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Abstract
Hemophagocytic lymphohistiocytosis (HLH) covers a wide array of related life-threatening conditions featuring ineffective immunity characterized by an uncontrolled hyperinflammatory response. HLH is often triggered by infection. Familial forms result from genetic defects in natural killer cells and cytotoxic T-cells, typically affecting perforin and intracellular vesicles. HLH is likely under-recognized, which contributes to its high morbidity and mortality. Early recognition is crucial for any reasonable attempt at curative therapy to be made. Current treatment regimens include immunosuppression, immune modulation, chemotherapy, and biological response modification, followed by hematopoietic stem-cell transplant (bone marrow transplant). A number of recent studies have contributed to the understanding of HLH pathophysiology, leading to alternate treatment options; however, much work remains to raise awareness and improve the high morbidity and mortality of these complex conditions.
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Affiliation(s)
- Melissa R George
- Department of Pathology, Penn State Milton S Hershey Medical Center, Hershey, PA, USA
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102
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The many faces of hemophagocytic lymphohistiocytosis — a challenge in diagnosis and therapy. Clin Biochem 2014; 47:726-7. [DOI: 10.1016/j.clinbiochem.2014.05.030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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103
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Schechter T, Naqvi A, Weitzman S. Risk for complications in patients with hemophagocytic lymphohistiocytosis who undergo hematopoietic stem cell transplantation: myeloablative versus reduced-intensity conditioning regimens. Expert Rev Clin Immunol 2014; 10:1101-6. [PMID: 24871821 DOI: 10.1586/1744666x.2014.920234] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Allogeneic hematopoietic stem cell transplantation (HSCT) is the only curative option for patients with primary hemophagocytic lymphohistiocytosis (HLH) and for patients with secondary HLH who fail to respond to therapy. Advances in HSCT and supportive care measures have resulted in improved patient outcomes and decreased treatment-related mortality. Despite the overall improvement in outcome, HLH patients who undergo HSCT using myeloablative conditioning regimens are still at significant risk for complications. The HLH-94 study conducted by the Histiocyte Society reported a 30% TRM with increased pulmonary and hepatic complications. Recently, the use of reduced-intensity conditioning (RIC) regimens has shown favorable outcomes when compared to conventional HSCT and lower rate of acute complications. In this review we compare the potential complications of myeloablative and RIC regimens for HSCT in HLH patients.
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Affiliation(s)
- Tal Schechter
- Division of Haematology/Oncology, The Hospital for Sick Children, University of Toronto, Toronto, Canada
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104
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Natu SA, Keskar US, Behera MK, Chate SC. Haemophagocytic lymphohistiocytosis with lung cavity and lytic bone lesion in a 45 day infant. J Clin Diagn Res 2014; 8:156-7. [PMID: 24783117 DOI: 10.7860/jcdr/2014/6521.4145] [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: 05/21/2013] [Accepted: 01/06/2014] [Indexed: 11/24/2022]
Abstract
Haemophagocytic lymphohistiocytosis (HLH) is a potentially fatal, hyper inflammatory condition which is caused by a highly stimulated but ineffective immune response. We are presenting here, a case of HLH which occurred in a 45 day infant. Presence of lung cavity and a lytic bone lesion in the skull, as was seen in this case, have not been reported in HLH in the literature. This raises a possibility of a simultaneous occurrence of HLH and Langerhans cell histiocytosis. In a child who presents with septicaemia but does not respond to treatment, the possibility of HLH needs to be considered.
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Affiliation(s)
- Sanjay A Natu
- Associate Professor, Department of Paediatrics, Smt Kashibai Navale Medical College , Pune, India
| | - Ujjwala S Keskar
- Associate Professor, Department of Paediatrics, Smt Kashibai Navale Medical College , Pune, India
| | - Manas K Behera
- Professor, Department of Paediatrics, Smt Kashibai Navale Medical College , Pune, India
| | - Sambhaji C Chate
- Assistant Professor, Department of Paediatrics, Smt Kashibai Navale Medical College , Pune, India
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105
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Parikh SA, Kapoor P, Letendre L, Kumar S, Wolanskyj AP. Prognostic factors and outcomes of adults with hemophagocytic lymphohistiocytosis. Mayo Clin Proc 2014; 89:484-92. [PMID: 24581757 DOI: 10.1016/j.mayocp.2013.12.012] [Citation(s) in RCA: 202] [Impact Index Per Article: 20.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2013] [Revised: 11/18/2013] [Accepted: 12/13/2013] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To describe the prognostic factors and outcomes of adults with hemophagocytic lymphohistiocytosis (HLH), a rare disorder caused by pathologic activation of the immune system. PATIENTS AND METHODS The study population consisted of a consecutive cohort of adult (age ≥18 years) patients treated at Mayo Clinic in Rochester, Minnesota, from January 1, 1996, through December 31, 2011, in whom a diagnosis of HLH was suspected and subsequently confirmed by retrospective review using the HLH-04 diagnostic criteria. RESULTS Of 250 adult patients suspected of having HLH, 62 met the HLH-04 diagnostic criteria and were included in the final analysis. The median age was 49 years (range, 18-87 years), and 42 (68%) were male. The underlying cause of HLH was malignant tumor in 32 patients (52%), infection in 21 patients (34%), autoimmune disorder in 5 patients (8%), and idiopathic disease in 4 patients (6%). After a median follow-up of 42 months, 41 patients (66%) had died. The median overall survival of the entire cohort was 2.1 months. The median overall survival of patients with tumor-associated HLH was 1.4 months compared with 22.8 months for patients with non-tumor-associated HLH (P=.01). The presence of a malignant tumor and hypoalbuminemia were significant predictors of inferior survival on multivariate analysis. CONCLUSION In this large series of adults with secondary HLH treated at a single tertiary care center, patients with low serum albumin levels and tumor-associated HLH had a markedly worse survival. Hemophagocytic lymphohistiocytosis remains elusive and challenging to clinicians who must maintain a high index of suspicion. The recent discovery of several novel diagnostic and therapeutic modalities may improve outcomes of adult patients with HLH.
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Affiliation(s)
| | | | | | - Shaji Kumar
- Division of Hematology, Mayo Clinic, Rochester, MN
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106
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Late Onset Combined Immunodeficiency Presenting with Recurrent Pneumocystis jiroveci Pneumonia. Case Rep Med 2014; 2014:801805. [PMID: 24799913 PMCID: PMC3988709 DOI: 10.1155/2014/801805] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2013] [Revised: 03/01/2014] [Accepted: 03/08/2014] [Indexed: 12/19/2022] Open
Abstract
Late onset combined immunodeficiency (LOCID) is a recently described variant of common variable immunodeficiency (CVID), involving adult patients presenting with opportunistic infections and/or low CD4+ lymphocyte counts. A 36-year-old male with unremarkable past medical history presented with fever, respiratory failure, and lymphocytopenia. He was found to have Pneumocystis jiroveci pneumonia (PJP), subsequently complicated by recurrent hospital-acquired Pseudomonas aeruginosa pneumonia and immune reconstitution phenomena, attributed to restoration of immunoglobulin levels. Clinicians should be aware of LOCID, which could be confused with HIV infection/AIDS or idiopathic CD4 lymphocytopenia. In the English bibliography there is only one case report, where PJP was the initial presentation of CVID (that case would probably be classified as LOCID). Phenomena of immune reconstitution are described in various settings, including primary immunodeficiency, manifesting as temporary clinical and radiologic deterioration and leading to misperceptions of therapeutic failure and/or presence of alternative/additional diagnoses.
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107
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Abstract
Familial hemophagocytic lymphohistiocytosis (HLH) is a rare, life-threatening condition characterized by immune hyperactivation and clinical signs of extreme inflammation. We describe a 7-year-old male who presented with fever resistant to antibiotic therapy, pancytopenia, splenomegaly, hypertriglyceridemia, and hyperferritinemia. Bone marrow aspirate showed hemophagocytosis. Epstein-Barr virus genome was positive in blood. Functional screening showed reduced capacity of cytotoxic degranulation. Mutation analysis of the FHL-related genes revealed compound heterozygous for UNC13D mutations: c. 753+1G>T, and the novel c.544C>T (p.P182S). Patients with a clinical presentation of HLH, even if older than typically seen, should be screened for familial HLH by mutation analysis.
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108
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Mishra K, Singla S, Sharma S, Saxena R, Batra VV. Griscelli syndrome type 2: a novel mutation in RAB27A gene with different clinical features in 2 siblings: a diagnostic conundrum. KOREAN JOURNAL OF PEDIATRICS 2014; 57:91-5. [PMID: 24678334 PMCID: PMC3965801 DOI: 10.3345/kjp.2014.57.2.91] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/19/2012] [Revised: 03/11/2013] [Accepted: 05/28/2013] [Indexed: 11/27/2022]
Abstract
Griscelli syndrome type 2 (GS2) is a rare autosomal recessive disease caused by mutations in the RAB27A gene. It is characterized by cutaneous hypopigmentation, immunodeficiency, and hemophagocytic lymphohistiocytosis. We describe 2 brothers who had GS2 with clinically diverse manifestations. The elder brother presented with a purely neurological picture, whereas the younger one presented with fever, pancytopenia, hepatosplenomegaly, and erythema nodosum. Considering that cutaneous hypopigmentation was a common feature between the brothers, genetic analysis for Griscelli syndrome was performed. As the elder sibling had died, mutation analysis was only performed on the younger sibling, which revealed a novel homozygous mutation in the RAB27A gene on chromosome 15 showing a single-base substitution (c.136T>A p.F46I). Both parents were heterozygous for the same mutation. This confirmed the diagnosis of GS2 in the accelerated phase in both siblings. The atypical features of GS2 in these cases are a novel mutation, isolated neurological involvement in one sibling, association with erythema nodosum, and 2 distinct clinical presentations in siblings with the same genetic mutation.
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Affiliation(s)
- Kirtisudha Mishra
- Department of Pediatrics, Kalawati Saran Children's Hospital, Lady Hardinge Medical College, New Delhi, India
| | - Shilpy Singla
- Department of Pediatrics, Kalawati Saran Children's Hospital, Lady Hardinge Medical College, New Delhi, India
| | - Suvasini Sharma
- Department of Pediatrics, Kalawati Saran Children's Hospital, Lady Hardinge Medical College, New Delhi, India
| | - Renu Saxena
- Department of Molecular Genetics, Sir Ganga Ram Hospital, New Delhi, India
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109
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Unal S, Tezol O, Oztas Y. A novel mutation of the transcobalamin II gene in an infant presenting with hemophagocytic lymphohistiocytosis. Int J Hematol 2014; 99:659-62. [PMID: 24563082 DOI: 10.1007/s12185-014-1545-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2013] [Revised: 02/03/2014] [Accepted: 02/12/2014] [Indexed: 11/25/2022]
Abstract
Transcobalamin II (TC II) deficiency is a rare disorder of cobalamin (CBL, vitamin B12) metabolism that occurs due to mutations in transcobalamin gene (TCN2). Hemophagocytic lymphohistiocytosis (HLH) in contrast is a syndrome characterized by uncontrolled immune response with hyperinflammation. A 2-month-old male baby was admitted with complaints of fever, cough, diarrhea, and respiratory distress. The parents were first cousins. The baby exhibited five of the eight diagnostic criteria for HLH-2004 and was diagnosed as HLH. A second bone marrow aspiration demonstrated megaloblastic changes in the erythroid series. The patient's vitamin B12 level was normal; however, hyperhomocysteinemia was present. A genetic deficiency of TC II was suspected. The patient and his parents were tested for TCN2 mutation. He had a homozygote mutation that was not included in Human 'Gene Mutation Database Cardiff'. The patient was treated with intramuscular vitamin B12, which was followed by improvement in both clinical and laboratory findings. He was 12 months old at the time of this report, with normal physical and neuromotor development. In this case presenting with the clinical and laboratory findings of HLH, TC II deficiency was diagnosed. A new mutation was found that was not reported before. Potential causative mechanisms of HLH induced by defects of cobalamin synthesis merit further investigation.
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Affiliation(s)
- Selma Unal
- Hematology Unit, Department of Pediatrics, Faculty of Medicine, Mersin University, Mersin, Turkey,
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110
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Mayson E, Saverimuttu J, Warburton P. Two-faced haemophagocytic lymphohistiocytosis: comparative review of two cases of adult haemophagocytic lymphohistiocytosis. Intern Med J 2014; 44:198-201. [DOI: 10.1111/imj.12347] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2013] [Accepted: 11/09/2013] [Indexed: 11/28/2022]
Affiliation(s)
- E. Mayson
- Haematology Department; Wollongong Hospital; Wollongong New South Wales Australia
| | - J. Saverimuttu
- Haematology Department; Wollongong Hospital; Wollongong New South Wales Australia
| | - P. Warburton
- Haematology Department; Wollongong Hospital; Wollongong New South Wales Australia
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111
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El-Haj N, Gonsalves WI, Gupta V, Smeltzer JP, Parikh SA, Singh PP, Gangat N. Secondary Hemophagocytic Syndrome Associated with Richter's Transformation in Chronic Lymphocytic Leukemia. Case Rep Hematol 2014; 2014:287479. [PMID: 24551464 PMCID: PMC3914353 DOI: 10.1155/2014/287479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2013] [Accepted: 12/11/2013] [Indexed: 11/18/2022] Open
Abstract
Hemophagocytic syndrome (HPS) is an extremely rare condition arising from the overactivation of one's own immune system. It results in excessive inflammation and tissue destruction. Prompt initiation of treatment is warranted in either scenario in order to decrease mortality. Most cases are triggered by infectious agents, malignancy, or drugs. We describe the first case of a CLL patient presenting with HPS due to acquisition of EBV-related large cell lymphoma in the setting of profound immunodeficiency.
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Affiliation(s)
| | - Wilson I. Gonsalves
- Department of Hematology, Mayo Clinic Rochester, 200 1st Street SW, Rochester, MN 55905, USA
| | - Vinay Gupta
- Department of Hematology, Mayo Clinic Rochester, 200 1st Street SW, Rochester, MN 55905, USA
| | - Jacob P. Smeltzer
- Department of Hematology, Mayo Clinic Rochester, 200 1st Street SW, Rochester, MN 55905, USA
| | - Sameer A. Parikh
- Department of Hematology, Mayo Clinic Rochester, 200 1st Street SW, Rochester, MN 55905, USA
| | - Preet P. Singh
- Department of Hematology, Mayo Clinic Rochester, 200 1st Street SW, Rochester, MN 55905, USA
| | - Naseema Gangat
- Department of Hematology, Mayo Clinic Rochester, 200 1st Street SW, Rochester, MN 55905, USA
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112
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Tothova Z, Berliner N. Hemophagocytic Syndrome and Critical Illness: New Insights into Diagnosis and Management. J Intensive Care Med 2014; 30:401-12. [PMID: 24407034 DOI: 10.1177/0885066613517076] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2013] [Accepted: 10/31/2013] [Indexed: 02/06/2023]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) comprises a heterogeneous group of diseases that are characterized by a hyperinflammatory state due to uncontrolled T cell, macrophage, and histiocyte activation, accompanied by excessive cytokine production. This rare condition is almost uniformly fatal unless promptly recognized and treated. Much progress has been made in the last two decades in our understanding of the mechanisms underlying familial, and to a lesser extent, acquired cases of HLH. Recurrent mutations in more than 10 different genes have now been identified, involving biological pathways converging on intracellular vesicle trafficking and cytolytic granule exocytosis. Mechanisms underlying the majority of patients with acquired HLH, however, remain elusive, hampering both diagnostic evaluation and therapeutic management of these patients. Given that the majority of intensive care unit (ICU) patients with sepsis or multiorgan failure share many features of HLH, it is especially critical for pediatric and adult intensivists to be able to recognize patients with bona fide HLH and initiate treatment without delay. In this article, we review our current understanding of the pathophysiology, clinical testing, diagnosis, and treatment of patients with HLH, especially as it pertains to the care of critically ill patients in pediatric and medical ICUs.
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Affiliation(s)
- Zuzana Tothova
- Division of Hematology, Brigham and Women's Hospital, Boston, MA, USA Department of Medical Oncology, Dana Farber Cancer Institute, Boston, MA, USA
| | - Nancy Berliner
- Division of Hematology, Brigham and Women's Hospital, Boston, MA, USA Department of Medical Oncology, Dana Farber Cancer Institute, Boston, MA, USA
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113
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Hibino M, Sato S, Shimizu T, Yamamoto S, Ohe M, Kondo T. Hemophagocytic lymphohistiocytosis secondary to Mycoplasma pneumoniae infection without pneumonia. Intern Med 2014; 53:1679-83. [PMID: 25088886 DOI: 10.2169/internalmedicine.53.2089] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Mycoplasma pneumoniae typically causes respiratory tract infections, including pneumonia. We herein report the case of a 30-year-old Japanese woman with hemophagocytic lymphohistiocytosis (HLH), which is rarely caused by bacteria, secondary to Mycoplasma pneumoniae infection and ensuing hypercytokinemia without pneumonia who was successfully treated with a combination of antibiotics and corticosteroids. Therefore, Mycoplasma pneumoniae infection, which is treatable with antibiotics, should be considered a possible trigger of HLH in patients who present with a viral-like illness without pneumonia.
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Affiliation(s)
- Makoto Hibino
- Department of Respiratory Medicine, Shonan Fujisawa Tokushukai Hospital, Japan
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114
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Secondary Hemophagocytic Syndrome: The Importance of Clinical Suspicion. Case Rep Hematol 2014; 2014:958425. [PMID: 24963424 PMCID: PMC4052119 DOI: 10.1155/2014/958425] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2014] [Revised: 04/22/2014] [Accepted: 05/06/2014] [Indexed: 11/17/2022] Open
Abstract
Hemophagocytic syndrome is a rare and potentially fatal disorder characterized by pathological immune activation associated with a primary familial disorder, genetic mutations, or occurring as a sporadic condition. The latter can be secondary to infections, malignancies, or autoimmune diseases. Clinically, patients present signs of severe inflammation, with unremitting fever, cytopenias, spleen enlargement, phagocytosis of bone marrow elements, hypertriglyceridemia, and hypofibrinogenemia. Increased suspicion is determinant to timely initiate treatment in an attempt to alter the natural history. The authors present three clinical cases of this syndrome, with a brief review of the diagnostic criteria and treatment.
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115
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Deveci K, Oflaz MB, Sancakdar E, Uysal EB, Guven AS, Kaya A, Alkan F, Cevit O. Evaluation of the serum levels of soluble IL-2 receptor and endothelin-1 in children with Crimean-Congo hemorrhagic fever. APMIS 2013; 122:643-7. [PMID: 24320760 DOI: 10.1111/apm.12209] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2013] [Accepted: 09/23/2013] [Indexed: 11/30/2022]
Abstract
We aimed to assess the association between serum levels of soluble IL-2 receptor (sIL-2r) and endothelin-1 and severe infection in children with Crimean-Congo hemorrhagic fever (CCHF). Fifty-two patients under 18 years of age with a laboratory- confirmed diagnosis of CCHF and 38 healthy controls were enrolled in the study. Patients were classified into two groups based on disease severity (severe group and non-severe group). The sIL-2r and endothelin-1 levels were observed to be significantly higher in patients with severe CCHF compared with those with non-severe CCHF and the control group (p < 0.05). In addition, those with non-severe CCHF were also found to have a significantly higher sIL-2r level relative to the control group (p < 0.001). Although there was a positive correlation between sIL-2r and endothelin-1 levels, serum levels of both sIL-2r and endothelin-1 were negatively correlated with the platelets count. In children with CCHF, serum levels of sIL-2r and endothelin-1 were increased, and this increase is related to the severity of the disease. In this study, we concluded through prognosis that serum levels of sIL-2r and endothelin-1 might be related, and that hemophagocytic lymphohistiocytosis and endothelial injury might contribute to a pathogenesis of the disease.
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Affiliation(s)
- Koksal Deveci
- Department of Clinical Biochemistry, Faculty of Medicine, Cumhuriyet University, Sivas, Turkey
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116
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Ce qu’il faut savoir sur le syndrome d’activation macrophagique en soins intensifs. ACTA ACUST UNITED AC 2013. [DOI: 10.1007/s13546-013-0816-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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117
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118
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Pinto-Patarroyo GP, Rytting ME, Vierling JM, Suarez-Almazor ME. Haemophagocytic lymphohistiocytosis presenting as liver failure following Epstein-Barr and prior hepatitis A infections. BMJ Case Rep 2013; 2013:bcr-2013-008979. [PMID: 23943807 DOI: 10.1136/bcr-2013-008979] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
Haemophagocytic lymphohistiocytosis (HLH) is associated with high mortality even after prompt diagnosis. We present a young man with HLH triggered by two common viral diseases, infectious mononucleosis and hepatitis A. This patient presented with fever, rapidly progressive liver failure, anasarca and cholestasis, followed by anaemia and neutropenia. His carbohydrate antigen 19-9 reached over 9000 U/mL. Initial bone marrow and liver biopsies did not show histological features of malignancy or HLH. The patient was finally diagnosed and treated almost 1 year after the initial symptoms started, and had an excellent response with etoposide and dexamethasone. This case is unusual because it was triggered following mononucleosis in a patient with positive total antibodies against hepatitis A, with rapidly developing liver failure, and also because the patient's response was excellent despite the delay in treatment. It underscores the importance of suspecting HLH when severe systemic illness develops after a viral infection, even in the absence of clear histological features.
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119
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120
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Bhasin A, Tolan RW. Hemophagocytic lymphohistiocytosis--a diagnostic dilemma: two cases and review. Clin Pediatr (Phila) 2013; 52:297-301. [PMID: 23172902 DOI: 10.1177/0009922812465945] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a severe inflammatory disorder characterized by activation and proliferation of lymphocytes and histiocytes with cytokine release and uncontrolled hemophagocytosis, especially late in the course of the disease. Clinical features include relapsing fevers, hepatosplenomegaly, cytopenias, lymphadenopathy, and coagulopathy. The diagnosis can be challenging, as the early signs and symptoms are nonspecific and no specific laboratory tests exist. This syndrome is frequently not recognized and has a significant mortality rate. Typical scenarios in which HLH should be considered include mononucleosis (fever, hepatosplenomegaly, and lymphadenopathy) in an infant or young child, aseptic meningitis associated with cytopenias, or a viral syndrome-like illness with cytopenias and lymphadenopathy or splenomegaly, for example. Our approach includes measuring a ferritin level as a screening tool early in the course of such an illness. Two cases of HLH are reviewed, illustrating the frequent complexity of these cases and potential pitfalls to making a prompt diagnosis.
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Affiliation(s)
- Aarti Bhasin
- Saint Peter's University Hospital, New Brunswick, NJ, USA
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121
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Atim-Oluk M. Cytomegalovirus associated haemophagocytic lymphohistiocytosis in the immunocompetent adult managed according to HLH-2004 diagnostic using clinical and serological means only. Eur J Microbiol Immunol (Bp) 2013; 3:81-9. [PMID: 24265923 DOI: 10.1556/eujmi.3.2013.1.12] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2012] [Accepted: 10/04/2012] [Indexed: 01/29/2023] Open
Abstract
Haemophagocytic lymphohistiocytosis (HLH) describes a rare, poorly recognised and under-diagnosed immunopathological syndrome whereby there is a highly stimulated yet ineffective multisystem inflammatory response [1]. I present the first case in English literature of Cytomegalovirus (CMV) associated HLH diagnosed by clinical and serological means, and the fourth case of CMV associated haemophagocytic lymphohistiocytosis in an immunocompetent adult, according to HLH-2004 diagnostic guidelines. I include a literature review of CMV associated HLH in adults and raise awareness of checking serum ferritin in patients who present with a sepsis like syndrome. Additionally, this article discusses the merits of HLH-2004 diagnostic work-up without bone marrow biopsy, using clinical and serological means only. I support the reclassification of HLH alongside the other hyperinflammatory syndromes of SIRS, sepsis, septic shock, and MODS to improve understanding and recognition.
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Affiliation(s)
- M Atim-Oluk
- Hull and East Yorkshire National Health Service Trust, Castle Hill Hospital Castle Road, Cottingham, East Yorkshire, HU16 5JQ United Kingdom
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122
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Les histiocytoses : comment classer ces affections hétérogènes à fort tropisme cutané ? Ann Dermatol Venereol 2013; 140:79-82. [DOI: 10.1016/j.annder.2012.12.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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123
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A case of hemophagocytic lymphohistiocytosis in a patient with chronic lymphocytic leukemia after treatment with fludarabine, cyclophosphamide, and rituximab chemotherapy, with autopsy findings. Case Rep Hematol 2012; 2012:326053. [PMID: 23533846 PMCID: PMC3600305 DOI: 10.1155/2012/326053] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2012] [Accepted: 12/05/2012] [Indexed: 01/04/2023] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is rarely described in association with chronic lymphocytic leukemia (CLL), mostly triggered by disease progression or concurrent infection. A 68-year-old male received 4 cycles of fludarabine, cyclophosphamide, and rituximab (FCR) for CLL and achieved a complete response. Twenty-four days after the last chemotherapy, he presented with febrile neutropaenia and was diagnosed with HLH. The diagnosis was based upon persistent fever, pancytopenia, hyperferritinemia, splenomegaly, and hemophagocytosis on bone marrow aspirate. He began treatment with dexamethasone, cyclosporine, and etoposide. Fever resolved and hyperferritinemia improved but pancytopenia persisted. He died 13 days later from septic shock with positive blood cultures. A limited postmortem examination was performed and biopsies were taken from bone marrow, liver, and spleen. Biopsies demonstrated abundant hemophagocytosis by the activated macrophage as stained by CD68. There was no evidence of residual CLL as demonstrated by the lack of lymphocytes which was confirmed by the negative staining of CD79a. Chemotherapy appears to be responsible for the development of HLH in this patient. This is the second reported case of HLH developing after a rituximab-containing chemotherapy.
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124
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Clinical analysis and prognostic significance of lymphoma-associated hemophagocytosis in peripheral T cell lymphoma. Ann Hematol 2012; 92:481-6. [PMID: 23238896 PMCID: PMC3590418 DOI: 10.1007/s00277-012-1644-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2012] [Accepted: 11/25/2012] [Indexed: 11/04/2022]
Abstract
This study aims to retrospectively analyze the clinical characteristics, treatments, and prognosis of aggressive peripheral T cell lymphoma (PTCL) patients with a lymphoma-associated hemophagocytosis syndrome (LAHS). We compared the clinical features and the overall survival (OS) rates of 159 PTCL patients with and without LAHS as well as the treatment outcomes of these patients with CHOP (cyclophosphamide, doxorubicin, vincristine, and prednisone) or intensive chemotherapy regimens. We observed that in 23 % (36/159) patients PTCL was associated with LAHS. Different subtypes of PTCL in LAHS patients were diagnosed and peripheral T cell lymphoma, not otherwise specified (PTCL-NOS) was the main subtype (78 %). The median survival rates of the LAHS and non-LAHS groups were 3 and 16 months, respectively. The elevated rates of serum β2-microglobulin, ferritin, fasting triglycerides, and hypofibrinogen levels were higher in the LAHS group, so were bone marrow involvement, liver dysfunction, hepatosplenomegaly, and B symptoms. Three patients who were treated with a plasma exchange had a longer survival time. There was no statistically significant difference in the OS rates between the intensive chemotherapy and CHOP regimen groups (P > 0.05). PTCL patients with LAHS had a poorer prognosis. Awareness of the clinical symptoms and laboratory findings are crucial in order to diagnose LAHS in an early stage and repeated biopsies of multiple bone marrows from different locations in those patients without enlargement of superficial lymph nodes are necessary to improve the diagnosis. Intensive chemotherapy due to its severe toxicity was not obviously advantageous for the OS rate compared to the CHOP regimen.
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Kuppe C, Westphal S, Bücher E, Moeller MJ, Heintz B, Schneider ME, Floege J. Macrophage activation syndrome in a patient with pulmonary inflammatory myofibroblastic tumour. ALLERGY, ASTHMA, AND CLINICAL IMMUNOLOGY : OFFICIAL JOURNAL OF THE CANADIAN SOCIETY OF ALLERGY AND CLINICAL IMMUNOLOGY 2012; 8:6. [PMID: 22607519 PMCID: PMC3473307 DOI: 10.1186/1710-1492-8-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/05/2012] [Accepted: 05/07/2012] [Indexed: 11/10/2022]
Abstract
We describe for the first time a case of macrophage activation syndrome (MAS) in a patient with a history of inflammatory myofibroblastic tumour (inflammatory pseudotumour, IPT) of the lung and thoracic spine. The patient was admitted to the intensive care unit with a history of prolonged remitting fever, hepatosplenomegaly, bilaterally enlarged thoracic lymph nodes and an acute severe inflammatory response syndrome (SIRS). Up-regulated cytokine production (e.g. IL-1ß and IL-6), increased levels of ferritin and circulating soluble interleukin-2 receptor (sIL-2R, sCD25) led to the differential diagnosis of MAS. Bone marrow aspiration, the main tool for a definite diagnosis, revealed macrophages phagocytosing haematopoietic cells. Immunosuppressive therapy with corticosteroids and cyclosporine was an effective treatment in this patient.
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Affiliation(s)
- Christoph Kuppe
- Department of Nephrology and Clinical Immunology, University Hospital of the Aachen University of Technology (RWTH), Aachen, Germany
| | - Saskia Westphal
- Department of Pathology, University Hospital of the Aachen University of Technology (RWTH), Aachen, Germany
| | - Eva Bücher
- Department of Nephrology and Clinical Immunology, University Hospital of the Aachen University of Technology (RWTH), Aachen, Germany
| | - Marcus J Moeller
- Department of Nephrology and Clinical Immunology, University Hospital of the Aachen University of Technology (RWTH), Aachen, Germany
| | - Bernhard Heintz
- Department of Nephrology and Clinical Immunology, University Hospital of the Aachen University of Technology (RWTH), Aachen, Germany
| | - Marion E Schneider
- Department of Experimental Anesthesiology, University Hospital, Ulm, Germany
| | - Jürgen Floege
- Department of Nephrology and Clinical Immunology, University Hospital of the Aachen University of Technology (RWTH), Aachen, Germany
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