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18F-FDG PET/CT for Identifying the Potential Primary Diseases and Predicting Prognosis of Secondary Hemophagocytic Lymphohistiocytosis in Children. CONTRAST MEDIA & MOLECULAR IMAGING 2022; 2022:4849081. [PMID: 35510179 PMCID: PMC9034951 DOI: 10.1155/2022/4849081] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Accepted: 03/26/2022] [Indexed: 11/18/2022]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a rare, potentially fatal illness, which can be divided into primary HLH (pHLH) and secondary HLH (sHLH). pHLH can be driven by genetic defections. Moreover, the sHLH is usually be triggered by malignancy or non-malignancy diseases. Sixty-two newly diagnosed sHLH patients with known etiology and those who underwent 18F-FDG PET/CT examination from July 2018 to December 2020 were retrospectively analyzed. They were divided into malignancy-associated HLH (M-HLH, n = 13) and non-malignancy-associated HLH (NM-HLH, n = 49). The metabolic parameters of the liver (Li), spleen (Sp), bone marrow (BM), lymph nodes (LN), and their ratios to the liver background (LiBG) and mediastinum (M) were compared between two groups. These metabolic parameters were evaluated for correlation with laboratory parameters and prognostic parameters. We found that the SUVmax-LN/Sp/Li and SUVmean-Sp in M-HLH were significantly higher than those in NM-HLH (P=0.031, 0.035, 0.016, and 0.032). The malignant disease should be considered when SUVmax-LN was higher than 4.41 (sensitivity 61.5%, specificity 81.6%). Hypermetabolic lesions in extranodal organs were more likely to occur in M-HLH than in NM-HLH (P=0.011). IFN- γ was positively correlated with SUVmax-BM/Li/Sp and SUVmean-BM/Li/Sp (P < 0.05). Ferritin, sCD25, IL-6, and IL-10 were positively correlated with SUVmax-Sp and SUVmean-Sp (P < 0.05). In Epstein-Barr virus-associated HLH (EBV-HLH), the SUV parameters of bone marrow were significantly correlated with a poor 2-week treatment response, overall survival, and event-free survival (P < 0.05). We conclude that some 18F-FDG PET/CT metabolic parameters can help identify the etiology of sHLH in children and provide directions for further inspection. The malignant disease should be considered when the SUVmax-LN is higher than 4.41 and hypermetabolic lesions occur in extranodal organs. In EBV-HLH, a higher SUV of bone marrow is associated with a poorer prognosis.
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Expansion of CD4dimCD8+T cells characterizes macrophage activation syndrome and other secondary HLH. Blood 2022; 140:262-273. [PMID: 35500103 DOI: 10.1182/blood.2021013549] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Accepted: 04/14/2022] [Indexed: 11/20/2022] Open
Abstract
CD8+ T-cell activation has been demonstrated to distinguish patients with primary and infection-associated hemophagocytic lymphohistiocytosis (pHLH and iaHLH) from patients with early sepsis. We evaluated the activation profile of CD8+ T cells in patients with various forms of secondary HLH (sHLH), including macrophage activation syndrome (MAS). Flow-cytometry analysis was performed on peripheral blood mononuclear cells isolated from children with inactive systemic juvenile idiopathic arthritis (sJIA, n=17), active sJIA (n=27), MAS in sJIA (n=14), iaHLH (n=7) and with other forms of sHLH (n=9). Compared to patients with active sJIA, in patients with MAS and sHLH of different origins, beside a significant increase in the frequency of CD38high/HLA-DR+CD8+ T cells, we found a significant increase in the frequency of CD8+ T cells expressing the CD4 antigen (CD4dimCD8+ T cells). These cells not only expressed high levels of the activation markers CD38 and HLA-DR, suggesting that they were a subset of CD38high/HLA-DR+ CD8+ T cells, but also of the activation/exhaustion markers CD25, PD1, CD95, and IFNγ. The frequency of CD4dimCD8+ T cells strongly correlated with most of the laboratory parameters of MAS severity and with levels of the MAS biomarkers CXCL9 and IL-18. These findings were confirmed in a prospective replication cohort, in which no expansion of particular TCR Vβ family in CD3+ T cells of sHLH patients was found. Finally, frequency of CD4dimCD8+, but not of CD38high/HLA-DR+ CD8+ T cells, significantly correlated with a clinical severity score. Altogether, our data, showing that CD4dimCD8+T cells are increased in patients with MAS/sHLH and associated with disease severity, strongly support their involvement in MAS/sHLH pathogenesis.
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Kumar D, Rostad CA, Jaggi P, Villacis Nunez DS, Prince C, Lu A, Hussaini L, Nguyen TH, Malik S, Ponder LA, Shenoy SPV, Anderson EJ, Briones M, Sanz I, Prahalad S, Chandrakasan S. Distinguishing immune activation and inflammatory signatures of multisystem inflammatory syndrome in children (MIS-C) versus hemophagocytic lymphohistiocytosis (HLH). J Allergy Clin Immunol 2022; 149:1592-1606.e16. [PMID: 35304157 PMCID: PMC8923010 DOI: 10.1016/j.jaci.2022.02.028] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Revised: 02/18/2022] [Accepted: 02/23/2022] [Indexed: 11/17/2022]
Abstract
BACKGROUND Multisystem inflammatory syndrome in children (MIS-C) is a potentially life-threatening sequela of severe acute respiratory syndrome coronavirus 2 infection characterized by hyperinflammation and multiorgan dysfunction. Although hyperinflammation is a prominent manifestation of MIS-C, there is limited understanding of how the inflammatory state of MIS-C differs from that of well-characterized hyperinflammatory syndromes such as hemophagocytic lymphohistiocytosis (HLH). OBJECTIVES We sought to compare the qualitative and quantitative inflammatory profile differences between patients with MIS-C, coronavirus disease 2019, and HLH. METHODS Clinical data abstraction from patient charts, T-cell immunophenotyping, and multiplex cytokine and chemokine profiling were performed for patients with MIS-C, patients with coronavirus disease 2019, and patients with HLH. RESULTS We found that both patients with MIS-C and patients with HLH showed robust T-cell activation, markers of senescence, and exhaustion along with elevated TH1 and proinflammatory cytokines such as IFN-γ, C-X-C motif chemokine ligand 9, and C-X-C motif chemokine ligand 10. In comparison, the amplitude of T-cell activation and the levels of cytokines/chemokines were higher in patients with HLH when compared with patients with MIS-C. Distinguishing inflammatory features of MIS-C included elevation in TH2 inflammatory cytokines such as IL-4 and IL-13 and cytokine mediators of angiogenesis, vascular injury, and tissue repair such as vascular endothelial growth factor A and platelet-derived growth factor. Immune activation and hypercytokinemia in MIS-C resolved at follow-up. In addition, when these immune parameters were correlated with clinical parameters, CD8+ T-cell activation correlated with cardiac dysfunction parameters such as B-type natriuretic peptide and troponin and inversely correlated with platelet count. CONCLUSIONS Overall, this study characterizes unique and overlapping immunologic features that help to define the hyperinflammation associated with MIS-C versus HLH.
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Affiliation(s)
- Deepak Kumar
- Aflac Cancer and Blood Disorders Center, Department of Pediatrics, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Ga
| | - Christina A Rostad
- Center for Childhood Infections and Vaccines, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Ga
| | - Preeti Jaggi
- Center for Childhood Infections and Vaccines, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Ga
| | - D Sofia Villacis Nunez
- Division of Pediatric Rheumatology, Department of Pediatrics, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Ga
| | - Chengyu Prince
- Aflac Cancer and Blood Disorders Center, Department of Pediatrics, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Ga
| | - Austin Lu
- Center for Childhood Infections and Vaccines, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Ga
| | - Laila Hussaini
- Center for Childhood Infections and Vaccines, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Ga
| | - Thinh H Nguyen
- Aflac Cancer and Blood Disorders Center, Department of Pediatrics, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Ga
| | - Sakshi Malik
- Emory Vaccine Center, Emory University School of Medicine, Atlanta, Ga; Department of Microbiology and Immunology, Emory University School of Medicine, Atlanta, Ga
| | | | - Sreekala P V Shenoy
- Division of Pediatric Rheumatology, Department of Pediatrics, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Ga
| | - Evan J Anderson
- Center for Childhood Infections and Vaccines, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Ga; Department of Medicine, Emory University School of Medicine, Atlanta, Ga
| | - Michael Briones
- Aflac Cancer and Blood Disorders Center, Department of Pediatrics, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Ga
| | - Ignacio Sanz
- Division of Rheumatology, Department of Medicine, Emory University School of Medicine, Atlanta, Ga; Lowance Center for Human Immunology, Emory University, Atlanta, Ga
| | - Sampath Prahalad
- Division of Pediatric Rheumatology, Department of Pediatrics, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Ga; Department of Human Genetics, Emory University School of Medicine, Atlanta, Ga
| | - Shanmuganathan Chandrakasan
- Aflac Cancer and Blood Disorders Center, Department of Pediatrics, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Ga.
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Zu C, Wang K, Zhang Q, Hu Y, Huang H. Clinical features of hemophagocytic syndrome following BCMA CAR-T cell therapy in patients with relapsed/refractory multiple myeloma. Zhejiang Da Xue Xue Bao Yi Xue Ban 2022; 51:160-166. [PMID: 36161295 PMCID: PMC9353626 DOI: 10.3724/zdxbyxb-2022-0039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 03/20/2022] [Indexed: 06/16/2023]
Abstract
OBJECTIVE To analyze the clinical features of hemophagocytic syndrome (HLH) following B cell maturation antigen (BCMA) chimeric antigen receptor (CAR) T cell therapy in patients with relapsed/refractory multiple myeloma. METHODS Ninety-nine patients with relapsed/refractory multiple myeloma (including 3 cases of plasma cell leukemia) undergoing BCMA CAR-T cell therapy (monocentric phaseⅠclinical trial, ChiCTR1800017404) in the First Affiliated Hospital, Zhejiang University School of Medicine from July 2018 to December 2021 were enrolled in the study. The baseline features, laboratory findings, treatment, and clinical response of these patients were analyzed. RESULTS CAR-T cell associated HLH (carHLH) occurred in 20 patients (20.20%), and the median onset time was 7(0-19) d after cytokine release syndrome (CRS). Patients with carHLH were maily male patients, and manifested as high percentage of abnormal plasma cells, higher incidence of severe CRS (grade 3-4), and robust expansion of CAR-T cells in the peripheral blood (all P<0.05). The levels of interleukin (IL)-6, IL-10 and interferon (IFN)-γ, the peak value of international normalized ratio and D-dimer were elevated, and the valley value of fibrinogen was decreased in patients with carHLH (all P<0.01). All carHLH patients resolved with proper intervention (including 7 cases with tocilizumab, 5 with steroids, 6 with both). The objective response rate in carHLH patients was slightly higher than that in non-carHLH patients [100.0% (17/17) vs. 94.87% (74/78), P>0.05]. CONCLUSIONS The incidence of carHLH is relatively high in BCMA CAR-T cell treated patients, which is closely related to pretreatment tumor cell percentage in bone marrow, expansion of CAR-T cells and the secretion of cytokines. Medication based on tocilizumab and steroids can achieve considerable therapeutic effects in patient with carHLH.
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Affiliation(s)
- Cheng Zu
- 1. Bone Marrow Transplantation Center, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
- 2. Liangzhu Laboratory, Zhejiang University Medical Center, Hangzhou 311121, China
- 3. Institute of Hematology, Zhejiang University, Hangzhou 310058, China
- 4. Zhejiang Provincial Laboratory for Stem Cell and Immunity Therapy, Hangzhou 310058, China
| | - Kexin Wang
- 1. Bone Marrow Transplantation Center, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
- 2. Liangzhu Laboratory, Zhejiang University Medical Center, Hangzhou 311121, China
- 3. Institute of Hematology, Zhejiang University, Hangzhou 310058, China
- 4. Zhejiang Provincial Laboratory for Stem Cell and Immunity Therapy, Hangzhou 310058, China
| | - Qiqi Zhang
- 1. Bone Marrow Transplantation Center, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
- 2. Liangzhu Laboratory, Zhejiang University Medical Center, Hangzhou 311121, China
- 3. Institute of Hematology, Zhejiang University, Hangzhou 310058, China
- 4. Zhejiang Provincial Laboratory for Stem Cell and Immunity Therapy, Hangzhou 310058, China
| | - Yongxian Hu
- 1. Bone Marrow Transplantation Center, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
- 2. Liangzhu Laboratory, Zhejiang University Medical Center, Hangzhou 311121, China
- 3. Institute of Hematology, Zhejiang University, Hangzhou 310058, China
- 4. Zhejiang Provincial Laboratory for Stem Cell and Immunity Therapy, Hangzhou 310058, China
| | - He Huang
- 1. Bone Marrow Transplantation Center, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
- 2. Liangzhu Laboratory, Zhejiang University Medical Center, Hangzhou 311121, China
- 3. Institute of Hematology, Zhejiang University, Hangzhou 310058, China
- 4. Zhejiang Provincial Laboratory for Stem Cell and Immunity Therapy, Hangzhou 310058, China
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155
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Constantinescu C, Petrushev B, Rus I, Stefanescu H, Frasinariu O, Margarit S, Dima D, Tomuleasa C. Mechanistic Insights in Hemophagocytic Lymphohistiocytosis: Subsequent Acute Hepatic Failure in a Multiple Myeloma Patient following Therapy with Ixazomib-Lenalidomide-Dexamethasone. J Pers Med 2022; 12:jpm12050678. [PMID: 35629101 PMCID: PMC9145580 DOI: 10.3390/jpm12050678] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Revised: 04/08/2022] [Accepted: 04/21/2022] [Indexed: 12/16/2022] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a rare, elusive, and life-threatening condition that is characterized by the pathologic and uncontrolled secondary activation of the cytotoxic T-cells, natural killer cells (NK-cells), and macrophages of the innate immune system. This condition can develop in sporadic or familial contexts associated with hematological malignancies, as a paraneoplastic syndrome, or linked to an infection related to immune system deficiency. This leads to the systemic inflammation responsible for the overall clinical manifestations. Diagnosis should be thorough, and treatment should be initiated as soon as possible. In the current manuscript, we focus on classifying the HLH spectrum, describing the pathophysiology and the tools needed to search for and correctly identify HLH, and the current therapeutic opportunities. We also present the first case of a multiple myeloma patient that developed HLH following therapy with the ixazomib-lenalidomide-dexamethasone protocol.
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Affiliation(s)
- Catalin Constantinescu
- Department of Hematology, Iuliu Hatieganu University of Medicine and Pharmacy, 400349 Cluj-Napoca, Romania;
- Department of Anesthesia and Intensive Care, Iuliu Hatieganu University of Medicine and Pharmacy, 400349 Cluj-Napoca, Romania;
- Intensive Care Unit, Emergency Hospital, 400006 Cluj-Napoca, Romania
- Medfuture Research Center for Advanced Medicine, Iuliu Hatieganu University of Medicine and Pharmacy, 400337 Cluj-Napoca, Romania;
| | - Bobe Petrushev
- Medfuture Research Center for Advanced Medicine, Iuliu Hatieganu University of Medicine and Pharmacy, 400337 Cluj-Napoca, Romania;
- Department of Pathology, Octavian Fodor Regional Institute of Gastroenterology and Hepatology, 400158 Cluj-Napoca, Romania;
| | - Ioana Rus
- Department of Pathology, Octavian Fodor Regional Institute of Gastroenterology and Hepatology, 400158 Cluj-Napoca, Romania;
- Department of Hematology, Ion Chiricuta Clinical Cancer Center, 400015 Cluj-Napoca, Romania;
| | - Horia Stefanescu
- Department of Gastroenterology, Octavian Fodor Regional Institute of Gastroenterology and Hepatology, 400158 Cluj-Napoca, Romania;
- Department of Gastroenterology, Iuliu Hatieganu University of Medicine and Pharmacy, 400349 Cluj-Napoca, Romania
| | - Otilia Frasinariu
- Faculty of Medicine, Grigore T. Popa University of Medicine and Pharmacy, 700115 Iasi, Romania;
| | - Simona Margarit
- Department of Anesthesia and Intensive Care, Iuliu Hatieganu University of Medicine and Pharmacy, 400349 Cluj-Napoca, Romania;
- Intensive Care Unit, Octavian Fodor Regional Institute of Gastroenterology and Hepatology, 400349 Cluj-Napoca, Romania
| | - Delia Dima
- Department of Hematology, Ion Chiricuta Clinical Cancer Center, 400015 Cluj-Napoca, Romania;
| | - Ciprian Tomuleasa
- Department of Hematology, Iuliu Hatieganu University of Medicine and Pharmacy, 400349 Cluj-Napoca, Romania;
- Medfuture Research Center for Advanced Medicine, Iuliu Hatieganu University of Medicine and Pharmacy, 400337 Cluj-Napoca, Romania;
- Department of Hematology, Ion Chiricuta Clinical Cancer Center, 400015 Cluj-Napoca, Romania;
- Correspondence:
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Mc Dermott S, Dargan C, Gonzalez Dominguez E, Music Aplenc L, Flatt T, Iqbal N. Therapeutic plasma exchange for multiorgan dysfunction among critically ill pediatric patients with leukemia: A single-institutional experience. J Clin Apher 2022; 37:367-375. [PMID: 35405029 DOI: 10.1002/jca.21983] [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: 03/21/2022] [Accepted: 03/22/2022] [Indexed: 11/06/2022]
Abstract
INTRODUCTION Therapeutic plasma exchange (TPE) has well-documented applications in the adult population, outlined by the American Society for Apheresis (ASFA) 2019 guidelines. Limited data exist regarding the use of TPE in critically ill pediatric patients; however, these reports rarely include patients with oncological diseases. METHODS We highlight the use of TPE in the acute management of seven pediatric patients with leukemia treated at Children's Mercy Hospital ICU from 2015 to 2020, including TPE specifications, baseline and interval laboratory evaluation, and outcome measures. Analysis compared those who did (n = 4) and did not (n = 3) survive 30 days post-TPE. RESULTS Multiorgan failure (MOF) prompted the initiation of TPE in 85.7% of patients, 57.1% of whom were also diagnosed with hemophagocytic lymphohistiocytosis (HLH). Baseline laboratory evaluations prior to initiation of TPE were similar between the two groups. With subsequent TPE treatments, C-reactive protein (CRP) and lactic acid decreased. CRP and lactic acid following the last TPE treatment were significantly higher for those deceased 30 days post-TPE (P = .023 and .031, respectively). No TPE-associated adverse events necessitated discontinuation of TPE treatment. Several surviving patients required chemotherapy dose reductions or alterations. CONCLUSION Our cohort demonstrated MOF and HLH consistently as indications for TPE, currently ASFA category III indications (optimal role of apheresis is not yet established). Recognition of this treatment modality earlier in the clinical course for critically ill oncological patients may lead to the development of formal protocols that may result in earlier initiation of TPE and improved outcomes.
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Affiliation(s)
- Sarah Mc Dermott
- Department of Pediatric Hematology/Oncology/BMT, Children's Mercy Hospital, Kansas City, Missouri, USA
| | - Chandni Dargan
- Department of Pediatric Hematology/Oncology/BMT, Children's Mercy Hospital, Kansas City, Missouri, USA
| | | | - Lejla Music Aplenc
- Department of Pathology and Laboratory Medicine, Children's Mercy Hospital, Kansas City, Missouri, USA
| | - Terrie Flatt
- Department of Pediatric Hematology/Oncology/BMT, Children's Mercy Hospital, Kansas City, Missouri, USA
| | - Nazia Iqbal
- Department of Pediatric Hematology/Oncology/BMT, Children's Mercy Hospital, Kansas City, Missouri, USA
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Zheng M, Bao Y, Wang J, Ma Y, Yang Y, Zhang P, Chen L, Zheng K, Zhou J. The superiority of Epstein-Barr virus DNA in plasma over in peripheral blood mononuclear cells for monitoring EBV-positive NK-cell lymphoproliferative diseases. Hematol Oncol 2022; 40:381-389. [PMID: 35405763 DOI: 10.1002/hon.2998] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 02/25/2022] [Accepted: 03/28/2022] [Indexed: 11/12/2022]
Abstract
Epstein-Barr virus (EBV), characterized as an omnipresent virus, has been found able to infect NK cells and leads to NK-cell type EBV-positive lymphoproliferative diseases (EBV-NK-LPDs). We retrospective analysed 202 EBV-NK-LPDs (including 64 CAEBV-NK, 27 ANKL, and 111 ENKTL) patients' relationships between EBV DNA copies laboratory test results and clinical features. In CAEBV-NK cohort, EBV DNA loads in either plasma or PBMCs had significant differences between the active state and the inactive state. Receiver operating characteristic (ROC) curves were used to measure the diagnosis accuracy of EBV DNA copies. After comparing the area under the curve (AUC), EBV DNA loads in plasma had significantly higher accuracy in distinguishing disease activation than in PBMCs. Therefore, we propose redefining CAEBV-NK diagnosis criteria as increased EBV DNA copies in plasma (over 7.1×102 copies/ml) instead of in peripheral blood. In ANKL and ENKTL cohorts, patients who received effective therapy had significantly lower EBV DNA copies in plasma & PBMCs than in those with ineffective therapy. The significant and consistent decline indicated EBV DNA loads in plasma being a more sensitive biomarker in monitoring EBV-NK-LPDs therapy responses. Hemophagocytic lymphohistiocytosis (HLH) can occur secondary to EBV-NK-LPDs, mostly associated with a poor prognosis, so we try to estimate the combination of HLH by monitoring EBV DNA copies. When comparing the ROC curves of EBV DNA copies, EBV DNA loads in plasma had higher diagnosis accuracy. When the copies level over 4.16×103 copies/ml, it might indicate combining with HLH. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Miao Zheng
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yuhan Bao
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jiachen Wang
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yaxian Ma
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yang Yang
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Peiling Zhang
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Liting Chen
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Kai Zheng
- Department of Geriatrics, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jianfeng Zhou
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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Gnanasambandam J, Geminiganesan S, Vilvanathan V, Sankaranarayanan S, Padmanabhan R. Secondary Hemophagocytic Lymphohistiocytosis - A Common Ramification of Different Diseases. EJIFCC 2022; 33:63-69. [PMID: 35645690 PMCID: PMC9092716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Hemophagocytic lymphohistiocytosis is a rare and potentially fatal disorder caused by immune dysregulation. It can occur as a primary genetic disease or secondarily due to various causes including infections, malignancies or autoimmune diseases. In this case report, we present two cases of Hemophagocytic lymphohistiocytosis which were secondary to typhoid and dengue fever. While primary disease occurs predominantly in infants, secondary hemophagocytic lymphohistiocytosis can occur in any age group. Both primary and secondary hemophagocytic lymphohistiocytosis are characterised by fever, hepatosplenomegaly, pancytopenia and multiorgan dysfunction. But unusual persistence of fever and other organ involvement should need further workup for hemophagocytic lymphohistiocytosis. Secondary hemophagocytic lymphohistiocytosis may resolve on treating the underlying disorder. But severe cases need treatment with immunosuppressive/immunomodulation therapy to prevent morbidity. Early clinical suspicion, prompt diagnosis and treatment of hemophagocytic lymphohistiocytosis are essential to prevent deleterious effects to health.
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Affiliation(s)
| | - Sangeetha Geminiganesan
- Corresponding author: Sangeetha Geminiganesan Department of Paediatric Medicine Sri Ramachandra Institute of Higher Education and Research Chennai India E-mail:
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Wang D, Chen XH, Wei A, Zhou CJ, Zhang X, Ma HH, Lian HY, Zhang L, Zhang Q, Huang XT, Wang CJ, Yang Y, Liu W, Wang TY, Li ZG, Cui L, Zhang R. Clinical features and treatment outcomes of pediatric Langerhans cell histiocytosis with macrophage activation syndrome-hemophagocytic lymphohistiocytosis. Orphanet J Rare Dis 2022; 17:151. [PMID: 35379272 PMCID: PMC8981711 DOI: 10.1186/s13023-022-02276-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Accepted: 02/27/2022] [Indexed: 12/02/2022] Open
Abstract
Background Langerhans cell histiocytosis (LCH) is a rare myeloid neoplasm. A few LCH patients had Macrophage activation syndrome-hemophagocytic lymphohistiocytosis (MAS-HLH), a life-threatening, hyper-inflammatory syndrome. We retrospectively described the clinical-biological characteristics of a series of 28 pediatric LCH patients with MAS-HLH in a single center. We further analyzed the difference in treatment outcomes between second-line chemotherapy (cytarabine and cladribine) and targeted therapy (dabrafenib) for BRAF-V600E-positive patients. Results LCH patients with MAS-HLH were aged < 2 years, harbored high frequencies of risk organ, skin, or lymph nodes involvement, and most of them carried BRAF-V600E mutation in lesions (88.0%) or plasma (90.5%). Patients were firstly treated with the initial induction first-line therapy (vindesine-steroid combination), and most of them (26/28) failed to control the active MAS-HLH after one six-week course of induction treatment. Then they were shifted to second-line chemotherapy or targeted therapy dabrafenib. BRAF-V600E-mutant patients treated with dabrafenib had prompt resolution of MAS-HLH signs and symptoms with less toxicity than second-line chemotherapy. Moreover, the progression-free survival (PFS) rate for patients given dabrafenib was much higher than those treated with chemotherapy (4 year-PFS: 75% vs. 14.6%, P = 0.034). Conclusions LCH patients with MAS-HLH harbored specific clinical-biology characteristics compared to the multisystem LCH without MAS-HLH. The BRAF inhibitor dabrafenib provides a promising treatment option for LCH with MAS-HLH. Supplementary Information The online version contains supplementary material available at 10.1186/s13023-022-02276-y.
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Bogaert D, De Bruyne R, Vanlander AV, Garabedian L, Louis Y, Haerynck F, Bordon V, De Moerloose B. Familial hemophagocytic lymphohistiocytosis type 3 presenting as neonatal cholestasis and splenomegaly. Pediatr Allergy Immunol 2022; 33:e13774. [PMID: 35470934 DOI: 10.1111/pai.13774] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Revised: 03/29/2022] [Accepted: 04/01/2022] [Indexed: 11/29/2022]
Affiliation(s)
- Delfien Bogaert
- Division of Pediatric Hemato-Oncology and Stem Cell Transplantation, Department of Pediatrics, Ghent University Hospital, Ghent, Belgium.,Primary Immunodeficiency Research Lab, Center for Primary Immunodeficiency Ghent, Jeffrey Modell Diagnosis and Research Center, Ghent University Hospital, Ghent, Belgium
| | - Ruth De Bruyne
- Division of Gastroenterology and Hepatology, Department of Pediatrics, Ghent University Hospital, Ghent, Belgium
| | - Arnaud V Vanlander
- Division of Pediatric Neurology and Metabolism, Department of Pediatrics, Ghent University Hospital, Ghent, Belgium
| | - Lara Garabedian
- Neonatal Intensive Care Unit, Ghent University Hospital, Ghent, Belgium
| | - Yves Louis
- Department of Pediatrics, General Hospital Glorieux, Ronse, Belgium
| | - Filomeen Haerynck
- Primary Immunodeficiency Research Lab, Center for Primary Immunodeficiency Ghent, Jeffrey Modell Diagnosis and Research Center, Ghent University Hospital, Ghent, Belgium.,Division of Pediatric Pulmonology, Immunology and Infectious Diseases, Department of Pediatrics, Ghent University Hospital, Ghent, Belgium
| | - Victoria Bordon
- Division of Pediatric Hemato-Oncology and Stem Cell Transplantation, Department of Pediatrics, Ghent University Hospital, Ghent, Belgium
| | - Barbara De Moerloose
- Division of Pediatric Hemato-Oncology and Stem Cell Transplantation, Department of Pediatrics, Ghent University Hospital, Ghent, Belgium
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A study of Ruxolitinib-response-based stratified treatment for pediatric hemophagocytic lymphohistiocytosis. Blood 2022; 139:3493-3504. [PMID: 35344583 DOI: 10.1182/blood.2021014860] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 03/15/2022] [Indexed: 11/20/2022] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a lethal disorder characterized by hyperinflammation. Recently, ruxolitinib, targeting key cytokines in HLH, has shown promise for HLH treatment. However, there is a lack of robust clinical trials evaluating its efficacy, especially its utility as a front-line therapy. In this study (www.chictr.org.cn, ChiCTR2000031702), we designed ruxolitinib as a first-line agent for pediatric HLH and stratified the treatment based on its early response. Fifty-two newly diagnosed patients were enrolled. The overall response rate (ORR) of ruxolitinib monotherapy (day-28) was 69.2% (36/52), with 42.3% (22/52) achieving sustained complete remission (CR). All responders achieved their first response to ruxolitinib within 3-days. The response to ruxolitinib was significantly associated with the underlying etiology at enrollment (p=0.009). EBV-HLH patients were most sensitive to ruxolitinib, with an ORR of 87.5% (58.3% in CR). After ruxolitinib therapy, 57.7% (30/52) of the patients entered intensive therapy with additional chemotherapy. Among them, 53.3% (16/30) patients achieved CR, and 46.7% (14/30) patients dominated by chronic active Epstein Barr virus infection-associated HLH (CAEBV-HLH) developed refractory HLH by week-8. The median interval to additional treatment since first ruxolitinib administration was 6-days (range, 3-25). Altogether, 73.1% (38/52) of the enrolled patients achieved CR after treatment overall. The 12-month overall survival for all patients was 86.4% (95%CI, 77.1%-95.7%). Ruxolitinib had low toxicity and was well tolerated compared to intensive chemotherapy. Our study provides clinical evidence for ruxolitinib as a front-line agent for pediatric HLH. The efficacy was particularly exemplified with stratified regiment based on the early differential response to ruxolitinib. This study was registered in the Chinese Clinical Trials Registry Platform (http://www.chictr.org.cn/) as ChiCTR2000031702.
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Huang L, Wu W, Zhu Y, Yu H, Tang L, Fang X. Case Report: Hemophagocytic Lymphocytosis in a Patient With Glutaric Aciduria Type IIC. Front Immunol 2022; 12:810677. [PMID: 35095902 PMCID: PMC8792439 DOI: 10.3389/fimmu.2021.810677] [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: 11/07/2021] [Accepted: 12/24/2021] [Indexed: 12/04/2022] Open
Abstract
Hemophagocytic lymphocytosis (HLH) is a rare disease caused by inborn errors of immunity (IEI), secondary to infection, lymphoma or autoimmune disorders, but we often overlook the fact that HLH can be secondary to inborn errors of metabolism (IEM). Here, we describe a patient who was diagnosed with glutaric aciduria type IIC complicated by features suggestive of possible HLH. The diagnosis of glutaric aciduria type IIC, a IEM, was confirmed by whole exome sequencing. The patient was treated with coenzyme Q10 and riboflavin which effectively improved her liver function. During treatment, the patient developed severe anemia and thrombocytopenia. Persistent fever, splenomegaly, cytopenias, increased ferritin, hypertriglyceridemia, hypofibrinogenemia, and hemophagocytosis in the bone marrow pointed to the diagnosis of HLH; however, the patient eventually died of gastrointestinal bleeding. After other potential causes were ruled out, the patient was diagnosed with glutaric aciduria type IIC complicated by features suggestive of possible HLH. When cytopenias occurs in IEM patients, HLH is a possible complication that cannot be ignored. This case suggests a possible relationship between IEM and risk for immune dysregulation.
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Affiliation(s)
- Lingtong Huang
- Department of Critical Care Units, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Wei Wu
- Department of Infectious Diseases, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yijing Zhu
- Department of Hematology, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Huili Yu
- Department of Critical Care Units, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Lingling Tang
- Department of Infectious Diseases, Shulan (Hangzhou) Hospital, Zhejiang Shuren University of Shulan International Medical College, Hangzhou, China
| | - Xueling Fang
- Department of Critical Care Units, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
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Hemophagocytic Lymphohistiocytosis Secondary to Juvenile Myelomonocytic Leukemia: A Case Report and Review of the Literature. J Pediatr Hematol Oncol 2022; 44:e580-e584. [PMID: 34862352 DOI: 10.1097/mph.0000000000002273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2021] [Accepted: 05/25/2021] [Indexed: 11/26/2022]
Abstract
RATIONALE Juvenile myelomonocytic leukemia (JMML) is a rare hematopoietic disorder, which is more rarely accompanied by monosomy 5 or deletion of the long arm of chromosome 5q (-5/5q-) or monosomy 5 (5q-/-5), and hemophagocytic lymphohistiocytosis (HLH) is a rare, uncontrolled hyperinflammation condition, which is more rarely secondary to JMML. Up to now, only a few cases of JMML with -5/5q- and HLH secondary to JMML were described. Here we described an extremely rare case of HLH second to JMML with 5q-. PATIENT CONCERNS The patient had multiple cafe-au-lait-spots at birth and was found that NF1 gene mutation was positive. At his 6 years old, he developed hepatosplenomegaly, anemia, thrombocytopenia, monocyte count 4.12×109/L in peripheral blood, 13% blasts in peripheral blood, and 11% blasts in bone marrow, without BCR/ABL rearrangement, combining with positive NF1 gene mutation, he was diagnosed as JMML. In the bone marrow, there was chromosomal abnormalities with -5/5q-. In the treatment, HLH occurred. DIAGNOSES The patient was diagnosed as secondary HLH to JMML. INTERVENTIONS The patient received the chemotherapy treatment of the improved diffuse alveolar hemorrhage protocol, and meanwhile, he prepared for hematopoietic stem cell transplantation. Then on the basis of anti-infection, symptomatic and supportive therapy, he was commenced the treatment according to the HLH-2004 protocol. OUTCOMES He had a partial response, manifesting that his fever resolved, but the blood coagulation function did not improve, and the severe thrombocytopenia remained. Then, the parents refused the continual treatment, and the child died of intracranial hemorrhage 3 months after the diagnosis of JMML. LESSONS JMML and HLH were relatively easy to diagnose based on clinical and laboratory results. Due to the low incidence of JMML with -5/5q- and HLH secondary to JMML, no clinical practice guidelines for the treatment of the disease have been established yet. The clinical data of a case of HLH secondary to JMML with 5q- were analyzed, and relevant studies were studied.
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Liao M, Yu J. Secondary Leukemia in a Patient With EBV-HLH Carrying Heterozygous STXBP2 Variant. J Pediatr Hematol Oncol 2022; 44:e526-e528. [PMID: 33661178 DOI: 10.1097/mph.0000000000002141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2020] [Accepted: 02/09/2021] [Indexed: 11/25/2022]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a symptom with severe systemic hyperinflammation. A 26-month-old male presented with Epstein-Barr virus associated HLH with a heterozygous variant of syntaxin-binding protein-2 (STXBP2). Complete remission was achieved with the HLH-2004 protocol, but the disease soon relapsed. Four weeks after re-installing HLH-2004 protocol, HLH was resolved. The cumulative dosage of etoposide was 2100 mg/m2. He developed acute promyelocytic leukemia 17 months later. The patient underwent standard chemotherapy and since remained in complete remission. In conclusion, a regular screening of malignance might be in necessity for the patients harboring gene variants associated with familial HLH.
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Affiliation(s)
- Meiling Liao
- Department of Hematology and Oncology, Chongqing Medical University Affiliated Children's Hospital, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China
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Marsh RA, Hebert K, Kim S, Dvorak CC, Aquino VM, Baker KS, Chellapandian D, Saldaña BD, Duncan CN, Eckrich MJ, Georges GE, Olson TS, Pulsipher MA, Shenoy S, Stenger E, Lugt MV, Yu LC, Gennery AR, Eapen M. Comparison of hematopoietic cell transplant conditioning regimens for hemophagocytic lymphohistiocytosis disorders. J Allergy Clin Immunol 2022; 149:1097-1104.e2. [PMID: 34375618 PMCID: PMC8821728 DOI: 10.1016/j.jaci.2021.07.031] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 07/29/2021] [Accepted: 07/30/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Allogeneic hematopoietic cell transplantation for hemophagocytic lymphohistiocytosis (HLH) disorders is associated with substantial morbidity and mortality. OBJECTIVE The effect of conditioning regimen groups of varying intensity on outcomes after transplantation was examined to identify an optimal regimen or regimens for HLH disorders. METHODS We studied 261 patients with HLH disorders transplanted between 2005 and 2018. Risk factors for transplantation outcomes by conditioning regimen groups were studied by Cox regression models. RESULTS Four regimen groups were studied: (1) fludarabine (Flu) and melphalan (Mel) in 123 subjects; (2) Flu, Mel, and thiotepa (TT) in 28 subjects; (3) Flu and busulfan (Bu) in 14 subjects; and (4) Bu and cyclophosphamide (Cy) in 96 subjects. The day 100 incidence of veno-occlusive disease was lower with Flu/Mel (4%) and Flu/Mel/TT (0%) compared to Flu/Bu (14%) and Bu/Cy (22%) (P < .001). The 6-month incidence of viral infections was highest after Flu/Mel (72%) and Flu/Mel/TT (64%) compared to Flu/Bu (39%) and Bu/Cy (38%) (P < .001). Five-year event-free survival (alive and engrafted without additional cell product administration) was lower with Flu/Mel (44%) compared to Flu/Mel/TT (70%), Flu/Bu (79%), and Bu/Cy (61%) (P = .002). The corresponding 5-year overall survival values were 68%, 75%, 86%, and 64%, and did not differ by conditioning regimen (P = .19). Low event-free survival with Flu/Mel is attributed to high graft failure (42%) compared to Flu/Mel/TT (15%), Flu/Bu (7%), and Bu/Cy (18%) (P < .001). CONCLUSIONS Given the high rate of graft failure with Flu/Mel and the high rate of veno-occlusive disease with Bu/Cy and Flu/Bu, Flu/Mel/TT may be preferred for HLH disorders. Prospective studies are warranted.
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Affiliation(s)
- Rebecca A. Marsh
- University of Cincinnati, and Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Kyle Hebert
- Center for International Blood and Marrow Transplant Research, Division of Hematology/Oncology, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Soyoung Kim
- Center for International Blood and Marrow Transplant Research, Division of Hematology/Oncology, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Christopher C. Dvorak
- Division of Pediatric Allergy, Immunology, and Bone Marrow Transplantation, University of California San Francisco, Benioff Children’s Hospital, San Francisco, CA
| | | | | | - Deepak Chellapandian
- Center for Cell and Gene Therapy for Non-Malignant Conditions, Johns Hopkins All Children’s Hospital, St Petersburg, FL
| | | | | | - Michael J. Eckrich
- Sarah Cannon Pediatric Transplant and Cellular Therapy Program, Methodist Children’s Hospital, San Antonio, TX
| | | | - Timothy S. Olson
- Department of Pediatrics, Division of Oncology, Children’s Hospital of Philadelphia, Philadelphia, PA
| | | | - Shalini Shenoy
- Department of Pediatrics, Washington University School of Medicine, Saint Louis, MO
| | | | | | | | | | - Mary Eapen
- Center for International Blood and Marrow Transplant Research, Division of Hematology/Oncology, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
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Xu XJ, Luo ZB, Song H, Xu WQ, Henter JI, Zhao N, Wu MH, Tang YM. Simple Evaluation of Clinical Situation and Subtypes of Pediatric Hemophagocytic Lymphohistiocytosis by Cytokine Patterns. Front Immunol 2022; 13:850443. [PMID: 35296096 PMCID: PMC8918565 DOI: 10.3389/fimmu.2022.850443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Accepted: 02/04/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundHemophagocytic lymphohistiocytosis (HLH) is a rapidly fatal disease caused by immune dysregulation. Early initiation of treatment is imperative for saving lives. However, a laboratory approach that could be used to quickly evaluate the HLH subtype and clinical situation is lacking. Our previous studies indicated that cytokines such as interferon (IFN)-γ and interleukin (IL)-10 were helpful for the early diagnosis of HLH and were associated with disease severity. The purpose of this study is to clarify the different cytokine patterns of various subtypes of pediatric HLH and to investigate the role of cytokines in a simple evaluation of disease feature.Patients and MethodsWe enrolled 256 pediatric patients with newly diagnosed HLH. The clinical features and laboratory findings were collected and compared among different subtypes of HLH. A model integrating cytokines was established to stratify HLH patients into different clinical groups.ResultsTwenty-seven patients were diagnosed with primary HLH (pHLH), 179 with EBV-HLH, and 50 with other causes. The IL-6, IL-10, and IFN-γ levels and the ratios of IL-10 to IFN-γ were different among EBV-HLH, other infection-associated HLH, malignancy-associated HLH, familial HLH, and X-linked lymphoproliferative disease. Patients with the ratio of IL-10 to IFN-γ >1.33 and the concentration of IFN-γ ≤225 pg/ml were considered to have pHLH, with a sensitivity of 73% and a specificity of 84%. A four-quadrant model based on the two cutoff values was established to stratify the patients into different clinical situations. The HLH subtypes, cytokine levels, treatment regimens, treatment response, and outcomes were different among the four quadrants, with the 8-week mortality from 2.9 ± 2.9% to 21.4 ± 5.5% and the 5-year overall survival from 93.9 ± 4.2% to 52.6 ± 7.1%.ConclusionsDifferent subtypes of HLH present distinct cytokine patterns. IFN-γ and the ratio of IL-10 to IFN-γ are helpful tools to differentiate HLH subtypes. A four-quadrant model based on these two parameters is a useful tool for a simple evaluation of the HLH situation.
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Affiliation(s)
- Xiao-Jun Xu
- Division/Center of Pediatric Hematology-Oncology, the Children’s Hospital of Zhejiang University School of Medicine, Hangzhou, China
- The Pediatric Leukemia Diagnostic and Therapeutic Technology Research Center of Zhejiang Province, National Clinical Research Center for Child Health, Hangzhou, China
| | - Ze-Bin Luo
- Division/Center of Pediatric Hematology-Oncology, the Children’s Hospital of Zhejiang University School of Medicine, Hangzhou, China
- The Pediatric Leukemia Diagnostic and Therapeutic Technology Research Center of Zhejiang Province, National Clinical Research Center for Child Health, Hangzhou, China
| | - Hua Song
- Division/Center of Pediatric Hematology-Oncology, the Children’s Hospital of Zhejiang University School of Medicine, Hangzhou, China
- The Pediatric Leukemia Diagnostic and Therapeutic Technology Research Center of Zhejiang Province, National Clinical Research Center for Child Health, Hangzhou, China
| | - Wei-Qun Xu
- Division/Center of Pediatric Hematology-Oncology, the Children’s Hospital of Zhejiang University School of Medicine, Hangzhou, China
- The Pediatric Leukemia Diagnostic and Therapeutic Technology Research Center of Zhejiang Province, National Clinical Research Center for Child Health, Hangzhou, China
| | - Jan-Inge Henter
- Childhood Cancer Research Unit, Department of Women’s and Children’s Health, Karolinska Institute, Stockholm, Sweden
- Pediatric Oncology, Theme of Children’s Health, Karolinska University Hospital, Stockholm, Sweden
| | - Ning Zhao
- Division/Center of Pediatric Hematology-Oncology, the Children’s Hospital of Zhejiang University School of Medicine, Hangzhou, China
- The Pediatric Leukemia Diagnostic and Therapeutic Technology Research Center of Zhejiang Province, National Clinical Research Center for Child Health, Hangzhou, China
| | - Meng-Hui Wu
- Division/Center of Pediatric Hematology-Oncology, the Children’s Hospital of Zhejiang University School of Medicine, Hangzhou, China
- The Pediatric Leukemia Diagnostic and Therapeutic Technology Research Center of Zhejiang Province, National Clinical Research Center for Child Health, Hangzhou, China
| | - Yong-Min Tang
- Division/Center of Pediatric Hematology-Oncology, the Children’s Hospital of Zhejiang University School of Medicine, Hangzhou, China
- The Pediatric Leukemia Diagnostic and Therapeutic Technology Research Center of Zhejiang Province, National Clinical Research Center for Child Health, Hangzhou, China
- *Correspondence: Yong-Min Tang,
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Omachi T, Atsumi N, Yamazoe T, Yamanouchi S, Matsuno R, Kitawaki T, Kaneko K. Differential Diagnosis of Histiocytic Necrotizing Lymphadenitis and Malignant Lymphoma with Simple Clinical Findings. CHILDREN 2022; 9:children9020290. [PMID: 35205010 PMCID: PMC8870061 DOI: 10.3390/children9020290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/25/2021] [Revised: 02/17/2022] [Accepted: 02/18/2022] [Indexed: 11/16/2022]
Abstract
It is desirable that noninvasive differential diagnosis takes place without lymph node biopsy for histiocytic necrotizing lymphadenitis (HNL) or malignant lymphoma (ML). In this study, we propose a novel scoring model for the differential diagnosis of these diseases using clinical information and clinical findings. We retrospectively analyzed the data from 15 HNL and 13 ML pediatric patients. First, a univariate analysis identified 14 clinical factors with significant differences. Second, a subsequent analysis using receiver operating characteristic (ROC) curve analysis identified three factors among them with area under the ROC curve values of >0.95: body temperature (°C), maximum lymph node size (cm), and serum β2-microglobulin level (mg/L). Finally, the cut-off values of each of these three factors were determined and examined for the 28 cases. All 15 HNL cases were within 2–3 of the cut-off values among the three factors, no ML case was within two or more cut-off values. Thus, the diagnostic sensitivity and specificity of this novel scoring system were both 100%, indicating that clinical scoring with body temperature, maximum lymph node size, and β2-microglobulin are useful for distinguishing between HNL and ML.
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Affiliation(s)
- Taichi Omachi
- Department of Pediatrics, Kansai Medical University, 2-5-1 Shin-machi, Hirakata, Osaka 573-1010, Japan; (T.O.); (T.Y.); (S.Y.); (R.M.)
| | - Naho Atsumi
- Department of Pathology, Kansai Medical University, 2-5-1 Shin-machi, Hirakata, Osaka 573-1010, Japan;
| | - Takashi Yamazoe
- Department of Pediatrics, Kansai Medical University, 2-5-1 Shin-machi, Hirakata, Osaka 573-1010, Japan; (T.O.); (T.Y.); (S.Y.); (R.M.)
| | - Sohsaku Yamanouchi
- Department of Pediatrics, Kansai Medical University, 2-5-1 Shin-machi, Hirakata, Osaka 573-1010, Japan; (T.O.); (T.Y.); (S.Y.); (R.M.)
| | - Ryosuke Matsuno
- Department of Pediatrics, Kansai Medical University, 2-5-1 Shin-machi, Hirakata, Osaka 573-1010, Japan; (T.O.); (T.Y.); (S.Y.); (R.M.)
| | - Tomoki Kitawaki
- Department of Mathematics, Kansai Medical University, 2-5-1 Shin-machi, Hirakata, Osaka 573-1010, Japan;
| | - Kazunari Kaneko
- Department of Pediatrics, Kansai Medical University, 2-5-1 Shin-machi, Hirakata, Osaka 573-1010, Japan; (T.O.); (T.Y.); (S.Y.); (R.M.)
- Correspondence: ; Tel.: +81-72-804-0101; Fax: +81-72-804-2569
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Harel M, Fauteux-Daniel S, Girard-Guyonvarc'h C, Gabay C. Balance between Interleukin-18 and Interleukin-18 binding protein in auto-inflammatory diseases. Cytokine 2022; 150:155781. [DOI: 10.1016/j.cyto.2021.155781] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Accepted: 12/03/2021] [Indexed: 02/07/2023]
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Lu X, Wei A, Yang X, Liu J, Li S, Kan Y, Wang W, Wang T, Zhang R, Yang J. The Role of Pre-therapeutic 18F-FDG PET/CT in Pediatric Hemophagocytic Lymphohistiocytosis With Epstein-Barr Virus Infection. Front Med (Lausanne) 2022; 8:836438. [PMID: 35127776 PMCID: PMC8813965 DOI: 10.3389/fmed.2021.836438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 12/30/2021] [Indexed: 11/13/2022] Open
Abstract
Objective To evaluate the role of pre-therapeutic 18F-FDG PET/CT in pediatric hemophagocytic lymphohistiocytosis (HLH) with Epstein-Barr virus (EBV) infection. Methods This retrospective study included 29 HLH children (1–16 years) with EBV infection, who underwent pre-therapeutic 18F-FDG PET/CT from July 2018 to November 2020. Pathology results were considered as the reference standard. These patients were divided into two groups: EBV-induced malignancy-associated HLH (M-HLH, N = 9) and EBV-induced non-malignancy-associated HLH (NM-HLH, N = 20). The regions of interest (ROIs) of the liver, spleen (Sp), bone marrow (BM), lymph nodes (LN), hypermetabolic lesions, liver background (LiBG), and mediastinum (M) were drawn with software 3D-Slicer. The volumetric and metabolic parameters, including maximum standard uptake value (SUVmax), metabolic tumor volume, and total lesion glycolysis of these ROIs, clinical parameters, and laboratory parameters were compared between the two groups. The efficiency of the above parameters in predicting the treatment response and overall survival (OS) was analyzed. Results Receiver operating characteristic curve analysis indicated that SUVmax-lesions and SUVmax-LN/M (AUC = 0.822, 0.819, cut-off = 6.04, 5.74, respectively) performed better in differentiating M-HLH from NM-HLH. It had the best diagnostic performance when age was added with the SUVmax-LN/M (AUC = 0.933, sensitivity = 100%, specificity = 85.0%). The presence of extranodal hypermetabolic lesions in multiple organs indicated the M-HLH (P = 0.022). Older age, higher SUVmax-LN and SUVmax-lesions, and the presence of serous effusion were associated with poorer treatment response at the 2nd and 4th week (not reaching partial remission). Multivariate analysis showed that SUVmax-lesions > 7.66 and SUVmax-Sp/LiBG > 2.01 were independent prognostic factors for overall survival (P = 0.025, 0.036, respectively). Conclusions 18F-FDG PET/CT could be a valuable technique for identifying the underlying malignancy and predicting prognosis in pediatric HLH with EBV infection. M-HLH could be considered when SUVmax-lesions > 6.04, SUVmax-LN/M > 5.74, and the presence of extranodal hypermetabolic lesions in multiple organs on 18F-FDG PET/CT. SUVmax-lesions and SUVmax-Sp/LiBG might be independent prognostic factors for OS.
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Affiliation(s)
- Xia Lu
- Nuclear Medicine Department, Beijing Friendship Hospital Affiliated to Capital Medical University, Beijing, China
| | - Ang Wei
- National Center for Children's Health, Hematology Center, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Xu Yang
- Nuclear Medicine Department, Beijing Friendship Hospital Affiliated to Capital Medical University, Beijing, China
| | - Jun Liu
- Nuclear Medicine Department, Beijing Friendship Hospital Affiliated to Capital Medical University, Beijing, China
| | - Siqi Li
- Nuclear Medicine Department, Beijing Friendship Hospital Affiliated to Capital Medical University, Beijing, China
| | - Ying Kan
- Nuclear Medicine Department, Beijing Friendship Hospital Affiliated to Capital Medical University, Beijing, China
| | - Wei Wang
- Nuclear Medicine Department, Beijing Friendship Hospital Affiliated to Capital Medical University, Beijing, China
| | - Tianyou Wang
- National Center for Children's Health, Hematology Center, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Rui Zhang
- National Center for Children's Health, Hematology Center, Beijing Children's Hospital, Capital Medical University, Beijing, China
- Rui Zhang
| | - Jigang Yang
- Nuclear Medicine Department, Beijing Friendship Hospital Affiliated to Capital Medical University, Beijing, China
- *Correspondence: Jigang Yang
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Familial Hemophagocytic Lymphohistiocytosis Secondary to PRF1 Mutation. Case Rep Hematol 2022; 2021:7213939. [PMID: 35003815 PMCID: PMC8731261 DOI: 10.1155/2021/7213939] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Accepted: 12/17/2021] [Indexed: 12/03/2022] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening hyperinflammatory syndrome that causes systemic inflammation which can progress to multiorgan failure and death. Symptoms and signs commonly seen in HLH include high fever, hepatosplenomegaly, pancytopenia, and hypertriglyceridemia. This report describes the 8-month clinical course of a 17-year-old male with G6PD deficiency who presented with intermittent high fever of unknown origin for 8 months accompanied by pancytopenia and bilateral lower limb weakness. A pathogenic homozygous missense mutation (c.1081A > T p.(Arg361Trp)) in the PRF1 gene was detected by whole exome sequencing (WES). The brain and the whole spine MRI showed leptomeningeal enhancement at different levels involving both the brain and the spine. Therefore, a diagnosis of familial HLH type 2 with CNS involvement was confirmed. Accordingly, treatment with dexamethasone, cyclosporin, and etoposide in addition to intrathecal methotrexate and hydrocortisone was given. The patient showed a dramatic response with significant neurological improvement of the bilateral lower limb weakness. Genetic analysis has helped the patient's family with appropriate genetic counselling. This case highlights the importance of immediate treatment with immunosuppressants and the high clinical suspicion of physicians regarding HLH in areas where consanguinity is common.
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171
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Gordon SM, O'Connell AE. Inborn Errors of Immunity in the Premature Infant: Challenges in Recognition and Diagnosis. Front Immunol 2022; 12:758373. [PMID: 35003071 PMCID: PMC8738084 DOI: 10.3389/fimmu.2021.758373] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Accepted: 12/07/2021] [Indexed: 12/14/2022] Open
Abstract
Due to heightened awareness and advanced genetic tools, inborn errors of immunity (IEI) are increasingly recognized in children. However, diagnosing of IEI in premature infants is challenging and, subsequently, reports of IEI in premature infants remain rare. This review focuses on how common disorders of prematurity, such as sepsis, necrotizing enterocolitis, and bronchopulmonary dysplasia, can clinically overlap with presenting signs of IEI. We present four recent cases from a single neonatal intensive care unit that highlight diagnostic dilemmas facing neonatologists and clinical immunologists when considering IEI in preterm infants. Finally, we present a conceptual framework for when to consider IEI in premature infants and a guide to initial workup of premature infants suspected of having IEI.
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Affiliation(s)
- Scott M Gordon
- Division of Neonatology, Children's Hospital of Philadelphia, and Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Amy E O'Connell
- Division of Newborn Medicine, Boston Children's Hospital, and Department of Pediatrics, Harvard Medical School, Boston, MA, United States
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172
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Molecular diagnosis of childhood immune dysregulation, polyendocrinopathy, and enteropathy, and implications for clinical management. J Allergy Clin Immunol 2022; 149:327-339. [PMID: 33864888 PMCID: PMC8526646 DOI: 10.1016/j.jaci.2021.04.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 03/13/2021] [Accepted: 04/07/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Most patients with childhood-onset immune dysregulation, polyendocrinopathy, and enteropathy have no genetic diagnosis for their illness. These patients may undergo empirical immunosuppressive treatment with highly variable outcomes. OBJECTIVE We sought to determine the genetic basis of disease in patients referred with Immune dysregulation, polyendocrinopathy, enteropathy, X-linked-like (IPEX-like) disease, but with no mutation in FOXP3; then to assess consequences of genetic diagnoses for clinical management. METHODS Genomic DNA was sequenced using a panel of 462 genes implicated in inborn errors of immunity. Candidate mutations were characterized by genomic, transcriptional, and (for some) protein analysis. RESULTS Of 123 patients with FOXP3-negative IPEX-like disease, 48 (39%) carried damaging germline mutations in 1 of the following 27 genes: AIRE, BACH2, BCL11B, CARD11, CARD14, CTLA4, IRF2BP2, ITCH, JAK1, KMT2D, LRBA, MYO5B, NFKB1, NLRC4, POLA1, POMP, RAG1, SH2D1A, SKIV2L, STAT1, STAT3, TNFAIP3, TNFRSF6/FAS, TNRSF13B/TACI, TOM1, TTC37, and XIAP. Many of these genes had not been previously associated with an IPEX-like diagnosis. For 42 of the 48 patients with genetic diagnoses, knowing the critical gene could have altered therapeutic management, including recommendations for targeted treatments and for or against hematopoietic cell transplantation. CONCLUSIONS Many childhood disorders now bundled as "IPEX-like" disease are caused by individually rare, severe mutations in immune regulation genes. Most genetic diagnoses of these conditions yield clinically actionable findings. Barriers are lack of testing or lack of repeat testing if older technologies failed to provide a diagnosis.
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173
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Oh S, Niwa A, Nagahashi A, Asaka I, Nakahata T, Saito MK. iPS cells from Chediak-Higashi syndrome patients recapitulate the giant granules in myeloid cells. Pediatr Int 2022; 64:e15390. [PMID: 36259166 DOI: 10.1111/ped.15390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Revised: 10/11/2022] [Accepted: 10/14/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Chediak-Higashi syndrome (CHS) is a congenital disease characterized by immunodeficiency, hemophagocytic lymphohistiocytosis, oculocutaneous albinism, and neurological symptoms. The presence of giant granules in peripheral blood leukocytes is an important hallmark of CHS. Here we prepared induced pluripotent stem cells (iPSCs) from CHS patients (CHS-iPSCs) and differentiated them into hematopoietic cells to model the disease phenotypes. METHODS Fibroblasts were obtained from two CHS patients and then reprogrammed into iPSCs. The iPSCs were differentiated into myeloid cells; the size of the cytosolic granules was quantified by May-Grunwald Giemsa staining and myeloperoxidase staining. RESULTS Two clones of iPSCs were established from each patient. The differentiation efficiency to CD33+ CD45+ myeloid cells was not significantly different in CHS-iPSCs compared with control iPSCs, but significantly larger granules were observed. CONCLUSIONS We succeeded in reproducing a characteristic cellular phenotype, giant granules in myeloid cells, using CHS-iPSCs, demonstrating that iPSCs can be used to model the pathogenesis of CHS patients.
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Affiliation(s)
- Shigeharu Oh
- Department of Clinical Application, Center for iPS Cell Research and Application, Kyoto University, Kyoto, Japan
| | - Akira Niwa
- Department of Clinical Application, Center for iPS Cell Research and Application, Kyoto University, Kyoto, Japan
| | - Ayako Nagahashi
- Department of Fundamental Cell Technologies, Center for iPS Cell Research and Application, Kyoto University, Kyoto, Japan
| | - Isao Asaka
- Department of Fundamental Cell Technologies, Center for iPS Cell Research and Application, Kyoto University, Kyoto, Japan
| | - Tatsutoshi Nakahata
- Department of Clinical Application, Center for iPS Cell Research and Application, Kyoto University, Kyoto, Japan.,Department of Fundamental Cell Technologies, Center for iPS Cell Research and Application, Kyoto University, Kyoto, Japan
| | - Megumu K Saito
- Department of Clinical Application, Center for iPS Cell Research and Application, Kyoto University, Kyoto, Japan
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174
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Squires JE, Alonso EM, Ibrahim SH, Kasper V, Kehar M, Martinez M, Squires RH. North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition Position Paper on the Diagnosis and Management of Pediatric Acute Liver Failure. J Pediatr Gastroenterol Nutr 2022; 74:138-158. [PMID: 34347674 DOI: 10.1097/mpg.0000000000003268] [Citation(s) in RCA: 57] [Impact Index Per Article: 28.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
ABSTRACT Pediatric acute liver failure (PALF) is a rare, rapidly progressive clinical syndrome with significant morbidity and mortality. The phenotype of PALF manifests as abrupt onset liver dysfunction, which can be brought via disparate etiology. Management is reliant upon intensive clinical care and support, often provided by the collaborative efforts of hepatologists, critical care specialists, and liver transplant surgeons. The construction of an age-based diagnostic approach, the identification of a potential underlying cause, and the prompt implementation of appropriate therapy can be lifesaving; however, the dynamic and rapidly progressive nature of PALF also demands that diagnostic inquiries be paired with monitoring strategies for the recognition and treatment of common complications of PALF. Although liver transplantation can provide a potential life-saving therapeutic option, the ability to confidently determine the certainness that liver transplant is needed for an individual child has been hampered by a lack of adequately tested clinical decision support tools and accurate predictive models. Given the accelerated progress in understanding PALF, we will provide clinical guidance to pediatric gastroenterologists and other pediatric providers caring for children with PALF by presenting the most recent advances in diagnosis, management, pathophysiology, and associated outcomes.
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Affiliation(s)
- James E Squires
- Division of Gastroenterology, Hepatology and Nutrition, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - Estella M Alonso
- Department Pediatric Hepatology, Ann and Robert H Lurie Children's Hospital, Chicago, Illinois, USA
| | - Samar H Ibrahim
- Department of Pediatrics, Division of Pediatric Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Vania Kasper
- Division of Pediatric Gastroenterology, Nutrition and Liver Diseases, Hasbro Children's Hospital, Providence, RI
| | - Mohit Kehar
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Children Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Mercedes Martinez
- Department of Pediatrics, Vagelos College of Physician and Surgeons, Columbia University, New York, NY
| | - Robert H Squires
- Division of Gastroenterology, Hepatology and Nutrition, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
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175
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Redmond MT, Scherzer R, Prince BT. Novel Genetic Discoveries in Primary Immunodeficiency Disorders. Clin Rev Allergy Immunol 2022; 63:55-74. [PMID: 35020168 PMCID: PMC8753955 DOI: 10.1007/s12016-021-08881-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/24/2021] [Indexed: 01/12/2023]
Abstract
The field of Immunology is one that has undergone great expansion in recent years. With the advent of new diagnostic modalities including a variety of genetic tests (discussed elsewhere in this journal), the ability to diagnose a patient with a primary immunodeficiency disorder (PIDD) has become a more streamlined process. With increased availability of genetic testing for those with suspected or known PIDD, there has been a significant increase in the number of genes associated with this group of disorders. This is of great importance as a misdiagnosis of these rare diseases can lead to a delay in what can be critical treatment options. At times, those options can include life-saving medications or procedures. Presentation of patients with PIDD can vary greatly based on the specific genetic defect and the part(s) of the immune system that is affected by the variation. PIDD disorders lead to varying levels of increased risk of infection ranging from a mild increase such as with selective IgA deficiency to a profound risk with severe combined immunodeficiency. These diseases can also cause a variety of other clinical findings including autoimmunity and gastrointestinal disease.
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Affiliation(s)
- Margaret T. Redmond
- Division of Allergy and Immunology, Department of Pediatrics, Nationwide Children’s Hospital, The Ohio State University College of Medicine, Columbus, OH USA
| | - Rebecca Scherzer
- Division of Allergy and Immunology, Department of Pediatrics, Nationwide Children’s Hospital, The Ohio State University College of Medicine, Columbus, OH USA
| | - Benjamin T. Prince
- Division of Allergy and Immunology, Department of Pediatrics, Nationwide Children’s Hospital, The Ohio State University College of Medicine, Columbus, OH USA
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176
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Park JE, Lee T, Ha K, Cho EH, Ki CS. Carrier frequency and incidence estimation of familial hemophagocytic lymphohistiocytosis in East Asian populations by genome aggregation database (gnomAD) based analysis. Front Pediatr 2022; 10:975665. [PMID: 36440336 PMCID: PMC9692074 DOI: 10.3389/fped.2022.975665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 10/24/2022] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Hemophagocytic lymphohistiocytosis (HLH) is a clinical syndrome characterized by a life-threatening condition caused by severe hypercytokinemia. The hereditary forms of HLH, also called familial HLH (fHLH), have 4 different genes (PRF1, UNC13D, STX11, and STXBP2) and have been identified as being causative for fHLH. This study aimed to analyze the carrier frequency and expected incidence of fHLH in East Asians and Koreans using exome data from the Genome Aggregation Database (gnomAD). METHODS We analyzed 9,197 exomes for East Asian populations from gnomAD with 1,909 Korean for four fHLH genes. All identified variants were classified according to 2015 American College of Medical Genetics and Genomics and the Association for Molecular Pathology guideline. RESULTS 19 pathogenic variant/likely pathogenic variants (PV/LPVs) were identified in 30 East Asian individuals (0.33%). Among them, 7 PV/LPVs were identified in 17 Korean individuals (0.63%). The estimated incidence of fHLH was 1 in 1,105,652 for East Asians and l in 235,128 for Koreans. CONCLUSIONS This study is the first to identify carrier frequencies in East Asian and Korean populations for fHLH using gnomAD. It was confirmed that the carrier frequency of fHLH patients was high in Koreans among East Asians and the incidence was also predicted to be higher than that of other East Asians. The variant spectrum of fHLH genes in East Asian and Korean populations differed greatly from those of other ethnic groups.
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Affiliation(s)
- Jong Eun Park
- Department of Laboratory Medicine, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri, South Korea
| | | | | | - Eun Hye Cho
- Department of Laboratory Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, South Korea
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177
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Carneiro-Sampaio M, de Jesus AA, Bando SY, Moreira-Filho CA. Inborn Errors of Immunity With Fetal or Perinatal Clinical Manifestations. Front Pediatr 2022; 10:891343. [PMID: 35601409 PMCID: PMC9121170 DOI: 10.3389/fped.2022.891343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 04/18/2022] [Indexed: 11/28/2022] Open
Abstract
In this article we revised the literature on Inborn Errors of Immunity (IEI) keeping our focus on those diseases presenting with intrauterine or perinatal clinical manifestations. We opted to describe our findings according to the IEI categories established by the International Union of Immunological Societies, predominantly addressing the immunological features of each condition or group of diseases. The main finding is that such precocious manifestations are largely concentrated in the group of primary immune regulatory disorders (PIRDs) and not in the group of classical immunodeficiencies. The IEI categories with higher number of immunological manifestations in utero or in perinatal period are: (i) diseases of immune dysregulation (HLH, IPEX and other Tregopathies, autosomal recessive ALPS with complete lack of FAS protein expression) and (ii) autoinflammatory diseases (NOMID/CINCA, DIRA and some interferonopathies, such as Aicardi-Goutières syndrome, AGS, and USP18 deficiency). Regarding the other IEI categories, some patients with Omenn syndrome (an atypical form of SCID), and a few X-linked CGD patients present with clinical manifestations at birth associated to immune dysregulation. The most frequent clinical features were hydrops fetalis, intrauterine growth retardation leading to fetal loss, stillbirths, and prematurity, as in HLH and IPEX. Additionally, pseudo-TORCH syndrome was observed in AGS and in USP18 deficiency. The main goal of our review was to contribute to increasing the medical awareness of IEI with intrauterine and perinatal onset, which has obvious implications for diagnosis, treatment, and genetic counseling.
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Affiliation(s)
- Magda Carneiro-Sampaio
- Department of Pediatrics, Faculdade de Medicina, Universidade de São Paulo, Sao-Paulo, Brazil
| | - Adriana Almeida de Jesus
- Translational Autoinflammatory Disease Section, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, United States
| | - Silvia Yumi Bando
- Department of Pediatrics, Faculdade de Medicina, Universidade de São Paulo, Sao-Paulo, Brazil
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178
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Costagliola G, Peroni DG, Consolini R. Beyond Infections: New Warning Signs for Inborn Errors of Immunity in Children. Front Pediatr 2022; 10:855445. [PMID: 35757131 PMCID: PMC9226481 DOI: 10.3389/fped.2022.855445] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Accepted: 05/23/2022] [Indexed: 11/21/2022] Open
Abstract
Patients with inborn errors of immunity (IEI) are susceptible to developing a severe infection-related clinical phenotype, but the clinical consequences of immune dysregulation, expressed with autoimmunity, atopy, and lymphoproliferation could represent the first sign in a significant percentage of patients. Therefore, during the diagnostic work-up patients with IEI are frequently addressed to different specialists, including endocrinologists, rheumatologists, and allergologists, often resulting in a delayed diagnosis. In this paper, the most relevant non-infectious manifestations of IEI are discussed. Particularly, we will focus on the potential presentation of IEI with autoimmune cytopenia, non-malignant lymphoproliferation, severe eczema or erythroderma, autoimmune endocrinopathy, enteropathy, and rheumatologic manifestations, including vasculitis and systemic lupus erythematosus. This paper aims to identify new warning signs to suspect IEI and help in the identification of patients presenting with atypical/non-infectious manifestations.
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Affiliation(s)
- Giorgio Costagliola
- Section of Clinical and Laboratory Immunology, Division of Pediatrics, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Diego G Peroni
- Division of Pediatrics, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Rita Consolini
- Section of Clinical and Laboratory Immunology, Division of Pediatrics, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
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179
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Buda P, Strauss E, Januszkiewicz-Lewandowska D, Czerwinska E, Ludwikowska K, Szenborn L, Gowin E, Okarska-Napierała M, Kuchar E, Ksia Zyk J. Clinical characteristics of children with MIS-C fulfilling classification criteria for macrophage activation syndrome. Front Pediatr 2022; 10:981711. [PMID: 36186637 PMCID: PMC9520614 DOI: 10.3389/fped.2022.981711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 08/17/2022] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND Macrophage activation syndrome (MAS) is a potentially life-threatening complication of various inflammatory disorders, including multisystem inflammatory syndrome in children (MIS-C). MIS-C refractory to treatment should raise suspicion of MAS, which can be fatal if a definitive diagnosis is delayed. Unfortunately, there is a lack of data on MAS in children with MIS-C. OBJECTIVE Our study aims to analyze the risk factors for the development of MAS in MIS-C, its clinical course and response to treatment, and identify predictive factors for pediatric intensive care. MATERIAL AND METHODS We analyzed data from the Polish MIS-C registry of the MultiOrgan Inflammatory Syndromes COVID-19 Related Study. Patients were diagnosed according to the WHO MIS-C definition and treated according to national guidelines (Polish Pediatric Society) based on international consensus. MAS definition was based on 2016 Classification Criteria for Macrophage Activation Syndrome Complicating Systemic Juvenile Idiopathic Arthritis. RESULTS Two-hundred and seventy four children met the study inclusion criteria. Fifty-nine patients fulfilled MAS classification criteria, nine of which required admission to the pediatric intensive care unit (PICU). MIS-C patients with MAS were significantly older than patients without MAS (median 11.2 vs. 8.1 years). Multivariable analysis showed that age, symptoms characteristic of atypical Kawasaki disease, and skin erosions were significant factors associated with MAS in MIS-C patients. Analysis of laboratory parameters showed that on admission, MIS-C patients with MAS had significantly lower median lymphocyte and platelet counts, albumin and sodium levels, and higher median levels of C-reactive protein, procalcitonin, ferritin, D-dimers, triglycerides, serum creatinine, urea, and γ-glutamyl transpeptidase, and neutrophil count. Multivariate analysis showed that higher procalcitonin, ferritin, and fibrinogen levels at admission were predictive of MAS. Only elevated troponin level was a factor indicating a requirement of PICU hospitalization for children with MAS. MIS-C patients fulfilling MAS criteria were treated more often with intravenous immunoglobulins and steroids than children without MAS. Children with MAS more often required mechanical ventilation. None of the patients required biological agents. CONCLUSIONS The clinical course of MAS in MIS-C seems milder, treatment less aggressive, and the prognosis better than expected based on the current knowledge on MAS complicating other rheumatological diseases.
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Affiliation(s)
- Piotr Buda
- Department of Pediatrics, Nutrition and Metabolic Diseases, Children's Memorial Health Institute, Warsaw, Poland
| | - Ewa Strauss
- Institute of Human Genetics, Polish Academy of Sciences, Poznan, Poland
| | | | - Ewa Czerwinska
- Department of Pediatric Infectious Diseases, Wroclaw Medical University, Wroclaw, Poland
| | - Kamila Ludwikowska
- Department of Pediatric Infectious Diseases, Wroclaw Medical University, Wroclaw, Poland
| | - Leszek Szenborn
- Department of Pediatric Infectious Diseases, Wroclaw Medical University, Wroclaw, Poland
| | - Ewelina Gowin
- Health Promotion Department, Poznan University of Medical Sciences, Poznan, Poland
| | | | - Ernest Kuchar
- Department of Pediatrics With Clinical Decisions Unit, Medical University of Warsaw, Warsaw, Poland
| | - Janusz Ksia Zyk
- Department of Pediatrics, Nutrition and Metabolic Diseases, Children's Memorial Health Institute, Warsaw, Poland
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180
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Yang X, Lu X, Liu J, Kan Y, Wang W, Zhang S, Liu L, Li J, Yang J. Development and Validation of 18F-FDG PET/CT-Based Multivariable Clinical Prediction Models for the Identification of Malignancy-Associated Hemophagocytic Lymphohistiocytosis. Korean J Radiol 2022; 23:466-478. [PMID: 35289150 PMCID: PMC8961016 DOI: 10.3348/kjr.2021.0733] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Revised: 11/28/2021] [Accepted: 12/26/2021] [Indexed: 11/15/2022] Open
Abstract
Objective 18F-fluorodeoxyglucose (FDG) PET/CT is often used for detecting malignancy in patients with newly diagnosed hemophagocytic lymphohistiocytosis (HLH), with acceptable sensitivity but relatively low specificity. The aim of this study was to improve the diagnostic ability of 18F-FDG PET/CT in identifying malignancy in patients with HLH by combining 18F-FDG PET/CT and clinical parameters. Materials and Methods Ninety-seven patients (age ≥ 14 years) with secondary HLH were retrospectively reviewed and divided into the derivation (n = 71) and validation (n = 26) cohorts according to admission time. In the derivation cohort, 22 patients had malignancy-associated HLH (M-HLH) and 49 patients had non-malignancy-associated HLH (NM-HLH). Data on pretreatment 18F-FDG PET/CT and laboratory results were collected. The variables were analyzed using the Mann-Whitney U test or Pearson’s chi-square test, and a nomogram for predicting M-HLH was constructed using multivariable binary logistic regression. The predictors were also ranked using decision-tree analysis. The nomogram and decision tree were validated in the validation cohort (10 patients with M-HLH and 16 patients with NM-HLH). Results The ratio of the maximal standardized uptake value (SUVmax) of the lymph nodes to that of the mediastinum, the ratio of the SUVmax of bone lesions or bone marrow to that of the mediastinum, and age were selected for constructing the model. The nomogram showed good performance in predicting M-HLH in the validation cohort, with an area under the receiver operating characteristic curve of 0.875 (95% confidence interval, 0.686–0.971). At an appropriate cutoff value, the sensitivity and specificity for identifying M-HLH were 90% (9/10) and 68.8% (11/16), respectively. The decision tree integrating the same variables showed 70% (7/10) sensitivity and 93.8% (15/16) specificity for identifying M-HLH. In comparison, visual analysis of 18F-FDG PET/CT images demonstrated 100% (10/10) sensitivity and 12.5% (2/16) specificity. Conclusion 18F-FDG PET/CT may be a practical technique for identifying M-HLH. The model constructed using 18F-FDG PET/CT features and age was able to detect malignancy with better accuracy than visual analysis of 18F-FDG PET/CT images.
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Affiliation(s)
- Xu Yang
- Department of Nuclear Medicine, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Xia Lu
- Department of Nuclear Medicine, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Jun Liu
- Department of Nuclear Medicine, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Ying Kan
- Department of Nuclear Medicine, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Wei Wang
- Department of Nuclear Medicine, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Shuxin Zhang
- Department of Nuclear Medicine, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Lei Liu
- Sinounion Medical Technology (Beijing) Co., Ltd., Beijing, China
| | - Jixia Li
- Department of Laboratory Medicine, School of Medicine, Foshan University, Foshan, China
- Department of Molecular Medicine and Pathology, School of Medical Science, The University of Auckland, Auckland, New Zealand
| | - Jigang Yang
- Department of Nuclear Medicine, Beijing Friendship Hospital, Capital Medical University, Beijing, China
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181
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Yao S, Jin Z, He L, Zhang R, Liu M, Hua Z, Wang Z, Wang Y. Clinical Features and Prognostic Risk Prediction of Non-Hodgkin Lymphoma-Associated Hemophagocytic Syndrome. Front Oncol 2021; 11:788056. [PMID: 34938663 PMCID: PMC8685250 DOI: 10.3389/fonc.2021.788056] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 11/12/2021] [Indexed: 11/13/2022] Open
Abstract
Background Malignancies, especially lymphoma, are a common cause of adult secondary HLH and an independent risk factor for the prognosis of HLH patients. Methods Patients with lymphoma alone or concurrent lymphoma-associated phagocytic syndrome (LAHS) admitted to Beijing Friendship Hospital from January 2016 to December 2020 were enrolled in this study. Findings There were 348 lymphoma patients, 104 concurrent with LAHS. The pathological type of lymphoma without LAHS was dominated by B-cell lymphoma, while those with LAHS were T/NK-cell lymphoma predominantly (p < 0.001). Superficial lymph node enlargement was more significant in patients with B-LAHS (p = 0.006), while patients with T/NK-LAHS had lower neutrophil counts (p = 0.005), lower fibrinogen levels (p < 0.001), higher transaminase levels, and more co-infection with EBV (p < 0.001). B-LAHS had significantly higher IL-10 levels than with T/NK-LAHS (p = 0.006), and NK/T-LAHS had significantly higher IP-10 levels than other T-LAHS (p = 0.008). Age, platelet count, IPI, history of NK/T lymphoma, and no remission of HLH were independent risk factors for prognosis in patients with non-Hodgkin lymphoma-associated phagocytic syndrome (NHL-LAHS), and a prognostic risk score model for NHL-LAHS was developed. Conclusion LAHS is a life-threatening disease with a poor prognosis. The prognostic risk score model for NHL-LAHS with a good fit and validation for the test has value for clinical application.
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Affiliation(s)
- Shuyan Yao
- Department of Hematology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Zhili Jin
- Department of Hematology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Lingbo He
- Department of Hematology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Ruoxi Zhang
- Department of Hematology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Menghan Liu
- Department of Hematology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Zhengjie Hua
- Department of Hematology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Zhao Wang
- Department of Hematology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Yini Wang
- Department of Hematology, Beijing Friendship Hospital, Capital Medical University, Beijing, China.,Department of General Medicine, Beijing Friendship Hospital, Capital Medical University, Beijing, China
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182
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Yang X, Liu J, Lu X, Kan Y, Wang W, Zhang S, Liu L, Zhang H, Li J, Yang J. Development and Validation of a Nomogram Based on 18F-FDG PET/CT Radiomics to Predict the Overall Survival in Adult Hemophagocytic Lymphohistiocytosis. Front Med (Lausanne) 2021; 8:792677. [PMID: 35004761 PMCID: PMC8740551 DOI: 10.3389/fmed.2021.792677] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Accepted: 11/22/2021] [Indexed: 11/13/2022] Open
Abstract
Purpose: Hemophagocytic lymphohistiocytosis (HLH) is a rare and severe disease with a poor prognosis. We aimed to determine if 18F-fluorodeoxyglucose (18F-FDG) PET/CT-derived radiomic features alone or combination with clinical parameters could predict survival in adult HLH. Methods: This study included 70 adults with HLH (training cohort, n = 50; validation cohort, n = 20) who underwent pretherapeutic 18F-FDG PET/CT scans between August 2016 and June 2020. Radiomic features were extracted from the liver and spleen on CT and PET images. For evaluation of 6-month survival, the features exhibiting p < 0.1 in the univariate analysis between non-survivors and survivors were selected. The least absolute shrinkage and selection operator (LASSO) regression analysis was used to develop a radiomics score (Rad-score). A nomogram was built by the multivariate regression analysis to visualize the predictive model for 3-month, 6-month, and 1-year survival, while the performance and usefulness of the model were evaluated by calibration curves, the receiver operating characteristic (ROC) curves, and decision curves. Results: The Rad-score was able to predict 6-month survival in adult HLH, with area under the ROC curves (AUCs) of 0.927 (95% CI: 0.878–0.974) and 0.869 (95% CI: 0.697–1.000) in the training and validation cohorts, respectively. The radiomics nomogram combining the Rad-score with the clinical parameters resulted in better performance for predicting 6-month survival than the clinical model or the Rad-score alone. Moreover, the nomogram displayed superior discrimination, calibration, and clinical usefulness in both the cohorts. Conclusion: The newly developed Rad-score is a powerful predictor for overall survival (OS) in adults with HLH. The nomogram has great potential for predicting 3-month, 6-month, and 1-year survival, which may timely guide personalized treatments for adult HLH.
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Affiliation(s)
- Xu Yang
- Department of Nuclear Medicine, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Jun Liu
- Department of Nuclear Medicine, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Xia Lu
- Department of Nuclear Medicine, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Ying Kan
- Department of Nuclear Medicine, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Wei Wang
- Department of Nuclear Medicine, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Shuxin Zhang
- Department of Nuclear Medicine, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Lei Liu
- Sinounion Medical Technology (Beijing) Co., Ltd., Beijing, China
| | - Hui Zhang
- Department of Biomedical Engineering, School of Medicine, Tsinghua University, Beijing, China
| | - Jixia Li
- Department of Laboratory Medicine, School of Medicine, Foshan University, Foshan, China
- Department of Molecular Medicine and Pathology, School of Medical Science, The University of Auckland, Auckland, New Zealand
- Jixia Li
| | - Jigang Yang
- Department of Nuclear Medicine, Beijing Friendship Hospital, Capital Medical University, Beijing, China
- *Correspondence: Jigang Yang
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183
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Shabab J, Dubisky A, Singh A, Crippen M, Abulaban K, Aldrich A. A descriptive study on multisystem inflammatory syndrome in children in a single center in West Michigan. Pediatr Rheumatol Online J 2021; 19:172. [PMID: 34915906 PMCID: PMC8675109 DOI: 10.1186/s12969-021-00658-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 11/28/2021] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Multisystem Inflammatory Syndrome in Children (MIS-C) is a rare hyperinflammatory condition that occurs following SARS-CoV-2 infection. There is a paucity of research describing risk factors, optimal management, and outcomes of this life-threatening condition. METHODS This is a case series of 26 patients diagnosed with MIS-C in a West Michigan pediatric tertiary care center from April 2020 to February 2021. We describe the clinical, imaging, and laboratory characteristics of these patients and detail their treatments and outcomes with comparisons between Pediatric Intensive Care Unit (PICU) and non-PICU patients. Categorical testing utilized Chi-square and Fisher's Exact tests. Comparison between groups used T-tests or Kruskal-Wallis. RESULTS Fifteen patients (57%) required intensive care. There was no statistically significant difference in demographics between PICU and non-PICU patients, however all Black patients required intensive care. Gastrointestinal symptoms were present in 22 patients (84%). Seventeen patients (65%) had Kawasaki-like features and 12 (46%) developed coronary artery dilation. Patients requiring intensive care were less likely to have a reported history of COVID-19 disease or exposure (p = 0.0362). Statistically significant differences were also noted in peak ferritin (p = 0.0075), procalcitonin, and BNP in those who required intensive care. CONCLUSIONS Although overlap exists with other hyperinflammatory conditions, our study provides further evidence that MIS-C is a distinct, albeit heterogenous, disorder with various degrees of cardiac involvement. Anakinra, in conjunction with steroid use, appears to be effective and safe in the treatment of MIS-C. This report identifies procalcitonin, peak ferritin, and BNP as potentially useful biomarkers for severity of disease.
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Affiliation(s)
- Jonathan Shabab
- Spectrum Health Helen DeVos Children's Hospital/Michigan State University Pediatric Residency Program, Grand Rapids, MI, USA
| | - Allysen Dubisky
- Michigan State University College of Human Medicine, Grand Rapids, MI, USA
| | - Ambaris Singh
- Spectrum Health Helen DeVos Children's Hospital/Michigan State University Pediatric Residency Program, Grand Rapids, MI, USA
| | - Megan Crippen
- Spectrum Health Helen DeVos Children's Hospital/Michigan State University Pediatric Residency Program, Grand Rapids, MI, USA
| | - Khalid Abulaban
- Michigan State University College of Human Medicine, Grand Rapids, MI, USA
- Department of Pediatric Rheumatology, Spectrum Health Helen DeVos Children's Hospital, Grand Rapids, MI, USA
| | - Aileen Aldrich
- Michigan State University College of Human Medicine, Grand Rapids, MI, USA.
- Department of Pediatric Infectious Diseases, Spectrum Health Helen DeVos Children's Hospital, 35 Michigan St. NE, Suite 4150, Grand Rapids, MI, 49503, USA.
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184
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Lichtenstein DA, Schischlik F, Shao L, Steinberg SM, Yates B, Wang HW, Wang Y, Inglefield J, Dulau-Florea A, Ceppi F, Hermida LC, Stringaris K, Dunham K, Homan P, Jailwala P, Mirazee J, Robinson W, Chisholm KM, Yuan C, Stetler-Stevenson M, Ombrello AK, Jin J, Fry TJ, Taylor N, Highfill SL, Jin P, Gardner RA, Shalabi H, Ruppin E, Stroncek DF, Shah NN. Characterization of HLH-like manifestations as a CRS variant in patients receiving CD22 CAR T cells. Blood 2021; 138:2469-2484. [PMID: 34525183 PMCID: PMC8832442 DOI: 10.1182/blood.2021011898] [Citation(s) in RCA: 89] [Impact Index Per Article: 29.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Accepted: 08/26/2021] [Indexed: 11/20/2022] Open
Abstract
Chimeric antigen receptor (CAR) T-cell toxicities resembling hemophagocytic lymphohistiocytosis (HLH) occur in a subset of patients with cytokine release syndrome (CRS). As a variant of conventional CRS, a comprehensive characterization of CAR T-cell-associated HLH (carHLH) and investigations into associated risk factors are lacking. In the context of 59 patients infused with CD22 CAR T cells where a substantial proportion developed carHLH, we comprehensively describe the manifestations and timing of carHLH as a CRS variant and explore factors associated with this clinical profile. Among 52 subjects with CRS, 21 (40.4%) developed carHLH. Clinical features of carHLH included hyperferritinemia, hypertriglyceridemia, hypofibrinogenemia, coagulopathy, hepatic transaminitis, hyperbilirubinemia, severe neutropenia, elevated lactate dehydrogenase, and occasionally hemophagocytosis. Development of carHLH was associated with preinfusion natural killer(NK) cell lymphopenia and higher bone marrow T-cell:NK cell ratio, which was further amplified with CAR T-cell expansion. Following CRS, more robust CAR T-cell and CD8 T-cell expansion in concert with pronounced NK cell lymphopenia amplified preinfusion differences in those with carHLH without evidence for defects in NK cell mediated cytotoxicity. CarHLH was further characterized by persistent elevation of HLH-associated inflammatory cytokines, which contrasted with declining levels in those without carHLH. In the setting of CAR T-cell mediated expansion, clinical manifestations and immunophenotypic profiling in those with carHLH overlap with features of secondary HLH, prompting consideration of an alternative framework for identification and management of this toxicity profile to optimize outcomes following CAR T-cell infusion.
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Affiliation(s)
- Daniel A Lichtenstein
- Pediatric Oncology Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Fiorella Schischlik
- Cancer Data Science Laboratory, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Lipei Shao
- Center for Cellular Engineering, Department of Transfusion Medicine, NIH Clinical Center, Bethesda, MD
| | - Seth M Steinberg
- Biostatistics and Data Management Section, Center for Cancer Research, Bethesda, MD
| | - Bonnie Yates
- Pediatric Oncology Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Hao-Wei Wang
- Laboratory of Pathology, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Yanyu Wang
- Applied Developmental Research Directorate, Leidos Biomedical Research, Inc, Frederick National Laboratory for Cancer Research, National Cancer Institute, Frederick, MD
| | - Jon Inglefield
- Applied Developmental Research Directorate, Leidos Biomedical Research, Inc, Frederick National Laboratory for Cancer Research, National Cancer Institute, Frederick, MD
| | - Alina Dulau-Florea
- Laboratory of Pathology, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Francesco Ceppi
- Department of Pediatrics, Seattle Children's Hospital, Seattle, WA
- Paediatric Haematology-Oncology Unit, Division of Paediatrics, Department Woman-Mother-Child, University Hospital of Lausanne, Lausanne, Switzerland
| | - Leandro C Hermida
- Cancer Data Science Laboratory, National Cancer Institute, National Institutes of Health, Bethesda, MD
- Center for Bioinformatics and Computational Biology, University of Maryland, College Park, MD
| | - Kate Stringaris
- Transplantation Immunology, National Heart, Lung and Blood Institute, Bethesda, MD
| | - Kim Dunham
- Applied Developmental Research Directorate, Leidos Biomedical Research, Inc, Frederick National Laboratory for Cancer Research, National Cancer Institute, Frederick, MD
| | - Philip Homan
- Center for Cancer Research Collaborative Bioinformatics Resource, National Cancer Institute, National Institutes of Health, Bethesda, MD
- Advanced Biomedical Computational Science, Frederick National Laboratory for Cancer Research, Fredrick, MD
| | - Parthav Jailwala
- Center for Cancer Research Collaborative Bioinformatics Resource, National Cancer Institute, National Institutes of Health, Bethesda, MD
- Advanced Biomedical Computational Science, Frederick National Laboratory for Cancer Research, Fredrick, MD
| | - Justin Mirazee
- Pediatric Oncology Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Welles Robinson
- Cancer Data Science Laboratory, National Cancer Institute, National Institutes of Health, Bethesda, MD
- Paediatric Haematology-Oncology Unit, Division of Paediatrics, Department Woman-Mother-Child, University Hospital of Lausanne, Lausanne, Switzerland
| | - Karen M Chisholm
- Department of Laboratories, Seattle Children's Hospital, Seattle, WA
| | - Constance Yuan
- Laboratory of Pathology, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | | | - Amanda K Ombrello
- Inflammatory Disease Section, National Human Genome Research Institute, National Institutes of Health, Bethesda, MD; and
| | - Jianjian Jin
- Center for Cellular Engineering, Department of Transfusion Medicine, NIH Clinical Center, Bethesda, MD
| | - Terry J Fry
- Pediatric Oncology Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD
- University of Colorado Anschutz Medical Campus and Center for Cancer and Blood Disorders, Children's Hospital of Colorado, Aurora, CO
| | - Naomi Taylor
- Pediatric Oncology Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Steven L Highfill
- Center for Cellular Engineering, Department of Transfusion Medicine, NIH Clinical Center, Bethesda, MD
| | - Ping Jin
- Center for Cellular Engineering, Department of Transfusion Medicine, NIH Clinical Center, Bethesda, MD
| | - Rebecca A Gardner
- Applied Developmental Research Directorate, Leidos Biomedical Research, Inc, Frederick National Laboratory for Cancer Research, National Cancer Institute, Frederick, MD
| | - Haneen Shalabi
- Pediatric Oncology Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Eytan Ruppin
- Cancer Data Science Laboratory, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - David F Stroncek
- Center for Cellular Engineering, Department of Transfusion Medicine, NIH Clinical Center, Bethesda, MD
| | - Nirali N Shah
- Pediatric Oncology Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD
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185
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Shah K, Al-Haidari A, Sun J, Kazi JU. T cell receptor (TCR) signaling in health and disease. Signal Transduct Target Ther 2021; 6:412. [PMID: 34897277 PMCID: PMC8666445 DOI: 10.1038/s41392-021-00823-w] [Citation(s) in RCA: 133] [Impact Index Per Article: 44.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 11/02/2021] [Accepted: 11/02/2021] [Indexed: 12/18/2022] Open
Abstract
Interaction of the T cell receptor (TCR) with an MHC-antigenic peptide complex results in changes at the molecular and cellular levels in T cells. The outside environmental cues are translated into various signal transduction pathways within the cell, which mediate the activation of various genes with the help of specific transcription factors. These signaling networks propagate with the help of various effector enzymes, such as kinases, phosphatases, and phospholipases. Integration of these disparate signal transduction pathways is done with the help of adaptor proteins that are non-enzymatic in function and that serve as a scaffold for various protein-protein interactions. This process aids in connecting the proximal to distal signaling pathways, thereby contributing to the full activation of T cells. This review provides a comprehensive snapshot of the various molecules involved in regulating T cell receptor signaling, covering both enzymes and adaptors, and will discuss their role in human disease.
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Affiliation(s)
- Kinjal Shah
- Division of Translational Cancer Research, Department of Laboratory Medicine, Lund University, Lund, Sweden
- Lund Stem Cell Center, Department of Laboratory Medicine, Lund University, Lund, Sweden
| | - Amr Al-Haidari
- Clinical Genetics and Pathology, Skåne University Hospital, Region Skåne, Lund, Sweden
- Clinical Sciences Department, Surgery Research Unit, Lund University, Malmö, Sweden
| | - Jianmin Sun
- Division of Translational Cancer Research, Department of Laboratory Medicine, Lund University, Lund, Sweden
- Lund Stem Cell Center, Department of Laboratory Medicine, Lund University, Lund, Sweden
- NHC Key Laboratory of Metabolic Cardiovascular Diseases Research, Science and Technology center, School of Basic Medical Sciences, Ningxia Medical University, Yinchuan, China
| | - Julhash U Kazi
- Division of Translational Cancer Research, Department of Laboratory Medicine, Lund University, Lund, Sweden.
- Lund Stem Cell Center, Department of Laboratory Medicine, Lund University, Lund, Sweden.
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186
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Li Y, Sun C, Cui L, Wang Q. NLRC4 Gene Single Nucleotide Polymorphisms Are Associated with the Prognosis of Hemophagocytic Lymphohistiocytosis. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2021; 2021:8581746. [PMID: 34925545 PMCID: PMC8683185 DOI: 10.1155/2021/8581746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 11/23/2021] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To analyze and study the correlation between NLR family CARD domain-containing 4 (NLRC4) gene single nucleotide polymorphisms and the prognosis of patients with hemophagocytic lymphohistiocytosis (HLH). METHODS In this study, we retrospectively studied the clinical data of 62 HLH patients, including 40 males and 22 females. The genomic DNA was extracted, and the genotypes at rs385076 locus and rs479333 locus of the NLRC4 gene were analyzed. The level of blood interleukin-18 (IL-18) was analyzed by enzyme-linked immunosorbent assay (ELISA). RESULTS Compared with the TT genotype at the NLRC4 gene rs385076 locus, the mortality of HLH patients with TC genotype and CC genotype was higher (RR = 3.205, 95% CI: 1.277-4.788, p = 0.012; RR = 3.052, 95% CI: 1.098-4.753, p = 0.031). Taking the CC genotype at rs479333 of the NLRC4 gene as a reference, HLH patients with CG genotype and GG genotype had a higher risk of death (RR = 3.475, 95% CI: 1.488-5.775, p = 0.003; RR = 2.986, 95% CI: 1.014-5.570, p = 0.047). NLRC4 gene rs385076 T>C and rs479333 C>G were significantly related to the poor prognosis of HLH patients. The area under the curve (AUC) of the receiver operating curve (ROC) for the prognostic outcome of HLH with serum IL-18 level was 0.6813 (95% CI: 0.5365-0.8260, p = 0.0189). NLRC4 gene rs385076 T>C and rs479333 C>G were related to higher serum IL-18 levels. CONCLUSION NLRC4 gene rs385076 T>C and rs479333 C>G are related to the poor prognosis of HLH patients.
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Affiliation(s)
- Yan Li
- Department of Hematology, Xuanwu Hospital, Capital Medical University, Beijing 100053, China
| | - Chengdong Sun
- Department of Infectious Diseases, Beijing Jishuitan Hospital, Beijing 100096, China
| | - Liying Cui
- Department of Hematology, Xuanwu Hospital, Capital Medical University, Beijing 100053, China
| | - Qiuying Wang
- Department of Hematology, Xuanwu Hospital, Capital Medical University, Beijing 100053, China
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187
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Steen EA, Hermiston ML, Nichols KE, Meyer LK. Digenic Inheritance: Evidence and Gaps in Hemophagocytic Lymphohistiocytosis. Front Immunol 2021; 12:777851. [PMID: 34868048 PMCID: PMC8635482 DOI: 10.3389/fimmu.2021.777851] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Accepted: 10/19/2021] [Indexed: 12/26/2022] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a hyperinflammatory disorder characterized by the inability to properly terminate an immune response. Familial HLH (FHLH) and related immune dysregulation syndromes are associated with mutations in the genes PRF1, UNC13D, STX11, STXBP2, LYST, AP3B1, and RAB27A, all of which are required for the assembly, exocytosis, and function of cytotoxic granules within CD8+ T cells and natural killer (NK) cells. Loss-of-function mutations in these genes render the cytotoxicity pathway ineffective, thereby failing to eradicate immune stimuli, such as infectious pathogens or malignant cells. The resulting persistent immune system stimulation drives hypercytokinemia, ultimately leading to severe tissue inflammation and end-organ damage. Traditionally, a diagnosis of FHLH requires the identification of biallelic loss-of-function mutations in one of these degranulation pathway genes. However, this narrow definition fails to encompass patients with other genetic mechanisms underlying degranulation pathway dysfunction. In particular, mounting clinical evidence supports a potential digenic mode of inheritance of FHLH in which single loss-of-function mutations in two different degranulation pathway genes cooperate to impair pathway activity. Here, we review the functions of the FHLH-associated genes within the degranulation pathway and summarize clinical evidence supporting a model in which cumulative defects along this mechanistic pathway may underlie HLH.
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Affiliation(s)
- Erica A Steen
- University of California, San Diego, San Diego, CA, United States
| | - Michelle L Hermiston
- Department of Pediatrics, University of California, San Francisco, San Francisco, CA, United States
| | - Kim E Nichols
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Lauren K Meyer
- Department of Pediatrics, University of California, San Francisco, San Francisco, CA, United States
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188
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Han HJ, Hong KT, Park HJ, Kim BK, An HY, Choi JY, Kang HJ. Hemophagocytic Lymphohistiocytosis as Initial Presentation of Malignancy in Pediatric Patients: Rare but Not to Be Ignored. CHILDREN (BASEL, SWITZERLAND) 2021; 8:children8121083. [PMID: 34943279 PMCID: PMC8699877 DOI: 10.3390/children8121083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Revised: 11/17/2021] [Accepted: 11/22/2021] [Indexed: 06/14/2023]
Abstract
It is complicated to establish a consensus on the management and diagnosis of malignancy-triggered hemophagocytic lymphohistiocytosis (M-HLH) in children, as an initial presentation of malignancy is complicated. In this paper, we analyze the clinical characteristics and outcomes of eight pediatric patients in which M-HLH was the initial presentation of malignancy. All patients had hematologic malignancies: three subcutaneous panniculitis-like T-cell lymphomas, two acute lymphoblastic leukemias, two anaplastic large cell lymphomas, and a systemic EBV + T-cell lymphoma of childhood. The incidence rate of M-HLH among leukemia and malignant lymphoma patients in our institution was 1.9%. From the initial diagnosis of HLH, the median time taken to be diagnosed as a malignancy was about 1.3 months. The majority of patients received HLH-targeted immunosuppression and/or etoposide at first. The patients' clinical response to treatment for HLH and malignancies were varied. Five out of the eight patients died, one of whom died due to HLH-related cerebral edema after the initiation of chemotherapy. The median overall survival was 1.6 years. In order to improve the survival rate, the early detection of M-HLH, rapid screening for malignancy, and complete control of M-HLH with HLH-directed therapy followed by a thorough response monitoring are required.
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Affiliation(s)
- Hye-ji Han
- Departments of Pediatrics, Seoul National University College of Medicine, Seoul 03080, Korea; (H.-j.H.); (H.J.P.); (B.K.K.); (H.Y.A.); (J.Y.C.); (H.J.K.)
| | - Kyung Taek Hong
- Departments of Pediatrics, Seoul National University College of Medicine, Seoul 03080, Korea; (H.-j.H.); (H.J.P.); (B.K.K.); (H.Y.A.); (J.Y.C.); (H.J.K.)
- Cancer Research Institute, Seoul National University, Seoul 03080, Korea
| | - Hyun Jin Park
- Departments of Pediatrics, Seoul National University College of Medicine, Seoul 03080, Korea; (H.-j.H.); (H.J.P.); (B.K.K.); (H.Y.A.); (J.Y.C.); (H.J.K.)
- Cancer Research Institute, Seoul National University, Seoul 03080, Korea
| | - Bo Kyung Kim
- Departments of Pediatrics, Seoul National University College of Medicine, Seoul 03080, Korea; (H.-j.H.); (H.J.P.); (B.K.K.); (H.Y.A.); (J.Y.C.); (H.J.K.)
- Cancer Research Institute, Seoul National University, Seoul 03080, Korea
| | - Hong Yul An
- Departments of Pediatrics, Seoul National University College of Medicine, Seoul 03080, Korea; (H.-j.H.); (H.J.P.); (B.K.K.); (H.Y.A.); (J.Y.C.); (H.J.K.)
- Cancer Research Institute, Seoul National University, Seoul 03080, Korea
| | - Jung Yoon Choi
- Departments of Pediatrics, Seoul National University College of Medicine, Seoul 03080, Korea; (H.-j.H.); (H.J.P.); (B.K.K.); (H.Y.A.); (J.Y.C.); (H.J.K.)
- Cancer Research Institute, Seoul National University, Seoul 03080, Korea
| | - Hyoung Jin Kang
- Departments of Pediatrics, Seoul National University College of Medicine, Seoul 03080, Korea; (H.-j.H.); (H.J.P.); (B.K.K.); (H.Y.A.); (J.Y.C.); (H.J.K.)
- Cancer Research Institute, Seoul National University, Seoul 03080, Korea
- Wide River Institute of Immunology, Hongcheon 25159, Korea
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189
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Heterozygous missense variant of the proteasome subunit β-type 9 causes neonatal-onset autoinflammation and immunodeficiency. Nat Commun 2021; 12:6819. [PMID: 34819510 PMCID: PMC8613290 DOI: 10.1038/s41467-021-27085-y] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Accepted: 11/01/2021] [Indexed: 12/30/2022] Open
Abstract
Impaired proteasome activity due to genetic variants of certain subunits might lead to proteasome-associated autoinflammatory syndromes (PRAAS). Here we report a de novo heterozygous missense variant of the PSMB9 proteasome subunit gene in two unrelated Japanese infants resulting in amino acid substitution of the glycine (G) by aspartic acid (D) at position 156 of the encoded protein β1i. In addition to PRAAS-like manifestations, these individuals suffer from pulmonary hypertension and immunodeficiency, which are distinct from typical PRAAS symptoms. The missense variant results in impaired immunoproteasome maturation and activity, yet ubiquitin accumulation is hardly detectable in the patients. A mouse model of the heterozygous human genetic variant (Psmb9G156D/+) recapitulates the proteasome defects and the immunodeficiency phenotype of patients. Structurally, PSMB9 G156D interferes with the β-ring-βring interaction of the wild type protein that is necessary for 20S proteasome formation. We propose the term, proteasome-associated autoinflammatory syndrome with immunodeficiency (PRAAS-ID), to indicate a separate category of autoinflammatory diseases, similar to, but distinct from PRAAS, that describes the patients in this study. Genetic variants of proteasome subunit genes have been shown to associate with perturbed immune function. Here authors show that a heterozygous missense variant of the immunoproteasome subunit β-type 9 causes an autoinflammatory/immune deficiency syndrome in humans and in a mouse model.
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190
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Yang Y, Luo Z, Yuan T. Familial hemophagocytic lymphohistiocytosis in a neonate: Case report and literature review. Medicine (Baltimore) 2021; 100:e27786. [PMID: 34964741 PMCID: PMC8615344 DOI: 10.1097/md.0000000000027786] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2021] [Accepted: 10/29/2021] [Indexed: 01/05/2023] Open
Abstract
RATIONALE Familial hemophagocytic lymphohistiocytosis (FHL) is a potentially fatal disease that rarely presents in the neonatal period. Timely diagnosis is a key challenge owing to the atypical clinical manifestations. Here, we describe a case of FHL type 3 with disease onset in the early neonatal period and review the relevant literature. Our findings may provide insights into the diagnosis and treatment of this rare disease. PATIENT CONCERNS A 6-day-old male neonate presented with fever, hepatosplenomegaly, cytopenia, hyperferritinemia, hypofibrinogenemia, hemophagocytosis, and hypertriglyceridemia. DIAGNOSIS Considering the clinical picture (prolonged fever, progressive hepatosplenomegaly, high triglycerides, low fibrinogen, and high ferritin), along with abnormal natural killer-cell activity, combining sequence analysis of genomic DNA results (compound heterozygous mutations of UNC13D), the patient was finally diagnosed with FHL type 3 (FHL3). INTERVENTIONS The patient was initially treated with HLH-1994 protocol and subsequently switched to an oral regimen of ruxolitinib due to incomplete remission of the disease. OUTCOMES The trend of change in weekly cytokine levels, neutrophil counts, hemoglobin, and platelet counts indicated that the complete remission was not achieved after the treatment of HLH-1994 protocol. The platelet counts fluctuated within the normal range after oral administration of ruxolitinib. But soon after, the patient did not respond to treatment and eventually died of respiratory failure. LESSON Timely diagnosis of FHL is challenging. This case report illustrates that thrombocytopenia can be the first clinical sign of FHL with neonatal onset. Genetic testing, detection of cytokines, and flow cytometry should be performed as soon as possible to confirm the diagnosis. Given the high morbidity and mortality of FHL, pediatricians should have a high suspicion index for this disease.
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Affiliation(s)
- Yue Yang
- Department of Neonatology, Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Zhejiang, China
| | - Zebin Luo
- Department of Hematology, Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Zhejiang, China
| | - Tianming Yuan
- Department of Neonatology, Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Zhejiang, China
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191
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Maloney LT, Baz B, Hazra D. HLH-Like Syndrome and Rhabdomyolysis in an Adolescent Patient. Pediatrics 2021; 148:peds.2021-050162. [PMID: 34702719 DOI: 10.1542/peds.2021-050162] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/06/2021] [Indexed: 01/01/2023] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a rare heterogeneous group of disorders characterized by immune overactivation. It can occur because of primary genetic mutations or secondary to almost any inflammatory or infectious process. The clinical manifestations of this syndrome are varied and life-threatening and resemble those of many malignancies, infections, sepsis, and multisystem inflammatory syndrome in children. Laboratory abnormalities often are not diagnostic for HLH until late in the disease course, and the laboratory studies are send-out tests at most institutions. Thus, quickly and accurately diagnosing pediatric patients with HLH presents significant challenges to the clinician. Furthermore, there has been recent discussion in the literature regarding the use of diagnostic criteria for HLH. In this case report, we detail an adolescent male individual who developed persistent unexplained fever, rhabdomyolysis, and regional ischemic immune myopathy. To our knowledge, there is no previous report of a pediatric patient with this rare myopathy or HLH presenting with persistent rhabdomyolysis in the literature. The patient was hospitalized for a total of 61 days, with multiple treatments attempted throughout during his course of illness. In this report, we highlight the importance of using diagnostic flexibility when HLH is suspected in pediatric patients and provide insight into the unique challenges of identifying this condition.
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Affiliation(s)
| | - Bronwyn Baz
- Department of Pediatrics, Oregon Health and Science University, Portland, Oregon.,Northwest Permanente Physicians and Surgeons, Portland, Oregon
| | - Dia Hazra
- Department of Pediatrics, Oregon Health and Science University, Portland, Oregon.,Northwest Permanente Physicians and Surgeons, Portland, Oregon
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192
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Abstract
PURPOSE OF REVIEW Red blood cell (RBC) clearance has been studied for decades in many different pathologies, which has revealed different routes of RBC degradation, depending on the situation. This review summarizes the latest mechanistic insights on RBC clearance in different contexts; during homeostatic removal, immune-mediated destruction, and systemic inflammation. RECENT FINDINGS Besides the recognition of a variety of potential 'eat me' signals on RBCs, recent evidence suggests that normal RBC degradation is driven by the increase of the adhesive properties of RBCs, mediating the retention in the spleen and leading to RBC hemolysis. Furthermore, immune-mediated degradation of RBCs seems to be fine-tuned by the balance between the density of the antigens expressed on RBCs and the presence of 'don't eat me' signals. Moreover, besides RBC clearance by macrophages, neutrophils seem to play a much more prominent role in immune-mediated RBC removal than anticipated. Lastly, RBC clearance during systemic inflammation appears to be driven by a combination of extreme macrophage activity in response to proinflammatory cytokines as well as direct damage of RBC by the inflammation or inflammatory agent. SUMMARY Recent studies on RBC clearance have expanded our knowledge on their destruction in different contexts.
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Affiliation(s)
- Silvia Neri
- Department of Molecular Hematology, Sanquin Research and Landsteiner Laboratory, University of Amsterdam, Amsterdam
| | - Dorine W Swinkels
- Translational Metabolic Laboratory, Department of Laboratory Medicine, RadboudUMC, Nijmegen, The Netherlands
| | - Hanke L Matlung
- Department of Molecular Hematology, Sanquin Research and Landsteiner Laboratory, University of Amsterdam, Amsterdam
| | - Robin van Bruggen
- Department of Molecular Hematology, Sanquin Research and Landsteiner Laboratory, University of Amsterdam, Amsterdam
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193
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Targeting interferon-γ in hyperinflammation: opportunities and challenges. Nat Rev Rheumatol 2021; 17:678-691. [PMID: 34611329 DOI: 10.1038/s41584-021-00694-z] [Citation(s) in RCA: 50] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/31/2021] [Indexed: 02/08/2023]
Abstract
Interferon-γ (IFNγ) is a pleiotropic cytokine with multiple effects on the inflammatory response and on innate and adaptive immunity. Overproduction of IFNγ underlies several, potentially fatal, hyperinflammatory or immune-mediated diseases. Several data from animal models and/or from translational research in patients point to a role of IFNγ in hyperinflammatory diseases, such as primary haemophagocytic lymphohistiocytosis, various forms of secondary haemophagocytic lymphohistiocytosis, including macrophage activation syndrome, and cytokine release syndrome, all of which are often managed by rheumatologists or in consultation with rheumatologists. Given the effects of IFNγ on B cells and T follicular helper cells, a role for IFNγ in systemic lupus erythematosus pathogenesis is emerging. To improve our understanding of the role of IFNγ in human disease, IFNγ-related biomarkers that are relevant for the management of hyperinflammatory diseases are progressively being identified and studied, especially because circulating levels of IFNγ do not always reflect its overproduction in tissue. These biomarkers include STAT1 (specifically the phosphorylated form), neopterin and the chemokine CXCL9. IFNγ-neutralizing agents have shown efficacy in the treatment of primary haemophagocytic lymphohistiocytosis in clinical trials and initial promising results have been obtained in various forms of secondary haemophagocytic lymphohistiocytosis, including macrophage activation syndrome. In clinical practice, there is a growing body of evidence supporting the usefulness of circulating CXCL9 levels as a biomarker reflecting IFNγ production.
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194
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Kikuchi A, Singh K, Gars E, Ohgami RS. Pathology updates and diagnostic approaches to hemophagocytic lymphohistiocytosis. Histopathology 2021; 80:616-626. [PMID: 34716920 DOI: 10.1111/his.14591] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Revised: 10/27/2021] [Accepted: 10/29/2021] [Indexed: 11/29/2022]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a complex, often under-recognized hyperinflammatory immune dysregulation syndrome arising in a diverse range of clinical scenarios and conditions. The accurate and timely diagnosis of HLH is crucial for patient survival, and usually requires a high level of clinical suspicion. The histologic corollary to clinical HLH - hemophagocytosis - is neither necessary nor sufficient for the diagnosis of HLH, as it may be seen in a variety of reactive conditions and may be absent in true HLH. Nevertheless, the finding of hemophagocytosis in specific clinical situations should prompt consideration of HLH and further testing to exclude the condition. While traditionally described in bone marrow, identification of hemophagocytosis in other tissues, including lymphoid, splenic, liver, or neural tissue, can be an important asset to the overall recognition of HLH. In this review we discuss the underlying pathophysiology and etiologies of HLH, morphologic aspects of hemophagocytosis and its associated histologic findings in different tissues, and give a brief overview of diagnostic criteria and clinical evaluation.
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Affiliation(s)
- Alexander Kikuchi
- Department of Pathology, University of California, San Francisco, San Francisco, CA, USA
| | - Kunwar Singh
- Department of Pathology, University of California, San Francisco, San Francisco, CA, USA
| | - Eric Gars
- Department of Pathology, Stanford University, Stanford, CA, USA
| | - Robert S Ohgami
- Department of Pathology, University of California, San Francisco, San Francisco, CA, USA
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195
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Significance of serum Th1/Th2 cytokine levels in underlying disease classification of childhood HLH. Cytokine 2021; 149:155729. [PMID: 34673333 DOI: 10.1016/j.cyto.2021.155729] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Revised: 09/20/2021] [Accepted: 09/24/2021] [Indexed: 12/14/2022]
Abstract
OBJECT Goal of this research was to investigate values of serum cytokines in childhood HLH with different triggers, with the expectation to find secretion spectrum of 5 main types of underlying diseases. METHOD 118 newly diagnosed HLH were included, and serum concentrations of 6 cytokines were tested before treatment began. Absolute cytokine levels and ratios between them were then studied in the HLH groups collectively and separately RESULTS: In general, IFN-γ, IL-10 and IL-6 showed differences among 5 HLH groups. Specifically, relative levels of these three cytokines to each other were meaningful in distinguishing 4 types of HLH. Level of IL-6 was higher than those of IFN-γ or IL-10 in HLH driven by Systemic auto-inflammatory disorders (SAIDs) or Langerhans Cell Histiocytosis (LCH), while primary HLH and EBV-HLH shared elevated ratio of IL-10 to IL-6. Although more than one distinctive ratios were found in 3 HLH groups, combination of these parameters didn't offer optimal balance between sensitivity and specificity. CONCLUSION As a group of easily gained laboratory findings, cytokine levels were reliable in the procedure of roughly classifying HLH cases with the help of patients' clinical phenotype. However, adequate data is still needed to explore the significance of these indicators in identifying one particular underlying disease accurately.
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196
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McClain KL, Bigenwald C, Collin M, Haroche J, Marsh RA, Merad M, Picarsic J, Ribeiro KB, Allen CE. Histiocytic disorders. Nat Rev Dis Primers 2021; 7:73. [PMID: 34620874 PMCID: PMC10031765 DOI: 10.1038/s41572-021-00307-9] [Citation(s) in RCA: 58] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/07/2021] [Indexed: 12/18/2022]
Abstract
The historic term 'histiocytosis' meaning 'tissue cell' is used as a unifying concept for diseases characterized by pathogenic myeloid cells that share histological features with macrophages or dendritic cells. These cells may arise from the embryonic yolk sac, fetal liver or postnatal bone marrow. Prior classification schemes align disease designation with terminal phenotype: for example, Langerhans cell histiocytosis (LCH) shares CD207+ antigen with physiological epidermal Langerhans cells. LCH, Erdheim-Chester disease (ECD), juvenile xanthogranuloma (JXG) and Rosai-Dorfman disease (RDD) are all characterized by pathological ERK activation driven by activating somatic mutations in MAPK pathway genes. The title of this Primer (Histiocytic disorders) was chosen to differentiate the above diseases from Langerhans cell sarcoma and malignant histiocytosis, which are hyperproliferative lesions typical of cancer. By comparison LCH, ECD, RDD and JXG share some features of malignant cells including activating MAPK pathway mutations, but are not hyperproliferative. 'Inflammatory myeloproliferative neoplasm' may be a more precise nomenclature. By contrast, haemophagocytic lymphohistiocytosis is associated with macrophage activation and extreme inflammation, and represents a syndrome of immune dysregulation. These diseases affect children and adults in varying proportions depending on which of the entities is involved.
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Affiliation(s)
- Kenneth L McClain
- Texas Children's Cancer Center, Department of Paediatrics, Baylor College of Medicine, Houston, TX, USA.
| | - Camille Bigenwald
- Department of Oncological Sciences and Translational and Molecular Imaging Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Matthew Collin
- Human Dendritic Cell Lab, Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Julien Haroche
- Department of Internal Medicine, Institut E3M French Reference Centre for Histiocytosis, Pitié-Salpȇtrière Hospital, Assistance Publique-Hôpitaux de Paris, Sorbonne Université, Paris, France
| | - Rebecca A Marsh
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, and University of Cincinnati, Cincinnati, OH, USA
| | - Miriam Merad
- Department of Oncological Sciences and Translational and Molecular Imaging Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jennifer Picarsic
- Division of Pathology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Karina B Ribeiro
- Faculdade de Ciȇncias Médicas da Santa Casa de São Paulo, Department of Collective Health, São Paulo, Brazil
| | - Carl E Allen
- Texas Children's Cancer Center, Department of Paediatrics, Baylor College of Medicine, Houston, TX, USA
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197
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Allard B, Delcroix O, Le Lez-Soquet S, Sacaze E, Querellou S. Central Nervous System Involvement of Hemophagocytic Lymphohistiocytosis: When 18F-FDG PET/CT Solves a Complex Diagnostic Investigation. Clin Nucl Med 2021; 46:832-836. [PMID: 33883485 DOI: 10.1097/rlu.0000000000003663] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT Hemophagocytic lymphohistiocytosis is rare life-threatening syndrome, hereditary or acquired, mainly affecting children. Hemophagocytic lymphohistiocytosis is an immune deficiency characterized by severe inflammation caused by uncontrolled proliferation of activated lymphocytes and macrophages. The usual biological and clinical data may associate polyadenopathy, hepatosplenomegaly, fever, multivisceral damages, and cytopenias with potential multiorgan dysfunction and death. We report the case of a 4-year-old girl, hospitalized for recurrent cerebellar symptoms (ataxia) associated later with fever and pancytopenia. 18F-FDG PET/CT revealed a node pathological uptake, which was biopsied and confirmed a diagnosis of hemophagocytic lymphohistiocytosis.
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198
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Li Y, Wang D, Zhang J, Huang P, Du H, Xu J, Chen H, Yan Y, Chen H, Lu X, Liu D. Human Adenovirus Type 7 Infections in Hubei, China During 2018-2019: Epidemic Features and Genetic Characterization of the Detected Viruses. Front Cell Infect Microbiol 2021; 11:684606. [PMID: 34490137 PMCID: PMC8417316 DOI: 10.3389/fcimb.2021.684606] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Accepted: 07/29/2021] [Indexed: 11/13/2022] Open
Abstract
Human adenoviruses (HAdVs) type 7 can cause severe respiratory disease. During the period between December 2018 and August 2019, HAdV-7 infection was identified in 129 patients in Wuhan Children's Hospital, Hubei Province, China. Samples were collected from hospitalized children and metagenomic sequencing was applied to detect the HAdV infections. Hemophagocytic lymphohistiocystosis (HLH) related to HAdV infections was observed in some patients clinically and patients were divided into two groups based on this to test the differences among clinical indicators. Genome variation, in silico restriction endonuclease analysis (REA), and phylogenetic analyses were carried out to show the genome characterization of HAdV-7 in this study. It was found that many indicators, such as all blood routine indicators, in patients of the HLH group showed significant levels. In this study, REA revealed that HAdV-7 might belong to genome 7d and genome variation analysis displayed the stable genome of HAdV. HAdV-7 is an ongoing threat to the public, and global surveillance should be established.
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Affiliation(s)
- Ying Li
- Wuhan Children's Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Decheng Wang
- CAS Key Laboratory of Special Pathogens and Biosafety, Wuhan Institute of Virology, Center for Biosafety Mega-Science, Chinese Academy of Sciences, Wuhan, China.,National Virus Resource Center, Chinese Academy of Sciences, Wuhan Institute of Virology, Center for Biosafety Mega-Science, Wuhan, China.,Wuhan Institute of Virology, University of Chinese Academy of Sciences, Beijing, China
| | - Jingjing Zhang
- Key Laboratory of Environment and Health (HUST), Ministry of Education & Ministry of Environmental Protection, and State Key Laboratory of Environmental Health (Incubation), School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Peiqi Huang
- Wuhan Children's Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Hui Du
- Wuhan Children's Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jiali Xu
- Wuhan Children's Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Hebin Chen
- Wuhan Children's Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yi Yan
- CAS Key Laboratory of Special Pathogens and Biosafety, Wuhan Institute of Virology, Center for Biosafety Mega-Science, Chinese Academy of Sciences, Wuhan, China.,National Virus Resource Center, Chinese Academy of Sciences, Wuhan Institute of Virology, Center for Biosafety Mega-Science, Wuhan, China.,Wuhan Institute of Virology, University of Chinese Academy of Sciences, Beijing, China
| | - Hongwei Chen
- Wuhan Children's Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xiaoxia Lu
- Wuhan Children's Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Di Liu
- CAS Key Laboratory of Special Pathogens and Biosafety, Wuhan Institute of Virology, Center for Biosafety Mega-Science, Chinese Academy of Sciences, Wuhan, China.,National Virus Resource Center, Chinese Academy of Sciences, Wuhan Institute of Virology, Center for Biosafety Mega-Science, Wuhan, China.,Wuhan Institute of Virology, University of Chinese Academy of Sciences, Beijing, China
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199
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Blanchard-Rohner G, Didierlaurent A, Tilmanne A, Smeesters P, Marchant A. Pediatric COVID-19: Immunopathogenesis, Transmission and Prevention. Vaccines (Basel) 2021; 9:1002. [PMID: 34579240 PMCID: PMC8473426 DOI: 10.3390/vaccines9091002] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Revised: 08/31/2021] [Accepted: 09/01/2021] [Indexed: 12/18/2022] Open
Abstract
Children are unique in the context of the COVID-19 pandemic. Overall, SARS-CoV-2 has a lower medical impact in children as compared to adults. A higher proportion of children than adults remain asymptomatic following SARS-CoV-2 infection and severe disease and death are also less common. This relative resistance contrasts with the high susceptibility of children to other respiratory tract infections. The mechanisms involved remain incompletely understood but could include the rapid development of a robust innate immune response. On the other hand, children develop a unique and severe complication, named multisystem inflammatory syndrome in children, several weeks after the onset of symptoms. Although children play an important role in the transmission of many pathogens, their contribution to the transmission of SARS-CoV-2 appears lower than that of adults. These unique aspects of COVID-19 in children must be considered in the benefit-risk analysis of vaccination. Several COVID-19 vaccines have been authorized for emergency use in adolescents and clinical studies are ongoing in children. As the vaccination of adolescents is rolled out in several countries, we shall learn about the impact of this strategy on the health of children and on transmission within communities.
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Affiliation(s)
- Geraldine Blanchard-Rohner
- Center of Vaccinology, Department of Pathology and Immunology, Faculty of Medicine, University of Geneva, 1205 Geneva, Switzerland
- Pediatric Immunology and Vaccinology Unit, Division of General Pediatrics, Department of Pediatrics, Gynecology and Obstetrics, Geneva University Hospitals, University of Geneva, 1205 Geneva, Switzerland;
- Children’s Hospital of Geneva, 6, Rue Willy-Donzé, 1211 Geneva, Switzerland
| | - Arnaud Didierlaurent
- Pediatric Immunology and Vaccinology Unit, Division of General Pediatrics, Department of Pediatrics, Gynecology and Obstetrics, Geneva University Hospitals, University of Geneva, 1205 Geneva, Switzerland;
| | - Anne Tilmanne
- Children’s Hospital Queen Fabiola, Université libre de Bruxelles, 1020 Brussels, Belgium; (A.T.); (P.S.)
| | - Pierre Smeesters
- Children’s Hospital Queen Fabiola, Université libre de Bruxelles, 1020 Brussels, Belgium; (A.T.); (P.S.)
| | - Arnaud Marchant
- Institute for Medical Immunology, Université libre de Bruxelles, 1050 Charleroi, Belgium;
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200
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Li N, Jiang M, Wu WC, Wei WW, Zou LQ. How to Identify Patients at High Risk of Developing Nasal-Type, Extranodal Nature Killer/T-Cell Lymphoma-Associated Hemophagocytic Syndrome. Front Oncol 2021; 11:704962. [PMID: 34490105 PMCID: PMC8416502 DOI: 10.3389/fonc.2021.704962] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 07/27/2021] [Indexed: 02/05/2023] Open
Abstract
Nasal-type, extranodal nature killer (NK)/T-cell lymphoma-associated hemophagocytic syndrome (NK/T-LAHS) is a rare and life-threatening disease, requiring investigation of risk stratification. We conducted a retrospective study and proposed nomograms to predict NK/T-LAHS. The discriminative ability and calibration of the nomograms for prediction were tested using C statistics and calibration plots. We analyzed 533 patients with extranodal NK/T-cell lymphoma (ENKTL), out of which 71 were diagnosed with hemophagocytic syndrome (HPS), with a cumulative incidence of 13.3%. Significant difference for 2-year survival was found between patients with and without HPS (14.7% vs. 77.5%). Analyses showed that Eastern Cooperative Oncology Group (ECOG) performance status (PS) ≥2, B symptoms, and bone marrow (BM) invasion were significantly associated with NK/T-LAHS. We used these data as the basis to establish a nomogram of risk index for ENKTL (RINK). In 335 patients with available data for Epstein-Barr virus DNA (EBV-DNA), we found high viral copies (≥4,450 copies/ml) were correlated with NK/T-LAHS. When these data were added to RINK, we developed another nomogram that included EBV-DNA data (RINK-E). The nomograms displayed good accuracy in predicting NK/T-LAHS with a C-statistics of 0.919 for RINK and a C-statistics of 0.946 for RINK-E, respectively. The calibration chart also showed an excellent consistency between the predicted and observed probabilities. The proposed nomograms provided individualized risk estimate of HPS in patients with ENKTL.
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Affiliation(s)
- Na Li
- Department of Medical Oncology of Cancer Center, West China Hospital, Sichuan University, Chengdu, China.,Department of Oncology, West China Fourth Hospital, Sichuan University, Chengdu, China
| | - Ming Jiang
- Department of Medical Oncology of Cancer Center, West China Hospital, Sichuan University, Chengdu, China
| | - Wan-Chun Wu
- Department of Medical Oncology of Cancer Center, West China Hospital, Sichuan University, Chengdu, China
| | - Wen-Wen Wei
- Department of Medical Oncology of Cancer Center, West China Hospital, Sichuan University, Chengdu, China
| | - Li-Qun Zou
- Department of Medical Oncology of Cancer Center, West China Hospital, Sichuan University, Chengdu, China
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