communication inside the body, including the immune, nervous, and blood systems. Pathologically non-cancerous mast cells participate in allergic processes but also may promote the development of autoinflammatory or neoplastic disease. In this article, we review the current literature regarding the role of mast cells in autoinflammatory, allergic, neoplastic skin disease, as well as the importance of these cells in systemic diseases with a pronounced course with skin symptoms.
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Affiliation(s)
- Ewelina Woźniak
- Department of Dermatology, Sexually Transmitted Diseases and Clinical Immunology, The University of Warmia and Mazury, 10-229 Olsztyn, Poland
| | - Agnieszka Owczarczyk-Saczonek
- Department of Dermatology, Sexually Transmitted Diseases and Clinical Immunology, The University of Warmia and Mazury, 10-229 Olsztyn, Poland
| | - Magdalena Lange
- Department of Dermatology, Venereology and Allergology, Medical University of Gdansk, 80-214 Gdansk, Poland
| | - Justyna Czarny
- Department of Dermatology, Venereology and Allergology, Medical University of Gdansk, 80-214 Gdansk, Poland
| | - Ewa Wygonowska
- Department of Dermatology, Sexually Transmitted Diseases and Clinical Immunology, The University of Warmia and Mazury, 10-229 Olsztyn, Poland
| | - Waldemar Placek
- Department of Dermatology, Sexually Transmitted Diseases and Clinical Immunology, The University of Warmia and Mazury, 10-229 Olsztyn, Poland
| | - Bogusław Nedoszytko
- Department of Dermatology, Venereology and Allergology, Medical University of Gdansk, 80-214 Gdansk, Poland
- Invicta Fertility and Reproductive Centre, Molecular Laboratory, 81-740 Sopot, Poland
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124
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Deng R, Meng X, Wang A, Li R. Cutaneous granuloma annulare in an adult patient with macrophage activation syndrome. Clin Case Rep 2023; 11:e7181. [PMID: 37038537 PMCID: PMC10082351 DOI: 10.1002/ccr3.7181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 03/22/2023] [Accepted: 03/24/2023] [Indexed: 04/12/2023] Open
Abstract
Macrophage activation syndrome (MAS) is a rare but life-threatening disorder that is associated with multiple organ involvement. Here, we described cutaneous granuloma annulare in MAS. This novel histological finding is a reminder to explore the underlying mechanisms of skin involvement in MAS, which may reveal its pathogenesis.
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Affiliation(s)
- Ruixin Deng
- Department of Dermatology and VenerologyPeking University First HospitalBeijingChina
- National Clinical Research Center for Skin and Immune DiseasesBeijingChina
- Research Center for Medical MycologyPeking UniversityBeijingChina
- Beijing Key Laboratory of Molecular Diagnosis on DermatosesBeijingChina
| | - Xingye Meng
- Department of Dermatology and VenerologyPeking University First HospitalBeijingChina
- National Clinical Research Center for Skin and Immune DiseasesBeijingChina
- Research Center for Medical MycologyPeking UniversityBeijingChina
- Beijing Key Laboratory of Molecular Diagnosis on DermatosesBeijingChina
| | - Aiping Wang
- Department of Dermatology and VenerologyPeking University First HospitalBeijingChina
- National Clinical Research Center for Skin and Immune DiseasesBeijingChina
- Research Center for Medical MycologyPeking UniversityBeijingChina
- Beijing Key Laboratory of Molecular Diagnosis on DermatosesBeijingChina
| | - Ruoyu Li
- Department of Dermatology and VenerologyPeking University First HospitalBeijingChina
- National Clinical Research Center for Skin and Immune DiseasesBeijingChina
- Research Center for Medical MycologyPeking UniversityBeijingChina
- Beijing Key Laboratory of Molecular Diagnosis on DermatosesBeijingChina
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125
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Irino K, Jinnouchi F, Nakano S, Sawabe T. A case of hemophagocytic lymphohistiocytosis with a significant response to baricitinib: a first report with review of literature. Clin Rheumatol 2023:10.1007/s10067-023-06579-8. [PMID: 36947281 DOI: 10.1007/s10067-023-06579-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2023] [Revised: 03/10/2023] [Accepted: 03/11/2023] [Indexed: 03/23/2023]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a febrile disease with hyperinflammation characterized by activated macrophages with phagocytosis. The treatment strategy of secondary HLH has not been clearly established. Because of the high mortality rate and poor prognosis of HLH, alternative treatment strategies have been sought in treatment-resistant cases. Recently, there have been several reports that ruxolitinib, a Janus kinase (JAK) 1/JAK2 inhibitor, was effective against secondary HLH. Since the pathogenesis of HLH involves the overproduction of cytokines and JAK transmits a variety of cytokine signals, JAK inhibitors are thought to be effective in HLH. We herein report a case of HLH that was refractory to glucocorticoids, cyclosporine, and etoposide but responded to baricitinib. In the field of rheumatology, treatment-resistant cases of secondary HLH remain unmet needs. This is the first report to show that baricitinib was effective in a case of HLH. The accumulation of more cases in the future may prove that baricitinib is a potent agent for treating HLH.
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Affiliation(s)
- Kensuke Irino
- Department of Rheumatology, Hiroshima Red Cross Hospital and Atomic-bomb Survivors Hospital, 1-9-6 Sendamachi, Naka-ku, 730-8619, Hiroshima, Japan.
| | - Fumiaki Jinnouchi
- Department of Hematology, Hiroshima Red Cross Hospital and Atomic-bomb Survivors Hospital, Hiroshima, Japan
| | - Shota Nakano
- Department of Rheumatology, Hiroshima Red Cross Hospital and Atomic-bomb Survivors Hospital, 1-9-6 Sendamachi, Naka-ku, 730-8619, Hiroshima, Japan
| | - Takuya Sawabe
- Department of Rheumatology, Hiroshima Red Cross Hospital and Atomic-bomb Survivors Hospital, 1-9-6 Sendamachi, Naka-ku, 730-8619, Hiroshima, Japan
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126
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Schmidt W, Pawlak-Buś K, Jóźwiak B, Leszczyński P. Identification of Clinical Response Predictors of Tocilizumab Treatment in Patients with Severe COVID-19 Based on Single-Center Experience. J Clin Med 2023; 12:jcm12062429. [PMID: 36983429 PMCID: PMC10051490 DOI: 10.3390/jcm12062429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Revised: 03/19/2023] [Accepted: 03/20/2023] [Indexed: 03/30/2023] Open
Abstract
Hyperinflammation in COVID-19 plays a crucial role in pathogenesis and severity; thus, many immunomodulatory agents are applied in its treatment. We aimed to identify good clinical response predictors of tocilizumab (TCZ) treatment in severe COVID-19, among clinical, laboratory, and radiological variables. We conducted a prospective, observational study with 120 patients with severe COVID-19 not improving despite dexamethasone (DEX) treatment. We used parametric and non-parametric statistics, univariate logistic regression, receiver operating characteristic (ROC) curves, and nonlinear factors tertile analysis. In total, 86 (71.7%) patients achieved the primary outcome of a good clinical response to TCZ. We identified forty-nine predictive factors with potential utility in patient selection and treatment monitoring. The strongest included time from symptom onset between 9 and 12 days, less than 70% of estimated radiological lung involvement, and lower activity of lactate dehydrogenase. Additional predictors were associated with respiratory function, vitamin D concentration, comorbidities, and inflammatory/organ damage biomarkers. Adverse events analysis proved the safety of such a regimen. Our study confirmed that using TCZ early in the hyperinflammatory phase, before severe respiratory failure development, is most beneficial. Considering the described predictive factors, employing simple and widely available laboratory, radiological, and clinical tools can optimize patient selection for immunomodulatory treatment with TCZ.
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Affiliation(s)
- Wiktor Schmidt
- Department of Rheumatology, Systemic Connective Tissue Diseases and Immunotherapy of Rheumatic Diseases, J. Strus Municipal Hospital, 61-285 Poznan, Poland
- Department of Internal Medicine, Poznan University of Medical Sciences, 61-701 Poznan, Poland
- Doctoral School, Poznan University of Medical Sciences, 60-812 Poznan, Poland
| | - Katarzyna Pawlak-Buś
- Department of Rheumatology, Systemic Connective Tissue Diseases and Immunotherapy of Rheumatic Diseases, J. Strus Municipal Hospital, 61-285 Poznan, Poland
- Department of Internal Medicine, Poznan University of Medical Sciences, 61-701 Poznan, Poland
| | - Barbara Jóźwiak
- Department of Rheumatology, Systemic Connective Tissue Diseases and Immunotherapy of Rheumatic Diseases, J. Strus Municipal Hospital, 61-285 Poznan, Poland
| | - Piotr Leszczyński
- Department of Rheumatology, Systemic Connective Tissue Diseases and Immunotherapy of Rheumatic Diseases, J. Strus Municipal Hospital, 61-285 Poznan, Poland
- Department of Internal Medicine, Poznan University of Medical Sciences, 61-701 Poznan, Poland
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127
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Lee JC, Logan AC. Diagnosis and Management of Adult Malignancy-Associated Hemophagocytic Lymphohistiocytosis. Cancers (Basel) 2023; 15:1839. [PMID: 36980725 PMCID: PMC10046521 DOI: 10.3390/cancers15061839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 03/08/2023] [Accepted: 03/16/2023] [Indexed: 03/22/2023] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a syndrome of severe, dysregulated inflammation driven by the inability of T cells to clear an antigenic target. When associated with malignancy (mHLH), the HLH syndrome is typically associated with extremely poor survival. Here, we review the diagnosis of secondary HLH (sHLH) syndromes in adults, with emphasis on the appropriate workup and treatment of mHLH. At present, the management of HLH in adults, including most forms of mHLH, is based on the use of corticosteroids and etoposide following the HLH-94 regimen. In some cases, this therapeutic approach may be cohesively incorporated into malignancy-directed therapy, while in other cases, the decision about whether to treat HLH prior to initiating other therapies may be more complicated. Recent studies exploring the efficacy of other agents in HLH, in particular ruxolitinib, offer hope for better outcomes in the management of mHLH. Considerations for the management of lymphoma-associated mHLH, as well as other forms of mHLH and immunotherapy treatment-related HLH, are discussed.
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Affiliation(s)
- Jerry C. Lee
- Hematology, Blood and Marrow Transplantation, and Cellular Therapy Program, Division of Hematology/Oncology, University of California, San Francisco, CA 94143, USA;
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128
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Abou-El-Hassan H, Kantono M, Bhagat A, Hu J, Karp D, Jerome R, Randhawa JS, Shafer D, Farmand F. Hemophagocytic Lymphohistiocytosis Caused by a Severe Epstein-Barr Virus Infection in a Young Patient Presenting With Hiccups. Cureus 2023; 15:e36199. [PMID: 37065339 PMCID: PMC10104683 DOI: 10.7759/cureus.36199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/15/2023] [Indexed: 03/17/2023] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening hyperinflammatory syndrome characterized by a pathologic immune response in the setting of infection, malignancy, acute illness, or any immunological stimulus. Infection is the most common etiology of HLH. HLH involves aberrant activation of lymphocytes and macrophages with resultant hypercytokinemia due to an inappropriately stimulated and ineffective immune response. Here, we present the case of a previously healthy 19-year-old male presenting with hiccups and scleral icterus, who was found to have HLH due to a severe Epstein-Barr virus infection. Despite a morphologically normal bone marrow biopsy, the patient met the diagnostic criteria for HLH, including a low natural killer cell count and elevated soluble interleukin-2 receptor. Notably, ferritin was severely elevated at 85,810 ng/mL. The patient was treated with an induction course of dexamethasone intravenously for eight weeks. Since HLH can progress into multi-organ failure, timely diagnosis and prompt initiation of treatment are critical. Novel disease-modifying therapies and further clinical trials are warranted to treat this potentially fatal immunological disease with multisystem ramifications.
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129
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Fadlallah MM, Salman SM, Fadlallah MM, Rahal H. Hemophagocytic Syndrome and COVID-19: A Comprehensive Review. Cureus 2023; 15:e36140. [PMID: 37065291 PMCID: PMC10101193 DOI: 10.7759/cureus.36140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/14/2023] [Indexed: 03/17/2023] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH), a hyperinflammatory hyperferritinemic syndrome, is triggered by various etiologies and diseases and can lead to multiorgan dysfunction and death. There are two types of HLH: primary and secondary. Primary HLH (pHLH) is caused by a genetic mutation resulting in dysfunction in cytotoxic T lymphocytes (CTLs), natural killer (NK) cells, hyperactivated immune cells, and hypercytokinemia. In secondary HLH (sHLH), an underlying etiology is the cause of the disease. Infections, malignancy, and autoimmune diseases are well-known triggers for sHLH. Infectious triggers for sHLH are most frequently viruses, where different mechanisms, including dysregulated CTLs and NK cell activity and persistent immune system stimulation, have been reported. Similarly, in severe coronavirus disease 2019 (COVID-19) patients, a hyperinflammatory mechanism leading to hypercytokinemia and hyperferritinemia has been demonstrated. A similar dysfunction in CTLs and NK cells, persistent immune system stimulation with increased cytokines production, and severe end-organ damage have been reported. Therefore, a significant overlap is present between the clinical and laboratory features seen in COVID-19 and sHLH. However, SARS-CoV-2, similar to other viruses, can trigger sHLH. Hence, a diagnostic approach is needed in severe COVID-19 patients presenting with multiorgan failure, in whom sHLH should be considered.
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130
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Zhao Y, Deng Y, Jiang Y, Zheng W, Tan Y, Yang Z, Wang Z, Xu F, Cheng Z, Yuan L, Peng H. Case report: Targeting the PD-1 receptor and genetic mutations validated in primary histiocytic sarcoma with hemophagocytic lymphohistiocytosis. Front Immunol 2023; 14:1127599. [PMID: 36969238 PMCID: PMC10030599 DOI: 10.3389/fimmu.2023.1127599] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 02/22/2023] [Indexed: 03/10/2023] Open
Abstract
Histiocytic sarcoma (HS) is a rare hematological malignancy with limited treatment options, and it is also prone to complications such as hemophagocytic lymphohistiocytosis (HLH) in the later stages of the disease, leading to difficulties in treatment and poor prognosis. It highlights the importance of developing novel therapeutic agents. Herein, we present a case of a 45-year-old male patient who was diagnosed with PD-L1-positive HS with HLH. The patient was admitted to our hospital with recurrent high fever, multiple skin rashes with pruritus throughout the body and enlarged lymph nodes. Subsequently, pathological biopsy of the lymph nodes revealed high expression of CD163, CD68, S100, Lys and CD34 in the tumor cells and no expression of CD1a and CD207, confirming this rare clinical diagnosis. Concerning the low remission rate by conventional treatment in this disease, the patient was administered with sintilimab (an anti-programmed cell death 1 [anti-PD-1] monoclonal antibody) at 200 mg/d combined with a first-line chemotherapy regimen for one cycle. Further exploration of pathological biopsy by using next-generation gene sequencing led to the use of targeted therapy of chidamide. After one cycle of combination therapy (chidamide+sintilimab, abbreviated as CS), the patient achieved a favorable response. The patient showed remarkable improvement in the general symptoms and laboratory examination results (e.g., elevated indicators of inflammation); even the clinical benefits was not persistent, he survived one more month after his cessation of treatment by himself due to economic difficulty. Our case suggests that PD-1 inhibitor coupled with targeted therapy might constitute a potential therapeutic option for primary HS with HLH.
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Affiliation(s)
- Yan Zhao
- Department of Hematology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Yating Deng
- Department of Hematology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Yi Jiang
- Department of Pathology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Wenli Zheng
- Department of Hematology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Yanlin Tan
- Department of Imaging, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Zhiwu Yang
- Department of Hematology, Yiyang Central Hospital, Yiyang, Hunan, China
| | - Zhihua Wang
- Department of Hematology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Feng Xu
- Department of Thyroid and Breast Surgery, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Zhao Cheng
- Department of Hematology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Lingli Yuan
- Department of Hematology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
- *Correspondence: Lingli Yuan, ; Hongling Peng,
| | - Hongling Peng
- Department of Hematology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
- Hunan Engineering Research Center of Cell Immunotherapy for Hematopoietic Malignancies, Changsha, Hunan, China
- *Correspondence: Lingli Yuan, ; Hongling Peng,
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131
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Ruan P, Zhang Y, Chen H, Chen H, Dong Z. Heterozygous gain-of-function mutations in human STAT1: A case of hemophagocytic lymphohistiocytosis due to chronic mucocutaneous candidiasis in a 17-month-old male. Pediatr Blood Cancer 2023; 70:e30284. [PMID: 36881481 DOI: 10.1002/pbc.30284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 02/11/2023] [Accepted: 02/14/2023] [Indexed: 03/08/2023]
Affiliation(s)
- Peisen Ruan
- Department of Pediatrics, Ningbo Women and Children's Hospital, Ningbo, Zhejiang, China
| | - Yizhi Zhang
- Department of Microbiology, Ningbo Women and Children's Hospital, Ningbo, Zhejiang, China
| | - Haier Chen
- Department of Hematology, Ningbo Women and Children's Hospital, Ningbo, Zhejiang, China
| | - Hehe Chen
- Department of Pediatrics, Ningbo Women and Children's Hospital, Ningbo, Zhejiang, China
| | - Zhuoya Dong
- Department of Pediatrics, Ningbo Women and Children's Hospital, Ningbo, Zhejiang, China
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132
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Diaz L, Jauzelon B, Dillies AC, Le Souder C, Faillie JL, Maria ATJ, Palassin P. Hemophagocytic Lymphohistiocytosis Associated with Immunological Checkpoint Inhibitors: A Pharmacovigilance Study. J Clin Med 2023; 12:jcm12051985. [PMID: 36902771 PMCID: PMC10004618 DOI: 10.3390/jcm12051985] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 02/16/2023] [Accepted: 02/28/2023] [Indexed: 03/06/2023] Open
Abstract
BACKGROUND Acquired hemophagocytic lymphohistiocytosis (HLH) is a rare but potentially fatal condition characterized by hyperactivation of macrophages and cytotoxic lymphocytes, combining a series of non-specific clinical symptoms and laboratory disorders. Etiologies are multiple: infectious (mainly viral) but also oncologic, autoimmune or drug-induced. Immune checkpoint inhibitors (ICI) are recent anti-tumor agents associated with a novel profile of adverse events triggered by immune system over-activation. Here, we sought to provide a comprehensive description and analysis of HLH cases reported with ICI since 2014. METHODS Disproportionality analyses were performed in order to further explore the association between ICI therapy and HLH. We selected 190 cases, 177 from the World Health Organization pharmacovigilance database and 13 from the literature. Detailed clinical characteristics were retrieved from the literature and from the French pharmacovigilance database. RESULTS The cases of HLH reported with ICI concerned men in 65% of cases with a median age of 64 years. HLH occurred in an average of 102 days after the initiation of ICI treatment and mostly concerned nivolumab, pembrolizumab and nivolumab/ipilimumab combination. All cases were considered serious. Most cases presented a favorable outcome (58.4%); however, death was reported for 15.3% of patients. Disproportionality analyses showed that HLH was seven times more frequently reported with ICI therapy than with other drugs and three times more than with other antineoplastic agents. CONCLUSIONS Clinicians should be aware of the potential risk of ICI-related HLH to improve the early diagnosis of this rare immune-related adverse event.
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Affiliation(s)
- Laurine Diaz
- Department of Medical Pharmacology and Toxicology, CHU Montpellier, Montpellier University, 34000 Montpellier, France
| | - Benjamin Jauzelon
- Internal Medicine & Immuno-Oncology (MedI2O), CHU Montpellier, 34000 Montpellier, France
| | - Anne-Charlotte Dillies
- Department of Medical Pharmacology and Toxicology, CHU Montpellier, Montpellier University, 34000 Montpellier, France
| | - Cosette Le Souder
- Department of Medical Pharmacology and Toxicology, CHU Montpellier, Montpellier University, 34000 Montpellier, France
| | - Jean-Luc Faillie
- Department of Medical Pharmacology and Toxicology, CHU Montpellier, Montpellier University, 34000 Montpellier, France
- Desbrest Institute of Epidemiology and Public Health (IDESP), Montpellier University, INSERM, 34000 Montpellier, France
| | - Alexandre Thibault Jacques Maria
- Internal Medicine & Immuno-Oncology (MedI2O), CHU Montpellier, 34000 Montpellier, France
- Institute for Regenerative Medicine and Biotherapy (IRMB), Montpellier University, 34000 Montpellier, France
| | - Pascale Palassin
- Department of Medical Pharmacology and Toxicology, CHU Montpellier, Montpellier University, 34000 Montpellier, France
- Correspondence: ; Tel.: +33-4-67336756; Fax: +33-4-67336751
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Uryu H, Nakamura T, Nakashima D, Yamamoto K, Honda Y, Ishikawa M, Tsujita T, Hata N, Oinuma T, Yamazaki H, Yahagi Y. Miliary tuberculosis-associated hemophagocytic lymphohistiocytosis with a high level of soluble interleukin-2 receptor successfully treated with concomitant recombinant thrombomodulin: A case report. J Infect Chemother 2023; 29:361-366. [PMID: 36481565 DOI: 10.1016/j.jiac.2022.11.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Revised: 10/30/2022] [Accepted: 11/30/2022] [Indexed: 12/12/2022]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a fatal disease characterized by a highly inflammatory state due to the abnormal activation of T lymphocytes and macrophages. Miliary tuberculosis (MTB) is a rare cause of HLH and its clinical appearances occasionally resembles that of intravascular lymphoma (IVL). A 76-year-old woman presented with persistent fever and fatigue. Abnormal laboratory findings showing thrombocytopenia (13,000/μL), hypofibrinogenemia (101 mg/dL), hyperferritinemia (2,312 ng/mL), and markedly elevated soluble interleukin-2 receptor (sIL-2R) level (32,200 U/mL), in addition, hemophagocytosis in the bone marrow (BM) smear, were suggestive of IVL-associated HLH. The pathology of the BM biopsy specimen showed granuloma with non-caseous necrosis, and culture tests using sputum, gastric fluid, urine, and peripheral and bone marrow blood revealed the presence of Mycobacterium tuberculosis, leading to the final diagnosis of MTB-associated HLH. Anti-TB medications and corticosteroids were administered, but thrombocytopenia, hypofibrinogenemia, and hyperferritinemia persisted. Concomitant use of recombinant thrombomodulin (rTM) enabled regression of clinical status. In this case, BM biopsy served as the diagnosis of MTB-associated HLH, although IVL-associated HLH is initially suspected by an extremely high level of sIL-2R. Furthermore, this case report informs that using rTM could improve the outcomes of MTB-associated HLH.
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Affiliation(s)
- Hideki Uryu
- Department of Hematology, Kawaguchi Municipal Medical Center, Saitama, Japan.
| | - Takashi Nakamura
- Department of Hematology, Kawaguchi Municipal Medical Center, Saitama, Japan
| | - Daisuke Nakashima
- Department of Nephrology, Kawaguchi Municipal Medical Center, Saitama, Japan
| | - Kazuyoshi Yamamoto
- Department of Nephrology, Kawaguchi Municipal Medical Center, Saitama, Japan
| | - Yu Honda
- Department of Nephrology, Kawaguchi Municipal Medical Center, Saitama, Japan
| | - Masahiro Ishikawa
- Department of Nephrology, Kawaguchi Municipal Medical Center, Saitama, Japan
| | - Tomohiro Tsujita
- Department of Respiratory Medicine, Kawaguchi Municipal Medical Center, Saitama, Japan
| | - Norihiko Hata
- Department of Respiratory Medicine, Kawaguchi Municipal Medical Center, Saitama, Japan
| | - Toshinori Oinuma
- Department of Pathology, Kawaguchi Municipal Medical Center, Saitama, Japan
| | - Hiroyuki Yamazaki
- Department of Hematology, Kawaguchi Municipal Medical Center, Saitama, Japan
| | - Yuichi Yahagi
- Department of Hematology, Kawaguchi Municipal Medical Center, Saitama, Japan
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134
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Khan SA, Amir M. Hemophagocytic Lymphohistiocytosis Masquerading as Autoimmune Hepatitis. Cureus 2023; 15:e36543. [PMID: 37095795 PMCID: PMC10121374 DOI: 10.7759/cureus.36543] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/21/2023] [Indexed: 04/26/2023] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a complex disease disorder that involves dysregulated activation of the immune system resulting in cytokine storm which can lead to widespread tissue injury. HLH is associated with a mortality rate of 41%. The diagnosis of HLH requires a median of 14 days to reach likely due to a varied range of symptoms and signs the disease can present with. Liver disease and HLH can have a significant overlap. Liver injury itself is frequently noticed in patients with HLH, with more than 50% of patients having elevated aspartate transaminase, alanine transaminase, and bilirubin levels. This case report describes a young individual who had developed intermittent fever, vomiting, fatigue, and weight loss with labs remarkable for elevated transaminases and bilirubin. His initial workup revealed an acute Epstein-Barr virus infection. The patient later presented again with similar signs and symptoms. He underwent a liver biopsy with histopathological features initially concerning for autoimmune hepatitis. However, by engaging a multidisciplinary team, a correct diagnosis was achieved. This case report serves to highlight the increased level of suspicion required to correctly diagnose HLH, especially in the presence of clinical features concerning for autoimmune hepatitis.
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Affiliation(s)
- Sarosh A Khan
- Department of Medicine, Integris Baptist Medical Center, Oklahoma City, USA
| | - Muhammad Amir
- Department of Hepatology, Integris Baptist Medical Center, Oklahoma City, USA
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135
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Loubet D, Sarton B, Lelièvre L, Grouteau G, Iriart X, Chauvin P, Fillaux J, Valentin A, Berry A, Silva S, Bonneville F, Cassaing S, Guemas E. Fatal mucormycosis and aspergillosis coinfection associated with haemophagocytic lymphohistiocytosis: A case report and literature review. J Mycol Med 2023; 33:101325. [PMID: 36270214 DOI: 10.1016/j.mycmed.2022.101325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 07/08/2022] [Accepted: 08/05/2022] [Indexed: 11/15/2022]
Abstract
Invasive mould infections are life-threatening and mainly occur in immunocompromised patients. Whereas aspergillosis is described during haemophagocytic lymphohistiocytosis (HLH), only a few cases of concomitant mucormycosis with HLH have been reported. Here, we present an uncommon coinfection of mucormycosis and aspergillosis associated with HLH probably due to a varicella zoster virus (VZV) viraemia which was unresponsive to triple antifungal therapy (liposomal amphotericin B combined with isavuconazole and caspofungin). A review of the cases of mucormycosis with HLH showed that this uncommon association was always lethal and underscored the relevance of screening for mould infections in patients with HLH.
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Affiliation(s)
- Dorian Loubet
- Department of Parasitology and Mycology, CHU Toulouse, Toulouse, France
| | - Benjamine Sarton
- Critical Care Unit, University Hospital of Purpan, Toulouse, France; Toulouse NeuroImaging Center, Unité Mixte de Recherche 1214, Institut National de la Santé et de la Recherche Médicale, Université Paul Sabatier, Toulouse, France
| | - Lucie Lelièvre
- Department of Infectious and Tropical Diseases, CHU Toulouse, Toulouse, France
| | - Gaspard Grouteau
- Department of Infectious and Tropical Diseases, CHU Toulouse, Toulouse, France
| | - Xavier Iriart
- Department of Parasitology and Mycology, CHU Toulouse, Toulouse, France; Institut Toulousain des Maladies Infectieuses et Inflammatoires (Infinity), Université Toulouse, CNRS UMR5051, INSERM UMR1291, UPS, Toulouse, France
| | - Pamela Chauvin
- Department of Parasitology and Mycology, CHU Toulouse, Toulouse, France
| | - Judith Fillaux
- Department of Parasitology and Mycology, CHU Toulouse, Toulouse, France
| | - Alexis Valentin
- Department of Parasitology and Mycology, CHU Toulouse, Toulouse, France; PHARMA-Dev, UMR 152 IRD-UPS, Université Toulouse, France
| | - Antoine Berry
- Department of Parasitology and Mycology, CHU Toulouse, Toulouse, France; Institut Toulousain des Maladies Infectieuses et Inflammatoires (Infinity), Université Toulouse, CNRS UMR5051, INSERM UMR1291, UPS, Toulouse, France
| | - Stein Silva
- Critical Care Unit, University Hospital of Purpan, Toulouse, France; Toulouse NeuroImaging Center, Unité Mixte de Recherche 1214, Institut National de la Santé et de la Recherche Médicale, Université Paul Sabatier, Toulouse, France
| | - Fabrice Bonneville
- Neuroradiology Department, Pierre-Paul-Riquet/Purpan University Hospital, Toulouse, France
| | - Sophie Cassaing
- Department of Parasitology and Mycology, CHU Toulouse, Toulouse, France; RESTORE Institute, UMR 1301-Inserm 5070-CNRS EFS Univ. P. Sabatier, Toulouse, France
| | - Emilie Guemas
- Department of Parasitology and Mycology, CHU Toulouse, Toulouse, France; Institut Toulousain des Maladies Infectieuses et Inflammatoires (Infinity), Université Toulouse, CNRS UMR5051, INSERM UMR1291, UPS, Toulouse, France.
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136
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Cytokine nanosponges suppressing overactive macrophages and dampening systematic cytokine storm for the treatment of hemophagocytic lymphohistiocytosis. Bioact Mater 2023; 21:531-546. [PMID: 36185750 PMCID: PMC9508173 DOI: 10.1016/j.bioactmat.2022.09.012] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 08/12/2022] [Accepted: 09/09/2022] [Indexed: 11/29/2022] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a highly fatal condition with the positive feedback loop between continued immune cell activation and cytokine storm as the core mechanism to mediate multiple organ dysfunction. Inspired by macrophage membranes harbor the receptors with special high affinity for proinflammation cytokines, lipopolysaccharide (LPS)-stimulated macrophage membrane-coated nanoparticles (LMNP) were developed to show strong sponge ability to both IFN-γ and IL-6 and suppressed overactivation of macrophages by inhibiting JAK/STAT signaling pathway both in vitro and in vivo. Besides, LMNP also efficiently alleviated HLH-related symptoms including cytopenia, hepatosplenomegaly and hepatorenal dysfunction and save the life of mouse models. Furthermore, its sponge effect also worked well for five human HLH samples in vitro. Altogether, it's firstly demonstrated that biocompatible LMNP could dampen HLH with high potential for clinical transformation, which also provided alternative insights for the treatment of other cytokine storm-mediated pathologic conditions such as COVID-19 infection and cytokine releasing syndrome during CAR-T therapy. LMNP functioned better as a multiple-cytokine sponging tool when compared with conventional macrophage coated nanoparticles. LMNP sponged inflammation cytokines and suppressed macrophage overactivation by inhibiting JAK/STAT signaling pathway. LMNP calmed down systematic cytokine storm and dampened HLH in HLH mice models. LMNP also worked well in sponging cytokines in human HLH samples which indicated high potential of clinical transformation.
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137
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Mechi AM, Al‐Khalidi AA, Hasan TA. Hemophagocytic Lymphohistiocytosis syndrome (HLH) associated with acute pancreatitis: A case report. Clin Case Rep 2023; 11:e7096. [PMID: 36950669 PMCID: PMC10025947 DOI: 10.1002/ccr3.7096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 02/22/2022] [Accepted: 10/19/2022] [Indexed: 03/24/2023] Open
Abstract
Hemophagocytic Lymphohistiocytosis syndrome is fatal hyper-inflammatory condition due to over-activation of the immune system, being of primary and secondary types. This case report emphasizes the difficulty and challenge in and of the HLH diagnosis, and therapy should be employed promptly given the high mortality associated with HLH.
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Affiliation(s)
- Ahmed Mohamad Mechi
- Internal Medicine Department, College of MedicineUniversity of KufaNajafIraq
| | - Alhan Abbas Al‐Khalidi
- Internal Medicine Department, College of MedicineJabir Ibn Hayyan Medical UniversityNajafIraq
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Tan M, Wang S, Li Q, Yuan R, Zhao M, Cao J. HELLP syndrome, intracerebral hemorrhage, and hemophagocytic syndrome after cesarean section in a pregnant patient with severe preeclampsia: a case report. BMC Pregnancy Childbirth 2023; 23:129. [PMID: 36855088 PMCID: PMC9972739 DOI: 10.1186/s12884-023-05462-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 02/21/2023] [Indexed: 03/02/2023] Open
Abstract
BACKGROUND Pregnancy-related intracranial hemorrhage (ICH) is a rare but potentially life-threatening event with complex and varied cause, such as HELLP syndrome and hemophagocytic syndrome. CASE PRESENTATION A 33-year-old patient underwent a cesarean section with a preliminary diagnosis of "severe preeclampsia and class3 HELLP syndrome ". The patient had poor response to language before surgery, and the catheter drainage fluid was hematuria. Later, the surgeon reported severe bleeding in the operation. Following thromboelastography (TEG) result and postoperative laboratory tests confirmed class1 HELLP syndrome and ICH occurred on the second day after the surgery, and hemophagocytic syndrome was diagnosed during subsequent treatments. CONCLUSION For patients with HELLP syndrome, we should pay attention to their coagulation condition. The coagulation tests and platelet counts should be repeated if their clinical presentation changed. Those with neurological alarm signs should receive CT or MRI scan. If a pregnant woman had prolonged hemocytopenia and thrombocytopenia, not only the HELLP but also the hemophagocytic syndrome should be considered.
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Affiliation(s)
- Minghe Tan
- grid.452206.70000 0004 1758 417XDepartment of Anesthesiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016 China
| | - Siqi Wang
- grid.452206.70000 0004 1758 417XDepartment of Anesthesiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016 China
| | - Qingshu Li
- grid.203458.80000 0000 8653 0555Department of Pathology, School of Basic Medicine, Chongqing Medical University, Chongqing, 400016 China
| | - Ruixue Yuan
- grid.452206.70000 0004 1758 417XDepartment of Anesthesiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016 China
| | - Maoji Zhao
- grid.452206.70000 0004 1758 417XDepartment of Anesthesiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016 China
| | - Jun Cao
- Department of Anesthesiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China.
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Vashisht A, Ahluwalia P, Mondal AK, Singh H, Sahajpal NS, Fulzele S, Kota V, Gahlay GK, Kolhe R. Immune Factors Drive Expression of SARS-CoV-2 Receptor Genes Amid Sexual Disparity. Viruses 2023; 15:v15030657. [PMID: 36992366 PMCID: PMC10056434 DOI: 10.3390/v15030657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 02/23/2023] [Accepted: 02/27/2023] [Indexed: 03/05/2023] Open
Abstract
The emergence of COVID-19 has led to significant morbidity and mortality, with around seven million deaths worldwide as of February 2023. There are several risk factors such as age and sex that are associated with the development of severe symptoms due to COVID-19. There have been limited studies that have explored the role of sex differences in SARS-CoV-2 infection. As a result, there is an urgent need to identify molecular features associated with sex and COVID-19 pathogenesis to develop more effective interventions to combat the ongoing pandemic. To address this gap, we explored sex-specific molecular factors in both mouse and human datasets. The host immune targets such as TLR7, IRF7, IRF5, and IL6, which are involved in the immune response against viral infections, and the sex-specific targets such as AR and ESSR were taken to investigate any possible link with the SARS-CoV-2 host receptors ACE2 and TMPRSS2. For the mouse analysis, a single-cell RNA sequencing dataset was used, while bulk RNA-Seq datasets were used to analyze the human clinical data. Additional databases such as the Database of Transcription Start Sites (DBTS), STRING-DB, and the Swiss Regulon Portal were used for further analysis. We identified a 6-gene signature that showed differential expression in males and females. Additionally, this gene signature showed potential prognostic utility by differentiating ICU patients from non-ICU patients due to COVID-19. Our study highlights the importance of assessing sex differences in SARS-CoV-2 infection, which can assist in the optimal treatment and better vaccination strategies.
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Affiliation(s)
- Ashutosh Vashisht
- Department of Pathology, Medical College of Georgia, Augusta University, Augusta, GA 30912, USA
- Department of Molecular Biology and Biochemistry, Guru Nanak Dev University, Amritsar 143005, India
| | - Pankaj Ahluwalia
- Department of Pathology, Medical College of Georgia, Augusta University, Augusta, GA 30912, USA
| | - Ashis K. Mondal
- Department of Pathology, Medical College of Georgia, Augusta University, Augusta, GA 30912, USA
| | - Harmanpreet Singh
- Department of Pathology, Medical College of Georgia, Augusta University, Augusta, GA 30912, USA
| | | | - Sadanand Fulzele
- Department of Medicine, Medical College of Georgia, Augusta University, Augusta, GA 30912, USA
| | - Vamsi Kota
- Department of Medicine, Medical College of Georgia, Augusta University, Augusta, GA 30912, USA
| | - Gagandeep K. Gahlay
- Department of Molecular Biology and Biochemistry, Guru Nanak Dev University, Amritsar 143005, India
- Correspondence: (G.K.G.); (R.K.)
| | - Ravindra Kolhe
- Department of Pathology, Medical College of Georgia, Augusta University, Augusta, GA 30912, USA
- Correspondence: (G.K.G.); (R.K.)
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140
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Monti M, Marconi G, Ambrosini-Spaltro A, Gallio C, Ghini V, Esposito L, Antonini S, Montanari D, Frassineti GL. Hemophagocytic lymphohistiocytosis in gastric cancer: A rare syndrome for the oncologist. Case report and brief review. Front Oncol 2023; 13:1010561. [PMID: 36845741 PMCID: PMC9945267 DOI: 10.3389/fonc.2023.1010561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Accepted: 01/10/2023] [Indexed: 02/10/2023] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a rare and life-threatening condition characterized by uncontrolled activation of the immune system. HLH is a reactive mononuclear phagocytic response that occurs in association with a constellation of conditions such as malignancies and infections. The clinical diagnosis of HLH remains challenging because HLH can present with symptoms that significantly overlap with other causes of cytopenia, such as sepsis, autoimmune diseases, hematological cancers, and multiorgan failure. A 50-year-old man went to the emergency room (ER) for hyperchromic urine, melena, gingivorrhagia, and spontaneous abdominal wall hematomas. The first blood tests showed severe thrombocytopenia, alteration of the INR, and consumption of fibrinogen, and therefore, a diagnosis of disseminated intravascular coagulation (DIC) was made. A bone marrow aspirate showed numerous images of hemophagocytosis. With the suspicion of immune-mediated cytopenia, oral etoposide, intravenous immunoglobulin, and intravenous methylprednisolone were administered. Then, a diagnosis of gastric carcinoma was performed with a lymph node biopsy and gastroscopy. On the 30th day, the patient was transferred to the oncology ward of another hospital. On admission, he had serious piastrinopenia, anemia, hypertriglyceridemia, and hyperferritinemia. He was supported with a platelet transfusion and underwent a bone biopsy that showed a picture compatible with myelophthisis from diffuse medullary localization of a carcinoma of gastric origin. A diagnosis of HLH secondary to solid neoplasm was formulated. The patient started chemotherapy with oxaliplatin, calcium levofolinate, 5-fluorouracil bolus, 5-fluorouracil for 48 h (mFOLFOX6), and methylprednisolone. Six days after the third cycle of mFOLFOX6, the patient was discharged with the stabilization of his piastrinopenia condition. The patient continued chemotherapy with an improvement in his clinical conditions and normalization of hematological values. After 12 cycles of mFOLFOX, it was decided to start maintenance chemotherapy with capecitabine but, unfortunately, after only one cycle, HLH reappeared. The oncologist has to keep in mind the existence of HLH when there is an unusual clinical presentation of cancer, such as cytopenia affecting ≥2 lineages and alterations of ferritin and triglycerides other than fibrinogen and coagulation. Increased attention and additional research as well as a close collaboration with hematologists are needed to benefit patients with solid tumors complicated by HLH.
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Affiliation(s)
- Manlio Monti
- Department of Medical Oncology, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) “Dino Amadori”, Meldola, Italy,*Correspondence: Manlio Monti,
| | - Giovanni Marconi
- Haematology Unit, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) “Dino Amadori”, Meldola, Italy
| | | | - Chiara Gallio
- Department of Medical Oncology, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) “Dino Amadori”, Meldola, Italy
| | - Virginia Ghini
- Department of Medical Oncology, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) “Dino Amadori”, Meldola, Italy
| | - Luca Esposito
- Department of Medical Oncology, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) “Dino Amadori”, Meldola, Italy
| | - Stefano Antonini
- Department of Medical Oncology, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) “Dino Amadori”, Meldola, Italy
| | - Daniela Montanari
- Department of Medical Oncology, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) “Dino Amadori”, Meldola, Italy
| | - Giovanni Luca Frassineti
- Department of Medical Oncology, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) “Dino Amadori”, Meldola, Italy
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141
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Peng LY, Liu JB, Zuo HJ, Shen GF. Unusual presentation of systemic lupus erythematosus as hemophagocytic lymphohistiocytosis in a female patient: A case report. World J Clin Cases 2023; 11:909-917. [PMID: 36818616 PMCID: PMC9928712 DOI: 10.12998/wjcc.v11.i4.909] [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: 10/13/2022] [Revised: 12/29/2022] [Accepted: 01/12/2023] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Hemophagocytic lymphohistiocytosis (HLH) is a rare life-threatening disorder, often resulting in the immune-mediated injury of multiple organ systems, including primary HLH and secondary HLH (sHLH). Among them, sHLH results from infections, malignant, or autoimmune conditions, which have quite poor outcomes even with aggressive management and are more common in adults.
CASE SUMMARY We report a rare case of a 36-year-old female manifested with sHLH on background with systemic lupus erythematosus (SLE). During hospitalization, the patient was characterized by recurrent high-grade fever, petechiae and ecchymoses of abdominal skin, and pulmonary infection. Whole exon gene sequencing revealed decreased activity of natural killer cells. She received systematic treatment with Methylprednisolone, Etoposide, and anti-infective drugs. Intravenous immunoglobulin and plasmapheresis were applied when the condition was extremely acute and progressive. The patient recovered and did not present any relapse of the HLH for one year of follow-up.
CONCLUSION The case showed sHLH, thrombotic microvascular, and infection in the whole course of the disease, which was rarely reported by now. The treatment of the patient emphasizes that early recognition and treatment of sHLH in SLE patients was of utmost importance to improve the prognosis and survival rate of patients.
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Affiliation(s)
- Li-Yuan Peng
- Division of Cardiology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, Hubei Province, China
| | - Jing-Bo Liu
- Division of Cardiology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, Hubei Province, China
| | - Hou-Juan Zuo
- Division of Cardiology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, Hubei Province, China
| | - Gui-Fen Shen
- Department of Rheumatology and Immunology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, Hubei Province, China
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142
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Chan D, Karimi S, Follows G, Torpey N, Suchanek O. Use of rituximab in SARS-CoV-2-positive renal transplant recipient with EBV reactivation and probable haemophagocytic lymphohistiocytosis. CEN Case Rep 2023; 12:27-31. [PMID: 35729310 PMCID: PMC9213214 DOI: 10.1007/s13730-022-00711-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Accepted: 05/24/2022] [Indexed: 02/04/2023] Open
Abstract
We present a case of a rapid clinical recovery in a critically ill kidney transplant recipient with SARS-CoV-2 positivity, Epstein-Barr virus (EBV) reactivation and probable secondary hemophagocytic lymphohistiocytosis (HLH) treated with etoposide-free regimen, based on dexamethasone and a single dose of rituximab. Although rituximab is often a part of EBV-HLH treatment strategy, its use in simultaneous Coronavirus 2019 disease (COVID-19) and solid-organ transplantation has not been reported yet. We review the current evidence for the potential of SARS-CoV-2 to trigger EBV reactivation, leading to a severe clinical illness. Finally, we compare the clinical features of hyper-inflammatory response typical for severe COVID-19 and classical secondary HLH and discuss the benefits of therapeutic B-cell depletion in both conditions.
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Affiliation(s)
- Derek Chan
- Department of Clinical Nephrology and Transplantation, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
- Department of Haematology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Trust, Cambridge, UK
| | - Sabina Karimi
- Department of Clinical Nephrology and Transplantation, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - George Follows
- Department of Haematology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Trust, Cambridge, UK
| | - Nicholas Torpey
- Department of Clinical Nephrology and Transplantation, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Ondrej Suchanek
- Department of Clinical Nephrology and Transplantation, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK.
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Stoian M, Procopiescu B, Șeitan S, Scarlat G. Post-COVID-19 syndrome: Insights into a novel post-infectious systemic disorder. J Med Life 2023; 16:195-202. [PMID: 36937488 PMCID: PMC10015558 DOI: 10.25122/jml-2022-0329] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Accepted: 01/17/2023] [Indexed: 03/21/2023] Open
Abstract
Coronavirus disease 2019 (COVID-19) is currently considered a complex systemic infectious and inflammatory disease, determined by the infection with severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), and the cause of one of the most important epidemiological phenomena in the last century - the COVID-19 pandemic. This infectious-inflammatory disease may generate a wide range of clinical manifestations and biological modifications, explained by the ubiquitous nature of the SARS-CoV-2 receptors, represented by the angiotensin-converting enzyme-2 (ACE-2), and by the host's violent immune and proinflammatory reaction to the viral infection. These manifestations include immunological disturbances, which, according to certain clinical findings, may persist post-infection, in the form of a presumed systemic inflammatory entity, defined by several clinical concepts with a common pathological significance: post-COVID-19 multisystem (or systemic) inflammatory syndrome, post-COVID syndrome or long-COVID. Although the pathophysiological mechanisms of the post-COVID-19 syndrome are elusive at the present moment, there are currently several studies that describe a systemic inflammatory or autoimmune phenomenon following the remission of the COVID-19 infection in some patients, which suggests the existence of molecular and cellular immune abnormalities, most probably due to the host's initial violent immune response to the viral infection, in the form of three overlapping entities: secondary hemophagocytic lymph histiocytosis (HLH), macrophage activation syndrome (MAS) and cytokine release syndrome (CRS). Thus, this is reminiscent of different classic autoimmune diseases, in which various infections are risk factors in developing the autoimmune process.
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Affiliation(s)
- Marilena Stoian
- Department of Internal Medicine, Dr. Ion Cantacuzino Clinical Hospital, Bucharest, Romania
- Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
- Corresponding Author: Marilena Stoian, Department of Internal Medicine, Dr. Ion Cantacuzino Clinical Hospital, Bucharest, Romania. Carol Davila University of Medicine and Pharmacy, Bucharest, Romania. E-mail:
| | - Bianca Procopiescu
- Department of Internal Medicine, Dr. Ion Cantacuzino Clinical Hospital, Bucharest, Romania
| | - Silviu Șeitan
- Department of Internal Medicine, Dr. Ion Cantacuzino Clinical Hospital, Bucharest, Romania
| | - Gabriel Scarlat
- Department of Internal Medicine, Dr. Ion Cantacuzino Clinical Hospital, Bucharest, Romania
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Tudesq JJ, Yakoub-Agha M, Bay JO, Courbon C, Paul F, Picard M, Pochon C, Sterin A, Vicente C, Canet E, Yakoub-Agha I, Moreau AS. [Management of cytokine release syndrome and macrophage activation syndrome following CAR-T cell therapy: Guidelines from the SFGM-TC]. Bull Cancer 2023; 110:S116-S122. [PMID: 34895696 DOI: 10.1016/j.bulcan.2021.11.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 11/02/2021] [Accepted: 11/08/2021] [Indexed: 11/22/2022]
Abstract
The use of chimeric antigen receptor T cells (CAR-T) has increased since their approval in the treatment of several relapsed/refractory B cell malignancies. The management of their specific toxicities, such as cytokine release syndrome (CRS), tends to be better understood and well-defined. During the twelfth edition of practice harmonization workshops of the Francophone Society of Bone Marrow Transplantation and Cellular Therapy (SFGM-TC), a working group focused its work on the management of patients developing CRS following CAR-T cell therapy. A special chapter has been allocated to macrophage activation syndrome (MAS), a rare but life-threatening complication post-CAR-T. In addition to symptomatic measures and preemptive broad-spectrum antibiotics, immunomodulators such as tocilizumab and corticosteroids remain the corner stone for the treatment of CRS. Tocilizumab/corticosteroids-resistant CRS associated with haemophagocytosis markers (spleen and liver enlargement, hyperferritinaemia>10,000ng/mL, hypofibrinogenemia…) should direct the diagnosis towards an overlapping CRS/MAS. An adapted treatment will be based on high-dose IV anakinra and corticosteroids and chemotherapy with etoposide at late refractory stages. These complications and others delignate the need of close collaboration with an intensive care unit.
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Affiliation(s)
- Jean-Jacques Tudesq
- CHU Montpellier, université Montpellier, département d'hématologie clinique, Montpellier, France
| | | | - Jacques-Olivier Bay
- CHU Clermont-Ferrand, service de thérapie cellulaire et d'hématologie clinique adulte, Clermont-Ferrand, France
| | - Corinne Courbon
- Institut de cancérologie de la Loire, service d'hématologie, St Priest en Jarez, France
| | - Franciane Paul
- CHU Toulouse, service de réanimation polyvalente, IUCT-oncopole, 1, avenue Joliot-Curie, 31059 Toulouse, France
| | - Muriel Picard
- CHU Toulouse, service de réanimation polyvalente, IUCT-oncopole, 1, avenue Joliot-Curie, 31059 Toulouse, France
| | - Cécile Pochon
- CHRU de Nancy, université de Lorraine, service d'onco-hématologie pédiatrique, UMR 7365 CNRS-UL IMoPA, Vandœuvre-Lès-Nancy, France
| | - Arthur Sterin
- Hôpital La Timone Enfants, service hémato-immunologie pédiatrique, Marseille, France
| | - Céline Vicente
- CHU Toulouse, département d'hématologie, IUCT-oncopole, Toulouse, France
| | - Emmanuel Canet
- CHU de Nantes, université de Nantes, service de médecine intensive - réanimation, Nantes, France
| | - Ibrahim Yakoub-Agha
- CHU de Lille, université de Lille, hôpital Huriez, service des maladies du sang, LIRIC, INSERM U995, Lille, France
| | - Anne-Sophie Moreau
- CHU Lille, hôpital Salengro, service de médecine intensive réanimation, Lille, France.
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Casado-Fernández G, Corona M, Torres M, Saez AJ, Ramos-Martín F, Manzanares M, Vigón L, Mateos E, Pozo F, Casas I, García-Gutierrez V, Rodríguez-Mora S, Coiras M. Sustained Cytotoxic Response of Peripheral Blood Mononuclear Cells from Unvaccinated Individuals Admitted to the ICU Due to Critical COVID-19 Is Essential to Avoid a Fatal Outcome. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:1947. [PMID: 36767310 PMCID: PMC9915056 DOI: 10.3390/ijerph20031947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 01/16/2023] [Accepted: 01/17/2023] [Indexed: 06/18/2023]
Abstract
The main objective of this study was to determine the influence of the cytotoxic activity of peripheral blood mononuclear cells (PBMCs) on the outcome of unvaccinated individuals with critical COVID-19 admitted to the ICU. Blood samples from 23 individuals were collected upon admission and then every 2 weeks for 13 weeks until death (Exitus group) (n = 13) or discharge (Survival group) (n = 10). We did not find significant differences between groups in sociodemographic, clinical, or biochemical data that may influence the fatal outcome. However, direct cellular cytotoxicity of PBMCs from individuals of the Exitus group against pseudotyped SARS-CoV-2-infected Vero E6 cells was significantly reduced upon admission (-2.69-fold; p = 0.0234) and after 4 weeks at the ICU (-5.58-fold; p = 0.0290), in comparison with individuals who survived, and it did not improve during hospitalization. In vitro treatment with IL-15 of these cells did not restore an effective cytotoxicity at any time point until the fatal outcome, and an increased expression of immune exhaustion markers was observed in NKT, CD4+, and CD8+ T cells. However, IL-15 treatment of PBMCs from individuals of the Survival group significantly increased cytotoxicity at Week 4 (6.18-fold; p = 0.0303). Consequently, immunomodulatory treatments that may overcome immune exhaustion and induce sustained, efficient cytotoxic activity could be essential for survival during hospitalization due to critical COVID-19.
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Affiliation(s)
- Guiomar Casado-Fernández
- Immunopathology Unit, National Center of Microbiology, Instituto de Salud Carlos III, 28029 Madrid, Spain
- Faculty of Sciences, Universidad de Alcalá, 28805 Madrid, Spain
- Biomedical Research Center Network in Infectious Diseases (CIBERINFEC), Instituto de Salud Carlos III, 28220 Madrid, Spain
| | - Magdalena Corona
- Faculty of Sciences, Universidad de Alcalá, 28805 Madrid, Spain
- Hematology and Hemotherapy Service, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Hospital Universitario Ramón y Cajal, 28034 Madrid, Spain
| | - Montserrat Torres
- Immunopathology Unit, National Center of Microbiology, Instituto de Salud Carlos III, 28029 Madrid, Spain
- Biomedical Research Center Network in Infectious Diseases (CIBERINFEC), Instituto de Salud Carlos III, 28220 Madrid, Spain
| | - Adolfo J. Saez
- Hematology and Hemotherapy Service, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Hospital Universitario Ramón y Cajal, 28034 Madrid, Spain
| | - Fernando Ramos-Martín
- Immunopathology Unit, National Center of Microbiology, Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Mario Manzanares
- Immunopathology Unit, National Center of Microbiology, Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Lorena Vigón
- Immunopathology Unit, National Center of Microbiology, Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Elena Mateos
- Immunopathology Unit, National Center of Microbiology, Instituto de Salud Carlos III, 28029 Madrid, Spain
- Biomedical Research Center Network in Infectious Diseases (CIBERINFEC), Instituto de Salud Carlos III, 28220 Madrid, Spain
| | - Francisco Pozo
- Respiratory Viruses Service, National Center of Microbiology, Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Inmaculada Casas
- Respiratory Viruses Service, National Center of Microbiology, Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Valentín García-Gutierrez
- Hematology and Hemotherapy Service, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Hospital Universitario Ramón y Cajal, 28034 Madrid, Spain
| | - Sara Rodríguez-Mora
- Immunopathology Unit, National Center of Microbiology, Instituto de Salud Carlos III, 28029 Madrid, Spain
- Biomedical Research Center Network in Infectious Diseases (CIBERINFEC), Instituto de Salud Carlos III, 28220 Madrid, Spain
| | - Mayte Coiras
- Immunopathology Unit, National Center of Microbiology, Instituto de Salud Carlos III, 28029 Madrid, Spain
- Biomedical Research Center Network in Infectious Diseases (CIBERINFEC), Instituto de Salud Carlos III, 28220 Madrid, Spain
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146
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Chevalier K, Schmidt J, Coppo P, Galicier L, Noël N, Lambotte O. Hemophagocytic Lymphohistiocytosis Associated With Cytomegalovirus Infection: 5 Cases and a Systematic Review of the Literature. Clin Infect Dis 2023; 76:351-358. [PMID: 35974465 DOI: 10.1093/cid/ciac649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 07/30/2022] [Accepted: 08/09/2022] [Indexed: 01/18/2023] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a rare, life-threatening disorder characterized by an uncontrolled, persistent, hyperimmune response. It can be triggered by an infectious, neoplastic, or autoimmune event. The involvement of cytomegalovirus (CMV) in the onset of HLH is subject to debate, and the epidemiology of CMV-associated HLH (HLH-CMV) remains poorly characterized. We identified 5 cases of HLH-CMV in our hospital, systematically searched the PubMed database for publications on HLH-CMV, and reviewed 57 publications with a total of 67 cases of HLH-CMV. Only 48 patients (71.6%) were immunodeficient, suggesting that HLH-CMV can occur in immunocompetent patients. The major cause of underlying immunodepression (51%) was inflammatory bowel disease (mainly treated with azathioprine). CMV infection was nearly always symptomatic, and lung involvement was frequent (31 cases). Fifty-five patients recovered. Nineteen patients were treated for CMV infection only and had a good outcome, suggesting that antiviral drugs might be the cornerstone of HLH-CMV treatment.
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Affiliation(s)
- Kevin Chevalier
- Université Paris-Saclay, AP-HP, Hôpital Bicêtre, service de Médecine Interne Immunologie Clinique, Centre de recherche en Immunologie des infections virales et des maladies auto-immunes ImVA, UMR1184, INSERM, CEA, Le Kremlin Bicêtre, France
| | - Julien Schmidt
- Université Paris-Saclay, AP-HP, Hôpital Bicêtre, service de Médecine Interne Immunologie Clinique, Centre de recherche en Immunologie des infections virales et des maladies auto-immunes ImVA, UMR1184, INSERM, CEA, Le Kremlin Bicêtre, France
| | - Paul Coppo
- Sorbonne Université, AP-HP, Hôpital St. Antoine, service d'hématologie clinique et thérapie cellulaire, Paris, France
| | - Lionel Galicier
- Université Paris Cité, AP-HP, Hôpital Saint-Louis, service d'immunologie clinique, Paris, France
| | - Nicolas Noël
- Université Paris-Saclay, AP-HP, Hôpital Bicêtre, service de Médecine Interne Immunologie Clinique, Centre de recherche en Immunologie des infections virales et des maladies auto-immunes ImVA, UMR1184, INSERM, CEA, Le Kremlin Bicêtre, France
| | - Olivier Lambotte
- Université Paris-Saclay, AP-HP, Hôpital Bicêtre, service de Médecine Interne Immunologie Clinique, Centre de recherche en Immunologie des infections virales et des maladies auto-immunes ImVA, UMR1184, INSERM, CEA, Le Kremlin Bicêtre, France
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147
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Zondag TCE, Lika A, van Laar JAM. The role of etoposide in the treatment of adult patients with hemophagocytic lymphohistiocytosis. Exp Hematol Oncol 2023; 12:2. [PMID: 36624539 PMCID: PMC9827679 DOI: 10.1186/s40164-022-00362-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 12/29/2022] [Indexed: 01/11/2023] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a potentially fatal inflammatory clinical condition, in which an exaggerated immune response is ineffectively regulated. Although etoposide-containing regimens are generally recommended for children with HLH, the exact role of etoposide in the adult setting remains unclear. We performed a systematic review of the literature on the use of etoposide in adults with HLH. All articles written in English on the use of etoposide in adults with HLH available from seven databases and published on or before July 2021 were analyzed. Thirteen studies were found to be relevant to the search results. Ten of these studies report a statistical analysis on the effect of etoposide, of which five found etoposide-containing regimens superior to non-etoposide-containing regimens. Seven studies provided sufficient data to be included in the meta-analysis. For these data, the estimated logit relative risk of etoposide on survival was 1.06 (95% confidence interval: 0.92-1.21, standard error: 2.06). The pooled data of the meta-analysis did thus not support a beneficial effect of etoposide. It should be taken into account that the presented results are highly susceptible to bias and that the effect of etoposide differs between HLH-triggers. Although the meta-analysis does not support the effect of etoposide, we do not recommend abandoning etoposide as treatment modality. The limitations of the meta-analysis, together with several individual articles confirming the benefit of etoposide, justify etoposide for select cases in adults with HLH such as refractory or severe disease with (threatening) multiorgan failure.
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Affiliation(s)
- Timo C. E. Zondag
- grid.5645.2000000040459992XDepartment of Internal Medicine, Clinical Immunology Section, Erasmus University Medical Center, ‘s-Gravendijkwal 230, 3015 CE Rotterdam, The Netherlands
| | - Aglina Lika
- grid.5645.2000000040459992XDepartment of Biostatistics, Erasmus MC University Medical Center, Rotterdam, The Netherlands ,grid.5645.2000000040459992XDepartment of Pediatrics, Center for Lysosomal and Metabolic Diseases, Erasmus MC University Medical Center, Rotterdam, The Netherlands ,grid.5645.2000000040459992XDepartment of Epidemiology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Jan A. M. van Laar
- grid.5645.2000000040459992XDepartment of Internal Medicine, Clinical Immunology Section, Erasmus University Medical Center, ‘s-Gravendijkwal 230, 3015 CE Rotterdam, The Netherlands ,grid.5645.2000000040459992XDepartment of Immunology, Clinical Immunology Section, Erasmus University Medical Center, Rotterdam, The Netherlands
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148
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Xu T, Xiong L, Tang L. Epstein-Barr virus-associated haemophagocytic lymphohistiocytosis complicated by neurological involvement in a patient with dermatomyositis: A case report and literature review. Mod Rheumatol Case Rep 2023; 7:293-297. [PMID: 35861298 DOI: 10.1093/mrcr/rxac056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 05/29/2022] [Accepted: 06/20/2022] [Indexed: 01/07/2023]
Abstract
Haemophagocytic lymphohistiocytosis (HLH) is an extremely high mortality condition that can occur at any age and lacks specific diagnostic characteristics. Despite its rarity, HLH is increasingly alarming because of the high mortality rate. It is a systemic hyperinflammatory immune response syndrome associated with abnormal activation of T cells and macrophages, which may be caused by genetic mutations or acquired factors, such as infection, autoimmune condition, and malignancy. Here, we present a fatal case of Epstein-Barr virus-associated HLH complicated by neurological involvement in a patient with dermatomyositis. We describe and discuss the pathological features, classification, and effective treatment options of HLH and discuss separately the special characteristics of Epstein-Barr virus-associated HLH and dermatomyositis-associated HLH.
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Affiliation(s)
- Tingting Xu
- Department of Infectious Diseases, Wuhan Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Lijuan Xiong
- Department of Infectious Diseases, Wuhan Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Liang Tang
- Department of Hematology, Wuhan Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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149
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Muacevic A, Adler JR, Duro JF, Aguiar P, Jacinto Correia C. Hemophagocytic Lymphohistiocytosis Secondary to Chronic Lymphocytic Leukemia Progression. Cureus 2023; 15:e34128. [PMID: 36843678 PMCID: PMC9949745 DOI: 10.7759/cureus.34128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/24/2023] [Indexed: 01/26/2023] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is an acute, rare systemic hyperinflammatory disorder caused by a dysregulated immune cell function and massive cytokine release, often leading to multiple organ involvement and failure. Fever, hepatosplenomegaly, cytopenia, elevated liver enzymes, hypertriglyceridemia, and hyperferritinemia are the hallmarks of the disease. Its primary (genetic) form is typically observed in pediatric patients and its secondary, acquired form is seen in adult patients with an underlying autoimmune, malignant, or infectious disease. It is not frequently reported in patients with chronic lymphocytic leukemia (CLL) without an infectious or pharmacological trigger. We present a case of a 71-year-old patient with hemophagocytic lymphohistiocytosis due to the progression of chronic lymphocytic leukemia.
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150
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Alfattal R, Sadeq H, Ali A. Spontaneous resolution of hemophagocytic lymphohistiocytosis in a child infected with epstein–Barr virus. JOURNAL OF APPLIED HEMATOLOGY 2023. [DOI: 10.4103/joah.joah_109_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/19/2023] Open
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