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Zheng Y, Hu G, Liu Y, Ma Y, Dang Y, Li F, Xing H, Wang T, Huo L. The role of 18F-FDG PET/CT in the management of patients with secondary haemophagocytic lymphohistiocytosis. Clin Radiol 2016; 71:1248-1254. [PMID: 27387105 DOI: 10.1016/j.crad.2016.05.011] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2016] [Revised: 05/13/2016] [Accepted: 05/19/2016] [Indexed: 01/12/2023]
Abstract
AIM To investigate the ability of combined 2-[18F]-fluoro-2-deoxy-d-glucose (18F-FDG) positron-emission tomography (PET)/computed tomography (CT) to determine potential causes of secondary haemophagocytic lymphohistiocytosis (sHLH) and to predict prognosis. MATERIAL AND METHODS Forty-three patients (male/female 20/23, median age 48.5 years), who were diagnosed with sHLH and underwent FDG-PET/CT before treatment, were retrospectively reviewed. The clinical characteristics were compared to identify the predictors of high-yield FDG-PET/CT. Univariate and multivariate analyses were conducted to identify factors associated with survival. Statistical analysis was performed using SPSS version 19.0. RESULTS PET results were helpful in 65.1% (28/43), whilst non-contributory in 34.9% (15/43) of patients with regard to the final diagnosis. Lymphoma was the most common (25/43) reason for sHLH, and patients with focal FDG uptake were more likely to be diagnosed with underlying diseases. C-reactive protein (CRP) was found to be a good indicator for the usefulness of PET/CT in HLH patients. Multivariate analysis showed that therapy regimen (hazard ratio [HR]=4.99, p=0.026), fibrinogen (FBG) <1.5 g/l (HR=3.87, p=0.049) and spleen:mediastinum ratio (SP/M) (HR=7.44, p=0.006) were independent prognostic factors for survival. CONCLUSION FDG-PET/CT could be a useful technique for detecting underlying diseases causing sHLH. CRP was a useful predictor of FDG-PET/CT effectiveness. Therapy regimen, FBG level, and SP/M were independent prognostic factors for HLH survival.
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Affiliation(s)
- Y Zheng
- Department of Nuclear Medicine, China-Japan Friendship Hospital, Beijing, PR China
| | - G Hu
- Department of Nuclear Medicine, Chinese Academy of Medical Sciences, Peking Union Medical College Hospital, Beijing, PR China
| | - Y Liu
- Department of Nuclear Medicine, Chinese Academy of Medical Sciences, Peking Union Medical College Hospital, Beijing, PR China
| | - Y Ma
- Department of Nuclear Medicine, Chinese Academy of Medical Sciences, Peking Union Medical College Hospital, Beijing, PR China
| | - Y Dang
- Department of Nuclear Medicine, Chinese Academy of Medical Sciences, Peking Union Medical College Hospital, Beijing, PR China
| | - F Li
- Department of Nuclear Medicine, Chinese Academy of Medical Sciences, Peking Union Medical College Hospital, Beijing, PR China
| | - H Xing
- Department of Nuclear Medicine, Chinese Academy of Medical Sciences, Peking Union Medical College Hospital, Beijing, PR China
| | - T Wang
- Department of Nuclear Medicine, Chinese Academy of Medical Sciences, Peking Union Medical College Hospital, Beijing, PR China
| | - L Huo
- Department of Nuclear Medicine, Chinese Academy of Medical Sciences, Peking Union Medical College Hospital, Beijing, PR China.
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Batu ED, Erden A, Seyhoğlu E, Kilic L, Büyükasık Y, Karadag O, Bilginer Y, Bilgen SA, Akdogan A, Kiraz S, Ertenli AI, Özen S, Kalyoncu U. Assessment of the HScore for reactive haemophagocytic syndrome in patients with rheumatic diseases. Scand J Rheumatol 2016; 46:44-48. [PMID: 27359073 DOI: 10.3109/03009742.2016.1167951] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
OBJECTIVES Reactive haemophagocytic syndrome (RHS) is a hyperinflammatory disorder often occurring in the background of several disorders such as infections, malignancies, and rheumatic diseases. Recently, a score known as the HScore was developed for the diagnosis of RHS. In the original study, most of the patients had underlying haematological malignancy or infection and the best cut-off value for the HScore was 169 (sensitivity 93%; specificity 86%). In this study we aimed to analyse the performance of the HScore in rheumatic disease-related RHS. METHOD The patients with rheumatic disorders evaluated in the Departments of Rheumatology and Paediatric Rheumatology at Hacettepe University, Ankara, Turkey between 2002 and 2014 were reviewed retrospectively. The first group (n = 30) consisted of patients with RHS; the control group (n = 64) included patients with active rheumatic diseases without RHS. RESULTS In the RHS group, 14 (46.7%) had adult-onset Still's disease (AOSD), 10 (33.3%) systemic juvenile idiopathic arthritis (SJIA), and six (20%) systemic lupus erythematosus (SLE). The control group (n = 64) consisted of 32 (50%) AOSD, 13 (20.3%) SJIA, and 19 (29.7%) SLE patients. Applying the HScore to the RHS patients, the best cut-off value was 190.5 with a sensitivity of 96.7% and specificity of 98.4%. When we excluded the patients from the control group who had not had bone marrow aspiration (n = 23), the same cut-off (190.5) performed best (sensitivity 96.7%; specificity 97.6%). Applying the 2004 haemophagocytic lymphohistiocytosis (HLH-2004) criteria gave a sensitivity of 56.6% and a specificity of 100% in the whole study group. CONCLUSIONS In our study, a cut-off value for the HScore different from the original study performed better. Further studies are warranted to determine optimum cut-off values in different studies.
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Affiliation(s)
- E D Batu
- a Department of Paediatrics, Division of Rheumatology , Hacettepe University Faculty of Medicine , Ankara , Turkey
| | - A Erden
- b Department of Internal Medicine, Division of Rheumatology , Hacettepe University Faculty of Medicine , Ankara , Turkey
| | - E Seyhoğlu
- c Department of Internal Medicine , Hacettepe University Faculty of Medicine , Ankara , Turkey
| | - L Kilic
- b Department of Internal Medicine, Division of Rheumatology , Hacettepe University Faculty of Medicine , Ankara , Turkey
| | - Y Büyükasık
- d Department of Internal Medicine, Division of Haematology , Hacettepe University Faculty of Medicine , Ankara , Turkey
| | - O Karadag
- b Department of Internal Medicine, Division of Rheumatology , Hacettepe University Faculty of Medicine , Ankara , Turkey
| | - Y Bilginer
- a Department of Paediatrics, Division of Rheumatology , Hacettepe University Faculty of Medicine , Ankara , Turkey
| | - S A Bilgen
- b Department of Internal Medicine, Division of Rheumatology , Hacettepe University Faculty of Medicine , Ankara , Turkey
| | - A Akdogan
- b Department of Internal Medicine, Division of Rheumatology , Hacettepe University Faculty of Medicine , Ankara , Turkey
| | - S Kiraz
- b Department of Internal Medicine, Division of Rheumatology , Hacettepe University Faculty of Medicine , Ankara , Turkey
| | - A I Ertenli
- b Department of Internal Medicine, Division of Rheumatology , Hacettepe University Faculty of Medicine , Ankara , Turkey
| | - S Özen
- a Department of Paediatrics, Division of Rheumatology , Hacettepe University Faculty of Medicine , Ankara , Turkey
| | - U Kalyoncu
- b Department of Internal Medicine, Division of Rheumatology , Hacettepe University Faculty of Medicine , Ankara , Turkey
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253
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Chen Y, Wang Z, Luo Z, Zhao N, Yang S, Tang Y. Comparison of Th1/Th2 cytokine profiles between primary and secondary haemophagocytic lymphohistiocytosis. Ital J Pediatr 2016; 42:50. [PMID: 27209435 PMCID: PMC4875745 DOI: 10.1186/s13052-016-0262-7] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Accepted: 05/10/2016] [Indexed: 12/26/2022] Open
Abstract
Background Haemophagocytic lymphohistiocytosis (HLH) is a life-threatening disorder of immune regulation, and HLH patients with mutations in genes including PRF1, UNC13D, STX11, STXBP2, SH2D1A, XIAP, and ITK were reported to be primary HLH. Due to the different treatment options, the differentiation between primary and secondary HLH is critical. Our previous studies have showed that a Th1/Th2 cytokine profile is diagnostic for HLH, yet the cytokine profiles between primary and secondary HLH have not been compared. The aim of the study was to test whether the Th1/Th2 cytokine profile could be used as a tool to differentiate between primary and secondary HLH. Methods A total of 45 hospitalized Chinese children with HLH during the period of February 2010 through September 2012 were enrolled in the study. Fifty healthy children were enrolled as controls. Primary HLH related genes were sequenced using genomic DNA samples. The Th1/Th2 cytokine levels including interferon-γ (IFN-γ), tumor necrosis factor-alpha (TNF-α), interleukin (IL)-10, IL-6, IL-4 and IL-2 were quantitatively determined by cytometric bead assay techniques. Results Primary HLH group (n = 4) included one patient with biallelic heterozygous mutations in PRF1 gene, and three patients with hemizygous mutation in SH2D1A gene. Based on the available genetic data, the other 41 patients were classified into the secondary HLH group. When compared the cytokine levels between the two groups, IL-4 level in primary-HLH was significantly lower than that in secondary HLH (P = 0.025), while IFN-γ level in primary HLH had a tendency of statistically lower than that in secondary HLH (P = 0.051). Area under receiver operating characteristic (ROC) curves of IL-4 and IFN-γ, IL-10, TNF-α, IL-2, and IL-6 levels were 0.841, 0.799, 0.506, 0.494, 0.457, and 0.250, respectively. ROC curves showed that 1.7 pg/ml of IL-4 had sensitivity and specificity for differentiation between primary and secondary HLH as 70.7 and 100.0 %, while 433.9 pg/ml of IFN-γ had sensitivity and specificity as 51.2 and 100.0 %, respectively. Conclusions HLH patients with lower IL-4 and IFN-γ levels have higher possibility to be primary HLH. The cytokine profile may be used as an additional tool for the quick differential diagnosis between primary and secondary HLH. Electronic supplementary material The online version of this article (doi:10.1186/s13052-016-0262-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Yuanyuan Chen
- Division of Hematology-oncology, Children's Hospital of Zhejiang University School of Medicine, #57 Zhuganxiang Road, Hangzhou, 310003, PR China
| | - Zhujun Wang
- Division of Hematology-oncology, Children's Hospital of Zhejiang University School of Medicine, #57 Zhuganxiang Road, Hangzhou, 310003, PR China
| | - Zebin Luo
- Division of Hematology-oncology, Children's Hospital of Zhejiang University School of Medicine, #57 Zhuganxiang Road, Hangzhou, 310003, PR China
| | - Ning Zhao
- Division of Hematology-oncology, Children's Hospital of Zhejiang University School of Medicine, #57 Zhuganxiang Road, Hangzhou, 310003, PR China
| | - Shilong Yang
- Division of Hematology-oncology, Children's Hospital of Zhejiang University School of Medicine, #57 Zhuganxiang Road, Hangzhou, 310003, PR China
| | - Yongmin Tang
- Division of Hematology-oncology, Children's Hospital of Zhejiang University School of Medicine, #57 Zhuganxiang Road, Hangzhou, 310003, PR China.
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Current Updates on Classification, Diagnosis and Treatment of Hemophagocytic Lymphohistiocytosis (HLH). Indian J Pediatr 2016; 83:434-43. [PMID: 26872683 DOI: 10.1007/s12098-016-2037-y] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2015] [Accepted: 01/11/2016] [Indexed: 10/22/2022]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a life threatening hyperinflammatory syndrome characterized by excessive activation of macrophages and T cells resulting from defective cytotoxicity. Severe hyperinflammation caused by uncontrolled proliferation of activated lymphocytes and histiocytes (macrophages) secreting high amounts of inflammatory cytokines threatens the life of the patient and may lead to death unless arrested by appropriate treatment. HLH can be caused either by certain underlying genetic diseases (familial HLH), or may also occur due to particular triggers in patients with no known inherited disorder (acquired HLH). Due to life threatening nature of the disease, early diagnosis and initiation of immunosuppressive therapy is extremely important. HLH diagnosis is based on constellation of clinical manifestations and laboratory parameters which often overlap with those of severe infection or sepsis. Identification of patients with familial HLH and their underlying genetic defects requires specialized laboratory tests and is important for predicting relapses and planning early therapeutic hematopoietic stem cell transplantation (HSCT). A high suspicion and thorough clinical, immunological and genetic work-up is required for diagnosis of HLH. Prompt initiation of adequate treatment is essential for the survival. Substantial progress has been made in exploring the complex cause and pathophysiology of HLH and also in management of HLH patients.
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Bienemann K, Daschkey S, Sörensen J, Schwabe D, Klingebiel T, Hönscheid A, Gombert M, Ginzel S, Borkhardt A. A novel homozygous mutation in UNC13D presenting as Epstein-Barr-virus-associated lymphoproliferative disease at 9 years of age. Leuk Lymphoma 2016; 57:2949-2951. [PMID: 27123661 DOI: 10.1080/10428194.2016.1177724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Kirsten Bienemann
- a Pediatric Oncology, Hematology and Clinical Immunology , Heinrich Heine University Medical Center , Düsseldorf , Germany
| | - Svenja Daschkey
- a Pediatric Oncology, Hematology and Clinical Immunology , Heinrich Heine University Medical Center , Düsseldorf , Germany
| | - Jan Sörensen
- b Clinic for Hematology/Oncology and Clinic for Stem Cell Transplantation and Immunology , University Children's Hospital , Frankfurt , Germany
| | - Dirk Schwabe
- b Clinic for Hematology/Oncology and Clinic for Stem Cell Transplantation and Immunology , University Children's Hospital , Frankfurt , Germany
| | - Thomas Klingebiel
- b Clinic for Hematology/Oncology and Clinic for Stem Cell Transplantation and Immunology , University Children's Hospital , Frankfurt , Germany
| | - Andrea Hönscheid
- a Pediatric Oncology, Hematology and Clinical Immunology , Heinrich Heine University Medical Center , Düsseldorf , Germany
| | - Michael Gombert
- a Pediatric Oncology, Hematology and Clinical Immunology , Heinrich Heine University Medical Center , Düsseldorf , Germany
| | - Sebastian Ginzel
- a Pediatric Oncology, Hematology and Clinical Immunology , Heinrich Heine University Medical Center , Düsseldorf , Germany
| | - Arndt Borkhardt
- a Pediatric Oncology, Hematology and Clinical Immunology , Heinrich Heine University Medical Center , Düsseldorf , Germany
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Gao L, Dang X, Huang L, Zhu L, Fang M, Zhang J, Xu X, Zhu L, Li T, Zhao L, Wei J, Zhou J. Search for the potential "second-hit" mechanism underlying the onset of familial hemophagocytic lymphohistiocytosis type 2 by whole-exome sequencing analysis. Transl Res 2016; 170:26-39. [PMID: 26739415 DOI: 10.1016/j.trsl.2015.12.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2015] [Revised: 11/22/2015] [Accepted: 12/03/2015] [Indexed: 01/30/2023]
Abstract
Familial hemophagocytic lymphohistiocytosis type 2 (FHL2), caused by perforin 1 (PRF1), is a genetic disorder of lymphocyte cytotoxicity that usually presents in the first 2 years of life and has a poor prognosis. Late onset of FHL2 has been sporadically reported, and the mechanism is largely unknown. A newly diagnosed FHL2 patient was detected to have compound mutations in both PRF1 alleles and positive Epstein-Barr virus (EBV) infection. Her brother carried the same mutations and EBV infection status but kept healthy. To search the potential unknown mechanisms, we performed whole-exome sequencing analysis. The patient and her asymptomatic brother carried the same heterozygous missense (c.916G>A) and frameshift mutation (c.65delC) in PRF1. Germline mutation analysis demonstrated that only the proband was exclusively detected with a homozygous missense mutation (S1006L) in the PCDH18 gene, whereas others were found to have a heterozygous mutation (S1006L) of PCDH18. The calculated stability (free energy) changes showed that the mutation of PCDH18 mainly destabilized the protein structure. Furthermore, the mutation (S1006L) could lessen the PCDH18-induced inhibition of target cell activation and reduce the apoptosis of T lymphocytes. This study is the first to perform whole-exome sequencing analysis to search the potential "second-hit" mechanism that underlies the onset of FHL2. A novel type of compound heterozygous mutation has been found in PRF1. The detection of the homozygous germline mutation in PCDH18 strongly argues that the presence of a "second" germline mutation besides the PRF1 gene might be potentially an important mechanism for triggering the onset of FHL2.
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Affiliation(s)
- Lili Gao
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People's Republic of China
| | - Xiao Dang
- BGI Education Center, University of Chinese Academy of Sciences, Shenzhen, People's Republic of China; BGI-Shenzhen, Shenzhen, People's Republic of China
| | - Liang Huang
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People's Republic of China
| | - Li Zhu
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People's Republic of China
| | - Mingyan Fang
- BGI-Shenzhen, Shenzhen, People's Republic of China
| | | | - Xun Xu
- BGI-Shenzhen, Shenzhen, People's Republic of China
| | - Lijun Zhu
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People's Republic of China
| | - Tongjuan Li
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People's Republic of China
| | - Lei Zhao
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People's Republic of China
| | - Jia Wei
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People's Republic of China.
| | - Jianfeng Zhou
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People's Republic of China.
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Revised classification of histiocytoses and neoplasms of the macrophage-dendritic cell lineages. Blood 2016; 127:2672-81. [PMID: 26966089 DOI: 10.1182/blood-2016-01-690636] [Citation(s) in RCA: 879] [Impact Index Per Article: 109.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Accepted: 03/02/2016] [Indexed: 12/11/2022] Open
Abstract
The histiocytoses are rare disorders characterized by the accumulation of macrophage, dendritic cell, or monocyte-derived cells in various tissues and organs of children and adults. More than 100 different subtypes have been described, with a wide range of clinical manifestations, presentations, and histologies. Since the first classification in 1987, a number of new findings regarding the cellular origins, molecular pathology, and clinical features of histiocytic disorders have been identified. We propose herein a revision of the classification of histiocytoses based on histology, phenotype, molecular alterations, and clinical and imaging characteristics. This revised classification system consists of 5 groups of diseases: (1) Langerhans-related, (2) cutaneous and mucocutaneous, and (3) malignant histiocytoses as well as (4) Rosai-Dorfman disease and (5) hemophagocytic lymphohistiocytosis and macrophage activation syndrome. Herein, we provide guidelines and recommendations for diagnoses of these disorders.
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Zhou XH, Luo JM, Bin Q, Huang XH. [Expression of porforin and granzyme B in familial hemophagocytic lymphohistiocytosis]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2016; 37:227-32. [PMID: 27033761 PMCID: PMC7342954 DOI: 10.3760/cma.j.issn.0253-2727.2016.03.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/21/2015] [Indexed: 12/28/2022]
Abstract
OBJECTIVE To analyze the correlation between genetic variants of PRF1 and expression level of perforin and granzyme B protein, and further determine the relationship between PRF1 gene variants and cytotoxic T lymphocyte/natural killer (CTL/NK) cell function in famililal hemophagocytic lymphohistiocytosis (FHL2). METHODS Eight children of FHL2 (P1-P8) after treatment, as well as parents and siblings of P1-P5 were included, and thirty healthy children came for physical examination were designated as controls. PRF1, Unc13D, STX11, STXBP2, RAB27A, LYST, SH2D1A, BIRC4 exons were amplified by PCR and followed by direct sequencing. Bioinformatics analysis of mutant PRF1 was performed by ExPASy online system. Perforin and granzyme B expression on cytotoxic lymphocyte was detected by flow cytometry. RESULTS ① Three of eight FHL2 children harbored heterozygous missense of PRF1 exons: P1 had compound heterozygous missense mutations (R4C and R33H) and P2 had heterozygous mutations (V50L), P3 had heterozygous mutations (R489W), which confirmed the diagnosis of FHL2. The father (F1) and younger brother (B1) of P1 also had compound heterozygous missense mutation (R4C/R33H), the mother (M2) and younger brother (B2) of P2 had V50L mutation, the father (F3) of P3 had no R489W mutation and the mother of P3 did not participate in this research, so mutation of R4C/R33H of P1 inherited from paternal line, and V50L mutation of P2 came from maternal line, R489W mutation of P3 came from maternal line. ② Comparing to control group, perforin expression of CD8(+) T cells and natural killer (NK) cells of P1, F1, B1, P2, M2 and B2 decreased significantly, but there was no significant difference between two groups in terms of granzyme B expression. CONCLUSIONS R4C/R33H compound heterozygous mutation and V50L heterozygous mutation all cause lower expression of perforin on CTL/NK cells, and may be causative mutations for familial hemophagocytic lymphohistiocytosis.
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Affiliation(s)
- X H Zhou
- Department of Pediatrics, Guangxi Medical University First Affiliated Hospital, Nanning 530021, China
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Put K, Brisse E, Avau A, Imbrechts M, Mitera T, Janssens R, Proost P, Fallarino F, Wouters CH, Matthys P. IDO1 Deficiency Does Not Affect Disease in Mouse Models of Systemic Juvenile Idiopathic Arthritis and Secondary Hemophagocytic Lymphohistiocytosis. PLoS One 2016; 11:e0150075. [PMID: 26914138 PMCID: PMC4767214 DOI: 10.1371/journal.pone.0150075] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2015] [Accepted: 02/04/2016] [Indexed: 01/16/2023] Open
Abstract
OBJECTIVES Indoleamine 2,3-dioxygenase-1 (IDO1) is an immune-modulatory enzyme that catalyzes the degradation of tryptophan (Trp) to kynurenine (Kyn) and is strongly induced by interferon (IFN)-γ. We previously reported highly increased levels of IFN-γ and corresponding IDO activity in patients with hemophagocytic lymphohistiocytosis (HLH), a hyper-inflammatory syndrome. On the other hand, IFN-γ and IDO were low in patients with systemic juvenile idiopathic arthritis (sJIA), an autoinflammatory syndrome. As HLH can occur as a complication of sJIA, the opposing levels of both IFN-γ and IDO are remarkable. In animal models for sJIA and HLH, the role of IFN-γ differs from being protective to pathogenic. In this study, we aimed to unravel the role of IDO1 in the pathogenesis of sJIA and HLH. METHODS Wild-type and IDO1-knockout (IDO1-KO) mice were used in 3 models of sJIA or HLH: complete Freund's adjuvant (CFA)-injected mice developed an sJIA-like syndrome and secondary HLH (sHLH) was evoked by either repeated injection of unmethylated CpG oligonucleotide or by primary infection with mouse cytomegalovirus (MCMV). An anti-CD3-induced cytokine release syndrome was used as a non-sJIA/HLH control model. RESULTS No differences were found in clinical, laboratory and hematological features of sJIA/HLH between wild-type and IDO1-KO mice. As IDO modulates the immune response via induction of regulatory T cells and inhibition of T cell proliferation, we investigated both features in a T cell-triggered cytokine release syndrome. Again, no differences were observed in serum cytokine levels, percentages of regulatory T cells, nor of proliferating or apoptotic thymocytes and lymph node cells. CONCLUSIONS Our data demonstrate that IDO1 deficiency does not affect inflammation in sJIA, sHLH and a T cell-triggered cytokine release model. We hypothesize that other tryptophan-catabolizing enzymes like IDO2 and tryptophan 2,3-dioxygenase (TDO) might compensate for the lack of IDO1.
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MESH Headings
- Animals
- Apoptosis/immunology
- Arthritis, Experimental/genetics
- Arthritis, Experimental/immunology
- Arthritis, Juvenile/genetics
- Arthritis, Juvenile/pathology
- Cell Proliferation
- Cytokines/blood
- Cytomegalovirus/immunology
- Cytomegalovirus Infections/immunology
- Cytomegalovirus Infections/pathology
- Freund's Adjuvant/immunology
- Indoleamine-Pyrrole 2,3,-Dioxygenase/genetics
- Indoleamine-Pyrrole 2,3,-Dioxygenase/metabolism
- Inflammation/immunology
- Interferon-gamma/genetics
- Interferon-gamma/immunology
- Interferon-gamma/metabolism
- Lymphohistiocytosis, Hemophagocytic/genetics
- Lymphohistiocytosis, Hemophagocytic/pathology
- Macrophage Activation Syndrome/genetics
- Macrophage Activation Syndrome/pathology
- Mice
- Mice, Inbred BALB C
- Mice, Inbred C57BL
- Mice, Knockout
- T-Lymphocytes/immunology
- Tryptophan Oxygenase/metabolism
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Affiliation(s)
- Karen Put
- Laboratory of Immunobiology, Rega-Institute for Medical Research, Department of Immunology and Microbiology, KU Leuven – University of Leuven, Leuven, Belgium
| | - Ellen Brisse
- Laboratory of Immunobiology, Rega-Institute for Medical Research, Department of Immunology and Microbiology, KU Leuven – University of Leuven, Leuven, Belgium
| | - Anneleen Avau
- Laboratory of Immunobiology, Rega-Institute for Medical Research, Department of Immunology and Microbiology, KU Leuven – University of Leuven, Leuven, Belgium
| | - Maya Imbrechts
- Laboratory of Immunobiology, Rega-Institute for Medical Research, Department of Immunology and Microbiology, KU Leuven – University of Leuven, Leuven, Belgium
| | - Tania Mitera
- Laboratory of Immunobiology, Rega-Institute for Medical Research, Department of Immunology and Microbiology, KU Leuven – University of Leuven, Leuven, Belgium
| | - Rik Janssens
- Laboratory of Molecular Immunology, Rega-Institute for Medical Research, Department of Immunology and Microbiology, KU Leuven – University of Leuven, Leuven, Belgium
| | - Paul Proost
- Laboratory of Molecular Immunology, Rega-Institute for Medical Research, Department of Immunology and Microbiology, KU Leuven – University of Leuven, Leuven, Belgium
| | - Francesca Fallarino
- Department of Experimental Medicine and Biochemical Sciences, University of Perugia, Perugia, Italy
| | - Carine H. Wouters
- Laboratory of Pediatric Immunology, University Hospitals Leuven, KU Leuven – University of Leuven, Leuven, Belgium
| | - Patrick Matthys
- Laboratory of Immunobiology, Rega-Institute for Medical Research, Department of Immunology and Microbiology, KU Leuven – University of Leuven, Leuven, Belgium
- * E-mail:
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Zhang M, Bracaglia C, Prencipe G, Bemrich-Stolz CJ, Beukelman T, Dimmitt RA, Chatham WW, Zhang K, Li H, Walter MR, De Benedetti F, Grom AA, Cron RQ. A Heterozygous RAB27A Mutation Associated with Delayed Cytolytic Granule Polarization and Hemophagocytic Lymphohistiocytosis. THE JOURNAL OF IMMUNOLOGY 2016; 196:2492-503. [PMID: 26880764 DOI: 10.4049/jimmunol.1501284] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 06/10/2015] [Accepted: 01/12/2016] [Indexed: 11/19/2022]
Abstract
Frequently fatal, primary hemophagocytic lymphohistiocytosis (HLH) occurs in infancy resulting from homozygous mutations in NK and CD8 T cell cytolytic pathway genes. Secondary HLH presents after infancy and may be associated with heterozygous mutations in HLH genes. We report two unrelated teenagers with HLH and an identical heterozygous RAB27A mutation (c.259G→C). We explore the contribution of this Rab27A missense (p.A87P) mutation on NK cell cytolytic function by cloning it into a lentiviral expression vector prior to introduction into the human NK-92 cell line. NK cell degranulation (CD107a expression), target cell conjugation, and K562 target cell lysis was compared between mutant- and wild-type-transduced NK-92 cells. Polarization of granzyme B to the immunologic synapse and interaction of mutant Rab27A (p.A87P) with Munc13-4 were explored by confocal microscopy and proximity ligation assay, respectively. Overexpression of the RAB27A mutation had no effect on cell conjugate formation between the NK and target cells but decreased NK cell cytolytic activity and degranulation. Moreover, the mutant Rab27A protein decreased binding to Munc13-4 and delayed granzyme B polarization toward the immunologic synapse. This heterozygous RAB27A mutation blurs the genetic distinction between primary and secondary HLH by contributing to HLH via a partial dominant-negative effect.
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Affiliation(s)
- Mingce Zhang
- Division of Pediatric Rheumatology, University of Alabama at Birmingham, Birmingham, AL 35233
| | - Claudia Bracaglia
- Divisione di Reumatologia Pediatrica, Ospedale Pediatrico Bambino Gesù, 00165 Rome, Italy
| | - Giusi Prencipe
- Divisione di Reumatologia Pediatrica, Ospedale Pediatrico Bambino Gesù, 00165 Rome, Italy
| | - Christina J Bemrich-Stolz
- Division of Pediatric Hematology-Oncology, University of Alabama at Birmingham, Birmingham, AL 35233
| | - Timothy Beukelman
- Division of Pediatric Rheumatology, University of Alabama at Birmingham, Birmingham, AL 35233; Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL 35294
| | - Reed A Dimmitt
- Division of Pediatric Gastroenterology, University of Alabama at Birmingham, Birmingham, AL 35233
| | - W Winn Chatham
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL 35294
| | - Kejian Zhang
- Human Genetics, University of Cincinnati, Cincinnati, OH 45229
| | - Hao Li
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL 35294
| | - Mark R Walter
- Department of Microbiology, University of Alabama at Birmingham, Birmingham, AL 35294; and
| | - Fabrizio De Benedetti
- Divisione di Reumatologia Pediatrica, Ospedale Pediatrico Bambino Gesù, 00165 Rome, Italy
| | - Alexei A Grom
- Division of Pediatric Rheumatology, University of Cincinnati, Cincinnati, OH 45229
| | - Randy Q Cron
- Division of Pediatric Rheumatology, University of Alabama at Birmingham, Birmingham, AL 35233; Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL 35294;
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261
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Polygenic mutations in the cytotoxicity pathway increase susceptibility to develop HLH immunopathology in mice. Blood 2016; 127:2113-21. [PMID: 26864340 DOI: 10.1182/blood-2015-12-688960] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2015] [Accepted: 02/06/2016] [Indexed: 02/06/2023] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening hyperinflammatory disease. Inherited forms of HLH are caused by biallelic mutations in several effectors of granule-dependent lymphocyte-mediated cytotoxicity. A small proportion of patients with a so-called "secondary" form of HLH, which develops in the aftermath of infection, autoimmunity, or cancer, carry a monoallelic mutation in one or more HLH-associated genes. Although this observation suggests that HLH may have a polygenic mode of inheritance, the latter is very difficult to prove in humans. In order to determine whether the accumulation of partial genetic defects in lymphocyte-mediated cytotoxicity can contribute to the development of HLH, we generated mice that were doubly or triply heterozygous for mutations in HLH-associated genes, those coding for perforin, Rab27a, and syntaxin-11. We found that the accumulation of monoallelic mutations did indeed increase the risk of developing HLH immunopathology after lymphocytic choriomeningitis virus infection. In mechanistic terms, the accumulation of heterozygous mutations in the two degranulation genes Rab27a and syntaxin-11, impaired the dynamics and secretion of cytotoxic granules at the immune synapse of T lymphocytes. In addition, the accumulation of heterozygous mutations within the three genes impaired natural killer lymphocyte cytotoxicity in vivo. The genetic defects can be ranked in terms of the severity of the resulting HLH manifestations. Our results form the basis of a polygenic model of the occurrence of secondary HLH.
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262
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Cifaldi L, Prencipe G, Caiello I, Bracaglia C, Locatelli F, De Benedetti F, Strippoli R. Inhibition of natural killer cell cytotoxicity by interleukin-6: implications for the pathogenesis of macrophage activation syndrome. Arthritis Rheumatol 2016; 67:3037-46. [PMID: 26251193 DOI: 10.1002/art.39295] [Citation(s) in RCA: 196] [Impact Index Per Article: 24.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2014] [Accepted: 07/16/2015] [Indexed: 12/16/2022]
Abstract
OBJECTIVE Systemic juvenile idiopathic arthritis (JIA) is associated with high levels of interleukin-6 (IL-6) in the serum and synovial fluid, and impairment of natural killer (NK) cell function is often observed. This study was undertaken to evaluate a possible link between these 2 biologic findings and whether they may be associated with the development of macrophage activation syndrome, a condition frequently observed in systemic JIA. METHODS Splenocytes from wild-type (WT) or IL-6-transgenic (Tg) mice were evaluated for NK cell cytotoxicity using a (51) Cr-release assay. Numbers of NK cells and expression of perforin, granzyme B, CD69, and CD107a were evaluated by flow cytometry. Human peripheral blood mononuclear cells (PBMCs) isolated from healthy donors were treated with IL-6 and cultured in the presence or absence of tocilizumab (TCZ), an IL-6 receptor blocker. Human polyclonal NK cells from healthy donor PBMCs were evaluated for cell cytotoxicity and expression of perforin, granzyme B, and CD107a. PBMCs harvested from patients with systemic JIA during periods of active or inactive disease were left untreated or treated with IL-6 in combination with soluble IL-6 receptor and analyzed for the expression of perforin and granzyme B. RESULTS Splenic NK cell cytotoxicity was reduced in IL-6-Tg mice compared to WT mice. Levels of CD69 and CD107a showed no significant differences, whereas expression of perforin and granzyme B was impaired in NK cells from IL-6-Tg mice. Exposure of human peripheral blood NK cells to IL-6 led to reduced expression of perforin and granzyme B. Culturing human polyclonal NK cells in the presence of TCZ significantly increased cell cytotoxicity, and also increased expression of perforin and granzyme B. In patients with systemic JIA, a reduction in IL-6 plasma levels during disease remission correlated with the rescue of perforin and granzyme B expression in NK cells from these patients. CONCLUSION In both mice and humans, IL-6 down-modulated the cytotoxic activity of NK cells. This decrease was associated with reduced perforin and granzyme B levels in the absence of altered granule exocytosis.
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Affiliation(s)
| | | | - Ivan Caiello
- IRCCS Bambino Gesú Children's Hospital, Rome, Italy
| | | | - Franco Locatelli
- IRCCS Bambino Gesú Children's Hospital, Rome, Italy, and University of Pavia, Pavia, Italy
| | | | - Raffaele Strippoli
- IRCCS Bambino Gesú Children's Hospital and Sapienza University of Rome, Rome, Italy
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263
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Janus kinase inhibition lessens inflammation and ameliorates disease in murine models of hemophagocytic lymphohistiocytosis. Blood 2016; 127:1666-75. [PMID: 26825707 DOI: 10.1182/blood-2015-12-684399] [Citation(s) in RCA: 179] [Impact Index Per Article: 22.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2015] [Accepted: 01/13/2016] [Indexed: 02/06/2023] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) comprises an emerging spectrum of inherited and noninherited disorders of the immune system characterized by the excessive production of cytokines, including interferon-γ and interleukins 2, 6, and 10 (IL-2, IL-6, and IL-10). The Janus kinases (JAKs) transduce signals initiated following engagement of specific receptors that bind a broad array of cytokines, including those overproduced in HLH. Based on the central role for cytokines in the pathogenesis of HLH, we sought to examine whether the inhibition of JAK function might lessen inflammation in murine models of the disease. Toward this end, we examined the effects of JAK inhibition using a model of primary (inherited) HLH in which perforin-deficient (Prf1(-∕-)) mice are infected with lymphocytic choriomeningitis virus (LCMV) and secondary (noninherited) HLH in which C57BL/6 mice receive repeated injections of CpG DNA. In both models, treatment with the JAK1/2 inhibitor ruxolitinib significantly lessened the clinical and laboratory manifestations of HLH, including weight loss, organomegaly, anemia, thrombocytopenia, hypercytokinemia, and tissue inflammation. Importantly, ruxolitinib treatment also significantly improved the survival of LCMV-infectedPrf1(-∕-)mice. Mechanistic studies revealed that in vivo exposure to ruxolitinib inhibited signal transducer and activation of transcription 1-dependent gene expression, limited CD8(+)T-cell expansion, and greatly reduced proinflammatory cytokine production, without effecting degranulation and cytotoxic function. Collectively, these findings highlight the JAKs as novel, druggable targets for mitigating the cytokine-driven hyperinflammation that occurs in HLH. These observations also support the incorporation of JAK inhibitors such as ruxolitinib into future clinical trials for patients with these life-threatening disorders.
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264
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Aguayo-Hiraldo P, Arasaratnam R, Rouce RH. Recent advances in the risk factors, diagnosis and management of Epstein-Barr virus post-transplant lymphoproliferative disease. BOLETIN MEDICO DEL HOSPITAL INFANTIL DE MEXICO 2016; 73:31-40. [PMID: 29421230 DOI: 10.1016/j.bmhimx.2015.11.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Accepted: 11/10/2015] [Indexed: 12/22/2022] Open
Abstract
Fifty years after the first reports of Epstein-Barr virus (EBV)-associated endemic Burkitt's lymphoma, EBV has emerged as the third most prevalent oncogenic virus worldwide. EBV infection is associated with various malignancies including Hodgkin and non-Hodgkin lymphoma, NK/T-cell lymphoma and nasopharyngeal carcinoma. Despite the highly specific immunologic control in the immunocompetent host, EBV can cause severe complications in the immunocompromised host (namely, post-transplant lymphoproliferative disease). This is particularly a problem in patients with delayed immune reconstitution post-hematopoietic stem cell transplant or solid organ transplant. Despite advances in diagnostic techniques and treatment algorithms allowing earlier identification and treatment of patients at highest risk, mortality rates remain as high as 90% if not treated early. The cornerstones of treatment include reduction in immunosuppression and in vivo B cell depletion with an anti-CD20 monoclonal antibody. However, these treatment modalities are not always feasible due to graft rejection, emergence of graft vs. host disease, and toxicity. Newer treatment modalities include the use of adoptive T cell therapy, which has shown promising results in various EBV-related malignancies. In this article we will review recent advances in risk factors, diagnosis and management of EBV-associated malignancies, particularly post-transplant lymphoproliferative disease. We will also discuss new and innovative treatment options including adoptive T cell therapy as well as management of special situations such as chronic active EBV and EBV-associated hemophagocytic lymphohistiocytosis.
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Affiliation(s)
- Paibel Aguayo-Hiraldo
- Texas Children's Cancer and Hematology Centers/Baylor College of Medicine, Houston, Texas, USA; Center for Cell and Gene Therapy, Baylor College of Medicine, Houston Methodist Hospital and Texas Children's Hospital, Houston, Texas, USA
| | - Reuben Arasaratnam
- Center for Cell and Gene Therapy, Baylor College of Medicine, Houston Methodist Hospital and Texas Children's Hospital, Houston, Texas, USA
| | - Rayne H Rouce
- Texas Children's Cancer and Hematology Centers/Baylor College of Medicine, Houston, Texas, USA; Center for Cell and Gene Therapy, Baylor College of Medicine, Houston Methodist Hospital and Texas Children's Hospital, Houston, Texas, USA.
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265
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Lerolle N, Laanani M, Rivière S, Galicier L, Coppo P, Meynard JL, Molina JM, Azoulay E, Aumont C, Marzac C, Fardet L, Lambotte O. Diversity and combinations of infectious agents in 38 adults with an infection-triggered reactive haemophagocytic syndrome: a multicenter study. Clin Microbiol Infect 2015; 22:268.e1-8. [PMID: 26686809 DOI: 10.1016/j.cmi.2015.11.018] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2015] [Revised: 10/25/2015] [Accepted: 11/29/2015] [Indexed: 12/21/2022]
Abstract
Reactive haemophagocytic syndrome (HS) is a rare condition that occurs in patients with infections, haematological malignancies or autoimmune diseases. Although various microorganisms are thought to trigger HS, most of the literature data on this topic have been gathered in single-centre case series. Here, we sought to characterize infectious triggers in a large, multicentre cohort of patients with HS. Patients were included in the present study if HS was solely due to one or more infections. Detailed microbiological data were recorded. Of the 162 patients with HS in the cohort, 40 (25%) had at least one infection and 38 of the latter (including 14 women, 36.8%) were included. The median age was 46 years. Seven patients were presumed to be immunocompetent (18.4%), whereas 19 patients (50%) were infected with human immunodeficiency virus and 12 patients (31.6%) were immunocompromised for other reasons. Twenty-seven patients (71.1%) had a single infection, whereas six (15.8%) and five (13.1%) patients had, respectively, two and three concomitant infections. We observed pyogenic bacterial infections (n = 7), tuberculosis (n = 10), non-tuberculous mycobacteriosis (n = 3), viral infections (n = 17: 11 cytomegalovirus, three Epstein-Barr virus, two human herpesvirus 8, one herpes simplex virus 2), parasitic infections (n = 8: four disseminated toxoplasmosis, one leishmaniasis, three malaria), fungal infections (n = 5: four pulmonary pneumocystosis and one candidaemia). Eighteen patients (47.4%) received corticosteroids and/or etoposide. Twelve patients died (31.6%). All multiple infections and all deaths occurred in immunocompromised patients. When compared with patients suffering from malignancy-associated HS, patients with infection-triggered HS were younger and more likely to be immunocompromised, and had a better outcome.
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Affiliation(s)
- N Lerolle
- Service de Médecine Interne-Immunologie clinique, Hôpital Bicêtre, Université Paris Sud, Paris, France.
| | - M Laanani
- INSERM CESP Centre for Research in Epidemiology and Population Health, Epidemiology of HIV and STI Group, Paris, France
| | - S Rivière
- Service de Médecine Interne, Hôpital Saint Antoine, Université Paris 6, Paris, France
| | - L Galicier
- Service d'Immunologie Clinique, Hôpital Saint Louis, Université Paris Diderot, Paris, France
| | - P Coppo
- Service d'Hématologie, Hôpital Saint Antoine, Université Paris 6, Centre de Référence des Microangiopathies Thrombotiques, Paris, France
| | - J-L Meynard
- Service de Maladies Infectieuses, Hôpital Saint Antoine, Université Paris 6, Paris, France
| | - J-M Molina
- Service de Maladies Infectieuses, Hôpital Saint Louis, Université Paris Diderot, Paris, France
| | - E Azoulay
- Service de Réanimation Médicale, Hôpital Saint Antoine, Université Paris 6, Paris, France
| | - C Aumont
- Service d'Hématologie Biologique, Hôpital Bicêtre, Université Paris Sud, Paris, France
| | - C Marzac
- Service d'Hématologie Biologique, Hôpital Saint Antoine, Université Paris 6, Paris, France
| | - L Fardet
- Service de Dermatologie, Hôpital Henri Mondor, Université Paris 12, Paris, France
| | - O Lambotte
- Service de Médecine Interne-Immunologie clinique, Hôpital Bicêtre, Université Paris Sud, Paris, France
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266
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Boom V, Anton J, Lahdenne P, Quartier P, Ravelli A, Wulffraat NM, Vastert SJ. Evidence-based diagnosis and treatment of macrophage activation syndrome in systemic juvenile idiopathic arthritis. Pediatr Rheumatol Online J 2015; 13:55. [PMID: 26634252 PMCID: PMC4669611 DOI: 10.1186/s12969-015-0055-3] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2015] [Accepted: 11/27/2015] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Macrophage activation syndrome (MAS) is a severe and potentially lethal complication of several inflammatory diseases but seems particularly linked to systemic juvenile idiopathic arthritis (sJIA). Standardized diagnostic and treatment guidelines for MAS in sJIA are currently lacking. The aim of this systematic literature review was to evaluate currently available literature on diagnostic criteria for MAS in sJIA and provide an overview of possible biomarkers for diagnosis, disease activity and treatment response and recent advances in treatment. METHODS A systematic literature search was performed in MEDLINE, EMBASE and Cochrane. 495 papers were identified. Potentially relevant papers were selected by 3 authors after which full text screening was performed. All selected papers were evaluated by at least two independent experts for validity and level of evidence according to EULAR guidelines. RESULTS 27 papers were included: 7 on diagnosis, 9 on biomarkers and 11 on treatment. Systematic review of the literature confirmed that there are no validated diagnostic criteria for MAS in sJIA. The preliminary Ravelli criteria, with the addition of ferritin, performed well in a large retrospective case-control study. Recently, an international consortium lead by PRINTO proposed a new set of diagnostic criteria able to distinguish MAS from active sJIA and/or infection with superior performance. Other promising diagnostic biomarkers potentially distinguish MAS complicating sJIA from primary and virus-associated hemophagocytic lymphohistiocytosis. The highest level of evidence for treatment comes from case-series. High dose corticosteroids with or without cyclosporine A were frequently reported as first-line therapy. From the newer treatment modalities, promising responses have been reported with anakinra. CONCLUSION MAS in sJIA seems to be diagnosed best by the recently proposed PRINTO criteria, although prospective validation is needed. Novel promising biomarkers for sJIA related MAS are in need of prospective validation as well, and are not widely available yet. Currently, treatment of MAS in sJIA relies more on experience than evidence based medicine. Taking into account the severity of MAS and the scarcity of evidence, early expert consultation is recommended as soon as MAS is suspected.
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Affiliation(s)
- V Boom
- Department of Pediatric Rheumatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands.
| | - J Anton
- Pediatric Rheumatology Unit, Hospital Sant Joan de Déu. Universitat de Barcelona, Barcelona, Spain.
| | - P Lahdenne
- Department of Pediatrics, Children's Hospital, University Hospital Helsinki, Helsinki, Finland.
| | - P Quartier
- Pediatric Immunology-Hematology and Rheumatology Unit and IMAGINE Institute, Necker-Enfants Malades Hospital, Assistance Publique Hopitaux de Paris and Universite Paris-Descartes, Paris, France.
| | - A Ravelli
- Department of pediatric rheumatology, Instituto Giannini Gaslini, Genua, Italy.
| | - N M Wulffraat
- Department of Pediatric Rheumatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands.
| | - S J Vastert
- Department of Pediatric Rheumatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands.
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267
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Greenhalgh M, Chopra M, Graf N, Isaacs D, Evans N. Unusual cause of hyperbilirubinaemia in a preterm baby. J Paediatr Child Health 2015; 51:1226-7. [PMID: 26041330 DOI: 10.1111/jpc.12931] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/20/2015] [Indexed: 11/28/2022]
Affiliation(s)
- Mark Greenhalgh
- Department of Newborn Care, Royal Prince Alfred Hospital, Sydney, New South Waless, Australia
| | - Maya Chopra
- Department of Medical Genomics, Royal Prince Alfred Hospital, Sydney, New South Waless, Australia
| | - Nicole Graf
- Department of Histopathology, Children's Hospital Westmead, Sydney, New South Waless, Australia
| | - David Isaacs
- Department of Infectious Disease, Children's Hospital Westmead, Sydney, New South Waless, Australia
| | - Nick Evans
- Department of Newborn Care, Royal Prince Alfred Hospital, Sydney, New South Waless, Australia
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268
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Intrinsic defects in erythroid cells from familial hemophagocytic lymphohistiocytosis type 5 patients identify a role for STXBP2/Munc18-2 in erythropoiesis and phospholipid scrambling. Exp Hematol 2015; 43:1072-1076.e2. [DOI: 10.1016/j.exphem.2015.08.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2015] [Revised: 08/19/2015] [Accepted: 08/20/2015] [Indexed: 11/17/2022]
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269
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Avau A, Matthys P. Therapeutic Potential of Interferon-γ and Its Antagonists in Autoinflammation: Lessons from Murine Models of Systemic Juvenile Idiopathic Arthritis and Macrophage Activation Syndrome. Pharmaceuticals (Basel) 2015; 8:793-815. [PMID: 26610523 PMCID: PMC4695810 DOI: 10.3390/ph8040793] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2015] [Revised: 11/09/2015] [Accepted: 11/18/2015] [Indexed: 01/05/2023] Open
Abstract
Interferon-γ (IFN-γ) affects immune responses in a complex fashion. Its immunostimulatory actions, such as macrophage activation and induction of T helper 1-type responsiveness, are widely acknowledged, however, as documented by a large body of literature, IFN-γ has also the potential to temper inflammatory processes via other pathways. In autoimmune and autoinflammatory disorders, IFN-γ can either play a disease-enforcing role or act as protective agent, depending on the nature of the disease. In animal models of any particular autoimmune disease, certain changes in the induction procedure can reverse the net outcome of introduction or ablation of IFN-γ. Here, we review the role of endogenous IFN-γ in inflammatory disorders and related murine models, with a focus on systemic juvenile idiopathic arthritis (sJIA) and macrophage activation syndrome (MAS). In particular, we discuss our recent findings in a mouse model of sJIA, in which endogenous IFN-γ acts as a regulatory agent, and compare with results from mouse models of MAS. Also, we elaborate on the complexity in the activity of IFN-γ and the resulting difficulty of predicting its value or that of its antagonists as treatment option.
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Affiliation(s)
- Anneleen Avau
- Laboratory of Immunobiology, Department of Microbiology and Immunology, Rega Institute, KU Leuven - University of Leuven, Leuven B-3000, Belgium.
| | - Patrick Matthys
- Laboratory of Immunobiology, Department of Microbiology and Immunology, Rega Institute, KU Leuven - University of Leuven, Leuven B-3000, Belgium.
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270
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Ab-Rahman HA, Wong PF, Rahim H, Abd-Jamil J, Tan KK, Sulaiman S, Lum CS, Syed-Omar SF, AbuBakar S. Dengue death with evidence of hemophagocytic syndrome and dengue virus infection in the bone marrow. SPRINGERPLUS 2015; 4:665. [PMID: 26558168 PMCID: PMC4630261 DOI: 10.1186/s40064-015-1463-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/12/2015] [Accepted: 10/21/2015] [Indexed: 01/09/2023]
Abstract
INTRODUCTION HPS is a potentially life-threatening histiocytic disorder that has been described in various viral infections including dengue. Its involvement in severe and fatal dengue is probably more common but is presently under recognized. CASE DESCRIPTION A 38-year-old female was admitted after 5 days of fever. She was deeply jaundiced, leukopenic and thrombocytopenic. Marked elevation of transaminases, hyperbilirubinemia and hypoalbuminemia were observed. She had deranged INR values and prolonged aPTT accompanied with hypofibrinogenemia. She also had splenomegaly. She was positive for dengue IgM. Five days later she became polyuric and CT brain image showed gross generalized cerebral edema. Her conditions deteriorated by day 9, became confused with GCS of 9/15. Her BMAT showed minimal histiocytes. Her serum ferritin level peaked at 13,670.00 µg/mL and her sCD163 and sCD25 values were markedly elevated at 4750.00 ng/mL and 4191.00 pg/mL, respectively. She succumbed to the disease on day 10 and examination of her tissues showed the presence of dengue virus genome in the bone marrow. DISCUSSION AND EVALUATION It is described here, a case of fatal dengue with clinical features of HPS. Though BMAT results did not show the presence of macrophage hemophagocytosis, other laboratory features were consistent with HPS especially marked elevation of ferritin, sCD163 and sCD25. Detection of dengue virus in the patient's bone marrow, fifteen days after the onset of fever was also consistent with the suggestion that the HPS is associated with dengue virus infection. CONCLUSIONS The findings highlight HPS as a possible complication leading to severe dengue and revealed persistent dengue virus infection of the bone marrow. Detection of HPS markers; ferritin, sCD163 and sCD25, therefore, should be considered for early recognition of HPS-associated dengue.
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Affiliation(s)
- Hasliana Azrah Ab-Rahman
- Tropical Infectious Diseases Research and Education Centre (TIDREC), Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur, Malaysia ; Department of Medical Microbiology, Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur, Malaysia ; Department of Pharmacology, Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur, Malaysia
| | - Pooi-Fong Wong
- Department of Pharmacology, Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur, Malaysia
| | - Hafiz Rahim
- Department of Medicine, Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur, Malaysia
| | - Juraina Abd-Jamil
- Tropical Infectious Diseases Research and Education Centre (TIDREC), Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur, Malaysia
| | - Kim-Kee Tan
- Tropical Infectious Diseases Research and Education Centre (TIDREC), Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur, Malaysia ; Department of Medical Microbiology, Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur, Malaysia
| | - Syuhaida Sulaiman
- Tropical Infectious Diseases Research and Education Centre (TIDREC), Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur, Malaysia ; Department of Medical Microbiology, Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur, Malaysia
| | - Chai-See Lum
- Department of Medicine, Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur, Malaysia ; Department of Paediatrics, Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur, Malaysia
| | | | - Sazaly AbuBakar
- Tropical Infectious Diseases Research and Education Centre (TIDREC), Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur, Malaysia ; Department of Medical Microbiology, Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur, Malaysia
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271
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Azevedo L, Gerivaz R, Simões J, Germano I. The challenging diagnosis of haemophagocytic lymphohistiocytosis in an HIV-infected patient. BMJ Case Rep 2015; 2015:bcr-2015-211817. [PMID: 26511991 DOI: 10.1136/bcr-2015-211817] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
The differential diagnosis of febrile pancytopenia in the setting of HIV infection can be challenging. The authors report a case of a 34-year-old man with advanced HIV infection (TCD4=8 cells/mm(3)) and a 2-month history of fever, weight loss and asthaenia. On observation, he was emaciated, hyperthermic and pale, with a haemorrhagic oropharyngeal lesion, penile violaceous lesions and palpable hepatosplenomegaly. Blood tests showed pancytopenia, hyperferritinaemia and hypertriglyceridaemia; imaging confirmed hepatosplenomegaly and a bone marrow biopsy revealed HIV-associated dyshematopoiesis. Biopsy of the aforementioned lesions displayed Kaposi sarcoma; extensive investigation was negative for other opportunistic infections or lymphoproliferative disease. Despite only a posteriori histological documentation, haemophagocytic lymphohistiocytosis (HLH) was considered; chemotherapy and antiretrovirals were started, with excellent response. There was, however, disease relapse requiring an intensification course, with sustained remission at 18-month follow-up. HLH is a rare disease, with non-specific presentation, requiring a high index of suspicion since treatment delay can be fatal.
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Affiliation(s)
- Luísa Azevedo
- Department of Internal Medicine, Centro Hospitalar Lisboa Central EPE, Lisboa, Portugal
| | - Rita Gerivaz
- Department of Hematology, Centro Hospitalar Lisboa Central EPE, Lisboa, Portugal
| | - Joana Simões
- Department of Internal Medicine, Centro Hospitalar Lisboa Central EPE, Lisboa, Portugal
| | - Isabel Germano
- Department of Internal Medicine, Centro Hospitalar Lisboa Central EPE, Lisboa, Portugal
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272
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Lim SH, Park S, Jang JH, Kim K, Kim HJ, Kim SH, Kang CI, Chung DR, Peck KR, Lee J, Cha HS, Koh EM, Ko YH, Kim WS, Jung CW, Kim SJ. Clinical significance of bone marrow hemophagocytosis in adult patients with malignancy and non-malignancy-induced hemophagocytic lymphohistiocytosis. Ann Hematol 2015; 95:325-35. [PMID: 26453074 DOI: 10.1007/s00277-015-2523-8] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2015] [Accepted: 10/04/2015] [Indexed: 10/23/2022]
Abstract
Bone marrow hemophagocytosis is a frequently observed but not mandatory finding for the diagnosis of hemophagocytic lymphohistiocytosis (HLH). However, the impact of bone marrow hemophagocytosis on the diagnosis of HLH is still not clear in adult patients. Thus, we retrospectively analyzed adult patients with bone marrow hemophagocytosis between 2000 and 2014 to determine its clinical significance. Among 264 patients with bone marrow hemophagocytosis, malignant disorders were the predominant underlying cause (n = 170, 64 %), especially T/NK-cell (n = 88) and B-cell (n = 45) lymphomas compared to infectious disease (48/264, 18 %). The data for HLH-2004 diagnostic criteria was available in 182 patients, and only 29 % (77/264) of patients with ≥ five positive criteria could be diagnosed with HLH. Among the criteria for the diagnosis of HLH, increased serum ferritin (89 %) was more common than hypofibrinogenemia, hypertriglyceridemia, and bicytopenia (<40 %). The median overall survival was worse in patients with malignancy (9.0 months, 95 % confidence interval [CI] 5.6-12.5) than in those with non-malignant disorders (71.8 months, 95 % CI 56.5-87.1, P < 0.001). In patients with malignancy, the overall survival of patients fulfilling the HLH-2004 criteria was significantly worse than patients who did not (P < 0.001). In conclusion, our results suggest that bone marrow hemophagocytosis might be an important finding in the diagnosis of HLH in adult patients. Considering the high incidence of malignancy as a predisposing disorder for HLH, immediate evaluation should be performed in adult patients with bone marrow hemophagocytosis.
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Affiliation(s)
- Sung Hee Lim
- Division of Hematology-Oncology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Silvia Park
- Division of Hematology-Oncology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Jun Ho Jang
- Division of Hematology-Oncology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Kihyun Kim
- Division of Hematology-Oncology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Hee-Jin Kim
- Department of Laboratory Medicine & Genetics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Sun-Hee Kim
- Department of Laboratory Medicine & Genetics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Cheol-In Kang
- Division of Infectious Diseases, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Doo Ryeon Chung
- Division of Infectious Diseases, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Kyong Ran Peck
- Division of Infectious Diseases, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Jaejoon Lee
- Division of Rheumatology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Hoon-Suk Cha
- Division of Rheumatology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Eun-Mi Koh
- Division of Rheumatology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Young Hyeh Ko
- Department of Pathology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Won Seog Kim
- Division of Hematology-Oncology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Chul Won Jung
- Division of Hematology-Oncology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Seok Jin Kim
- Division of Hematology-Oncology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea. .,Department of Health Sciences and Technology, SAIHST, Sungkyunkwan University, 50 Irwon-dong, Seoul, Gangnam-gu, 135-710, South Korea.
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273
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Otrock ZK, Gonzalez MD, Eby CS. Ehrlichia-Induced Hemophagocytic Lymphohistiocytosis: A Case Series and Review of Literature. Blood Cells Mol Dis 2015; 55:191-3. [DOI: 10.1016/j.bcmd.2015.06.009] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Accepted: 06/22/2015] [Indexed: 10/23/2022]
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274
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de Saint Basile G, Sepulveda FE, Maschalidi S, Fischer A. Cytotoxic granule secretion by lymphocytes and its link to immune homeostasis. F1000Res 2015; 4:930. [PMID: 26594351 PMCID: PMC4648190 DOI: 10.12688/f1000research.6754.1] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/28/2015] [Indexed: 12/21/2022] Open
Abstract
The granule-dependent cytotoxic activity of T and natural killer lymphocytes has progressively emerged as an important effector pathway not only for host defence but also for immune regulation. The analysis of an early-onset, severe, primary immune dysregulatory syndrome known as hemophagocytic lymphohistiocytosis (HLH) has been decisive in highlighting this latter role and identifying key effectors on the basis of gene mutation analyses and mediators in the maturation and secretion of cytotoxic granules. Studies of cytotoxicity-deficient murine counterparts have helped to define primary HLH as a syndrome in which uncontrolled T-cell activation in response to lymphocytic choriomeningitis virus infection results in excessive macrophage activation and inflammation-associated cytopenia. Recent recognition of late-onset HLH, which occurs in a variety of settings, in association with hypomorphic, monoallelic mutations in genes encoding components of the granule-dependent cytotoxic pathway or even in the absence of such mutations has broadened our view about the mechanisms that underlie the perturbation of immune homeostasis. These findings have led to the development of a model in which disease occurs when a threshold is reached through the accumulation of genetic and environmental risk factors. Nevertheless, validation of this model will require further investigations.
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Affiliation(s)
- Geneviève de Saint Basile
- INSERM UMR1163, Laboratory of Normal and Pathological Homeostasis of the Immune System, Paris, F-75015, France ; Paris Descartes University-Sorbonne Paris Cité, Imagine Institute, Paris, F-75015, France ; Centre d'Etudes des Déficits Immunitaires, Assistance Publique-Hôpitaux de Paris, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Fernando E Sepulveda
- INSERM UMR1163, Laboratory of Normal and Pathological Homeostasis of the Immune System, Paris, F-75015, France ; Paris Descartes University-Sorbonne Paris Cité, Imagine Institute, Paris, F-75015, France
| | - Sophia Maschalidi
- INSERM UMR1163, Laboratory of Normal and Pathological Homeostasis of the Immune System, Paris, F-75015, France ; Paris Descartes University-Sorbonne Paris Cité, Imagine Institute, Paris, F-75015, France
| | - Alain Fischer
- INSERM UMR1163, Laboratory of Normal and Pathological Homeostasis of the Immune System, Paris, F-75015, France ; Paris Descartes University-Sorbonne Paris Cité, Imagine Institute, Paris, F-75015, France ; Immunology and Pediatric Hematology Department, Necker Children's Hospital, AP-HP, Paris, France ; Collège de France, Paris, F-75005, France
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275
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Bonilla FA, Khan DA, Ballas ZK, Chinen J, Frank MM, Hsu JT, Keller M, Kobrynski LJ, Komarow HD, Mazer B, Nelson RP, Orange JS, Routes JM, Shearer WT, Sorensen RU, Verbsky JW, Bernstein DI, Blessing-Moore J, Lang D, Nicklas RA, Oppenheimer J, Portnoy JM, Randolph CR, Schuller D, Spector SL, Tilles S, Wallace D. Practice parameter for the diagnosis and management of primary immunodeficiency. J Allergy Clin Immunol 2015; 136:1186-205.e1-78. [PMID: 26371839 DOI: 10.1016/j.jaci.2015.04.049] [Citation(s) in RCA: 421] [Impact Index Per Article: 46.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2014] [Revised: 04/18/2015] [Accepted: 04/23/2015] [Indexed: 02/07/2023]
Abstract
The American Academy of Allergy, Asthma & Immunology (AAAAI) and the American College of Allergy, Asthma & Immunology (ACAAI) have jointly accepted responsibility for establishing the "Practice parameter for the diagnosis and management of primary immunodeficiency." This is a complete and comprehensive document at the current time. The medical environment is a changing environment, and not all recommendations will be appropriate for all patients. Because this document incorporated the efforts of many participants, no single individual, including those who served on the Joint Task Force, is authorized to provide an official AAAAI or ACAAI interpretation of these practice parameters. Any request for information about or an interpretation of these practice parameters by the AAAAI or ACAAI should be directed to the Executive Offices of the AAAAI, the ACAAI, and the Joint Council of Allergy, Asthma & Immunology. These parameters are not designed for use by pharmaceutical companies in drug promotion.
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276
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Intense and diffuse lung uptake of 99mTc-MDP in a patient with pneumonia associated with secondary hemophagocytic lymphohistiocytosis. Clin Nucl Med 2015; 39:1000-2. [PMID: 24999696 DOI: 10.1097/rlu.0000000000000483] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
99mTc-methylene diphosphonate (MDP) bone scan was performed in a 49-year-old female patient who had non-Hodgkin lymphoma. 99mTc-MDP uptake was significant in both lungs. Bilateral bacterial pneumonia associated with secondary hemophagocytic lymphohistiocytosis was diagnosed after extensive examination.
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277
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Affiliation(s)
- Edward M Behrens
- Division of Rheumatology, Department of Pediatrics, University of Pennsylvania, Philadelphia, PA 19104; and
| | - Randy Q Cron
- Division of Rheumatology, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL 35233
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278
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Gratton SM, Powell TR, Theeler BJ, Hawley JS, Amjad FS, Tornatore C. Neurological involvement and characterization in acquired hemophagocytic lymphohistiocytosis in adulthood. J Neurol Sci 2015. [PMID: 26198020 DOI: 10.1016/j.jns.2015.07.017] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To describe the neurological and neuroradiological features of acquired hemophagocytic lymphohistiocytosis (HLH) in adulthood by reporting a series of cases. METHODS Ten consecutive patients who were diagnosed with HLH at Medstar Georgetown University Hospital and Walter Reed National Military Medical Center were evaluated for neurological involvement. All underwent clinical neurological evaluation, and when indicated CSF analysis and MR imaging of the brain. Data were gathered and analyzed retrospectively. RESULTS Seven of the ten patients with HLH had neurological involvement. Mean age at onset was 50 (range: 21 to 73). Four patients were males. Prominent clinical features included mild to severe encephalopathy and seizures. Other findings included hemiparesis and spastic tetraparesis. Neuroimaging revealed a wide spectrum of abnormalities including cortical and subcortical edema, gadolinium enhancement, hemorrhage, and diffusion restriction. Basal ganglia involvement was present in four out of seven patients. Three patients died due to multisystem organ failure, and the other patients displayed varying degrees of recovery. CONCLUSIONS The neurological features of acquired HLH in adults have not been previously reported. These seven patients demonstrate the spectrum of neurological involvement that can occur. The diagnosis of HLH should be considered in patients who are systemically ill with unexplained fevers and hyperferritinemia who have evidence of inflammation in the CNS.
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Affiliation(s)
- Sean M Gratton
- Medstar Georgetown University Hospital, Department of Neurology, PHC, 7th Floor, 3800 Reservoir Road, NW, Washington, DC 20007, United States.
| | - Tasha R Powell
- Walter Reed National Military Medical Center, Department of Neurology, Building 19, 8901 Rockville Pike, Bethesda, MD 20889, United States.
| | - Brett J Theeler
- Walter Reed National Military Medical Center, Department of Neurology, Building 19, 8901 Rockville Pike, Bethesda, MD 20889, United States; Walter Reed National Military Medical Center, John P. Murtha Cancer Center, Building 19, 8901 Rockville Pike, Bethesda, MD 20889, United States.
| | - Jason S Hawley
- Walter Reed National Military Medical Center, Department of Neurology, Building 19, 8901 Rockville Pike, Bethesda, MD 20889, United States.
| | - Faria S Amjad
- Medstar Georgetown University Hospital, Department of Neurology, PHC, 7th Floor, 3800 Reservoir Road, NW, Washington, DC 20007, United States.
| | - Carlo Tornatore
- Medstar Georgetown University Hospital, Department of Neurology, PHC, 7th Floor, 3800 Reservoir Road, NW, Washington, DC 20007, United States.
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279
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Choi MH, Jung JI, Chung WD, Kim YJ, Lee SE, Han DH, Ahn MI, Park SH. Acute pulmonary complications in patients with hematologic malignancies. Radiographics 2015; 34:1755-68. [PMID: 25310429 DOI: 10.1148/rg.346130107] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Various acute pulmonary complications may occur in patients with hematologic malignancies because they are in an immunocompromised state due to systemic disease or to chemotherapy or hematopoietic stem cell transplantation. Pulmonary complications may arise from other treatment regimens, as well, or from direct pulmonary involvement in the malignant disease process. The differential diagnosis of pulmonary opacities in patients with hematologic malignancies is broad and includes both infectious and noninfectious causes. Pulmonary hemorrhage, edema, leukostasis, and pneumonia are well-known and common acute pulmonary complications. Less common complications are now encountered with increasing frequency because of the increasing complexity of therapeutic regimens for hematologic malignancies, which may include various drugs that are in clinical trials or were recently released to market. These once uncommon acute pulmonary complications include retinoic acid syndrome, tyrosine kinase inhibitor-induced pulmonary complications, engraftment syndrome, and hemophagocytic lymphohistiocytosis. It is often difficult to differentiate between these entities. However, the clinical setting and radiologic imaging findings may provide clues for interpreting imaging findings of abnormal pulmonary opacity in patients with a hematologic malignancy. Pulmonary hemorrhage is characterized by a sudden onset of symptoms and rapid progression of pulmonary imaging abnormalities and usually occurs in patients with impaired coagulation or a predisposition to bleed. Pulmonary edema should be considered when typical findings of hydrostatic pulmonary edema are seen. Pulmonary leukostasis develops in patients with hyperleukocytosis and leads to symptoms such as a cough, fever, and dyspnea. Various types of pneumonia may develop, depending on the degree and duration of immunosuppression in the patient. Retinoic acid syndrome, tyrosine kinase inhibitor-induced pulmonary complications, and engraftment syndrome occur after specific treatments, so a detailed medical history including recent or current treatments may be helpful for diagnosis. Accurate differentiation of these entities allows their appropriate management, with resultant decreases in morbidity and mortality.
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Affiliation(s)
- Moon Hyung Choi
- From the Department of Radiology, Seoul St. Mary's Hospital (M.H.C., J.I.J., W.D.C., D.H.H., M.I.A., S.H.P.), and Catholic Hematopoietic Stem Cell Transplantation Center (Y.J.K., S.E.L.), College of Medicine, Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul 137-701, Korea
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280
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Cron RQ, Davi S, Minoia F, Ravelli A. Clinical features and correct diagnosis of macrophage activation syndrome. Expert Rev Clin Immunol 2015; 11:1043-53. [PMID: 26082353 DOI: 10.1586/1744666x.2015.1058159] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Macrophage activation syndrome (MAS) is increasingly recognized among febrile hospitalized patients. Clinically, MAS resembles multiorgan dysfunction and shock. Laboratory features include hepatobiliary dysfunction, coagulopathy, pancytopenia, hyperferritinemia and markers of immune activation. Pathologically, hemophagocytosis is commonly seen but is only present in 60% of MAS patients. MAS, or secondary hemophagocytic lymphohistiocytosis (HLH), is triggered by infectious (e.g., herpes family viruses), rheumatologic (e.g., systemic lupus erythematosus [SLE]) and oncologic (e.g., T-cell leukemia) conditions. Formal HLH criteria, while specific, are frequently insensitive for MAS diagnosis. Thus, disease-specific (e.g., SLE) and generic MAS criteria have been published. Recently, novel criteria for MAS in children with systemic juvenile idiopathic arthritis (sJIA) were developed and are a key focus of this review.
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Affiliation(s)
- Randy Q Cron
- Children's of Alabama, 1600 7th Ave. S., CPP #M210, Birmingham, AL 35233-1711, USA
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281
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Zhang L, Zhou J, Sokol L. Hereditary and acquired hemophagocytic lymphohistiocytosis. Cancer Control 2015; 21:301-12. [PMID: 25310211 DOI: 10.1177/107327481402100406] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Hemophagocytic lymphohistiocytosis (HLH) is a rare but life-threatening hyperinflammatory/hypercytokinemia syndrome clinicopathologically manifested by fever, hepatosplenomegaly, cytopenias, liver dysfunction, and hemophagocytosis. METHODS We searched the medical literature for English-written articles and analyzed data regarding the diagnosis, pathoetiology, prognosis, and management of HLH. RESULTS HLH can be subcategorized into primary/genetic (PHLH) or secondary/acquired (SHLH) according to etiology. PHLH, including familial HLH and inherited immune deficiency syndromes, typically occurs in children harboring underlying genetic defects, whereas SHLH frequently manifests in adults and is associated with infection, autoimmunity, immune suppression, or malignancy. The pathogenesis of HLH is still elusive. Its known mechanisms include somatic mutations in gene coding for proteins implicated in the cytotoxic pathways of cytotoxic T or natural killer cells. The impaired ability of these cells to kill target cells leads to an uncontrolled hypercytokinemia and hyperinflammatory process, triggering hemophagocytosis and multiorgan failure. Corticosteroids, chemotherapy, and immunotherapy are the mainstay therapeutic strategies. The consolidation with allogeneic hematopoietic stem cell transplantation is a potentially curative option for PHLH and refractory or relapsed SHLH. CONCLUSIONS Understanding of the pathophysiology of HLH has improved in the last decade. The establishment of diagnostic and treatment guidelines for PHLH and SHLH has resulted in earlier diagnoses and the rapid initiation of therapy, both of which are associated with favorable outcomes.
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Affiliation(s)
- Ling Zhang
- Department of Hematopathology and Laboratory Medicine, Moffitt Cancer Center, Tampa, FL 33612, USA.
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282
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283
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Romero CAP, Sánchez IP, Gutierrez-Hincapié S, Álvarez-Álvarez JA, Pereañez JA, Ochoa R, Muskus-López CE, Eraso RG, Echeverry C, Arango C, Restrepo JLF, Trujillo-Vargas CM. A novel pathogenic variant in PRF1 associated with hemophagocytic lymphohistiocytosis. J Clin Immunol 2015; 35:501-11. [PMID: 25975970 DOI: 10.1007/s10875-015-0169-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2014] [Accepted: 05/04/2015] [Indexed: 10/23/2022]
Abstract
Familial Hemophagocytic Lymphohistiocytosis type 2 (FHL2) results from mutations in PRF1. We described two unrelated individuals who presented with FHL, in whom severely impaired NK cytotoxicity and decrease perforin expression was observed. DNA sequencing of PRF1 demonstrated that both were not only heterozygous for the p.54R > C/91A > V haplotype but also presented with the novel variant p.47G > V at the perforin protein. Perforin mRNA was found to be increased in a individual with that genotype. A carrier of the novel variant also demonstrated altered perforin mRNA and protein expression. Phylogenetic analysis and multiple alignments with perforin orthologous demonstrated a high level of conservation at Gly47. PolyPhen-2 and PROVEAN predicted p.47G > V to be "probably damaging" and "deleterious", respectively. A thermodynamic analysis showed that this variant was highly stabilizing, decreasing the protein internal energy. The ab initio perforin molecular modeling indicated that Gly47 is buried inside the hydrophobic core of the MACPF domain, which is crucial for the lytic pore formation and protein oligomerization. After the in silico induction of the p.47G > V mutation, Val47 increased the interactions with the surrounding amino acids due to its size and physical properties, avoiding a proper conformational change of the domain. To our knowledge, this is the first description supporting that p.47G > V is a pathogenic variant that in conjunction with p.54R > C/91A > V might result in the clinical phenotype of FHL2.
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Affiliation(s)
- Camilo Andrés Pérez Romero
- Grupo de Inmunodeficiencias Primarias, Facultad de Medicina, Universidad de Antioquia, Medellín, Colombia
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284
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Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a disease caused by dysregulation and hyperactivation of the immune system, and can be familial or acquired. HLH presenting in infancy can be rapidly fatal if not promptly recognized and treated. Congenital HLH can be caused by various genetic mutations or part of immunodeficiency syndromes. We present an infant with Griscelli syndrome and familial HLH with atypical genetic mutations, presenting as thrombocytopenia on the first day of life, cured with chemotherapy and unrelated cord blood transplant.
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285
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Yasumi T, Hori M, Hiejima E, Shibata H, Izawa K, Oda H, Yoshioka K, Nakagawa K, Kawai T, Nishikomori R, Ohara O, Heike T. Laboratory parameters identify familial haemophagocytic lymphohistiocytosis from other forms of paediatric haemophagocytosis. Br J Haematol 2015; 170:532-8. [DOI: 10.1111/bjh.13461] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2015] [Accepted: 03/15/2015] [Indexed: 12/01/2022]
Affiliation(s)
- Takahiro Yasumi
- Department of Paediatrics; Kyoto University Graduate School of Medicine; Kyoto Japan
| | - Masayuki Hori
- Department of Paediatrics; Kyoto University Graduate School of Medicine; Kyoto Japan
| | - Eitaro Hiejima
- Department of Paediatrics; Kyoto University Graduate School of Medicine; Kyoto Japan
| | - Hirofumi Shibata
- Department of Paediatrics; Kyoto University Graduate School of Medicine; Kyoto Japan
| | - Kazushi Izawa
- Department of Paediatrics; Kyoto University Graduate School of Medicine; Kyoto Japan
| | - Hirotsugu Oda
- Department of Paediatrics; Kyoto University Graduate School of Medicine; Kyoto Japan
- Laboratory for Integrative Genomics; RIKEN Centre for Integrative Medical Sciences; Yokohama Japan
| | - Kouhei Yoshioka
- Department of Paediatrics; Kyoto University Graduate School of Medicine; Kyoto Japan
| | - Kenji Nakagawa
- Department of Paediatrics; Kyoto University Graduate School of Medicine; Kyoto Japan
| | - Tomoki Kawai
- Department of Paediatrics; Kyoto University Graduate School of Medicine; Kyoto Japan
| | - Ryuta Nishikomori
- Department of Paediatrics; Kyoto University Graduate School of Medicine; Kyoto Japan
| | - Osamu Ohara
- Laboratory for Integrative Genomics; RIKEN Centre for Integrative Medical Sciences; Yokohama Japan
- Department of Human Genome Research; KAZUSA DNA Research Institute; Kisarazu Japan
| | - Toshio Heike
- Department of Paediatrics; Kyoto University Graduate School of Medicine; Kyoto Japan
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286
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Hemophagocytic Lymphohistiocytosis-A Rare Complication of Hepatitis A Virus Infection. ARCHIVES OF PEDIATRIC INFECTIOUS DISEASES 2015. [DOI: 10.5812/pedinfect.21150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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287
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Trapani JA, Voskoboinik I, Jenkins MR. Perforin-dependent cytotoxicity: 'Kiss of death' or prolonged embrace with darker elocation-idnseque11es? Oncoimmunology 2015; 4:e1036215. [PMID: 26405605 DOI: 10.1080/2162402x.2015.1036215] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2015] [Accepted: 03/26/2015] [Indexed: 10/23/2022] Open
Abstract
Failure of natural killer (NK) cells or cytotoxic T-lymphocytes (CTL) to kill cognate target cells results in cytokine/chemokine hypersecretion and markedly delayed killer/target cell detachment. With congenital perforin deficiency, fatal cytokine storm results. In cancer cells, where corrupted apoptotic signaling frequently delays apoptosis, we propose that failed death may alter the tumor microenvironment and skew immune infiltrates, even when perforin is delivered normally.
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Affiliation(s)
- Joseph A Trapani
- Cancer immunology Program; Peter MacCallum Cancer Centre ; East Melbourne, VIC, Australia
| | - Ilia Voskoboinik
- Cancer immunology Program; Peter MacCallum Cancer Centre ; East Melbourne, VIC, Australia
| | - Misty R Jenkins
- Cancer immunology Program; Peter MacCallum Cancer Centre ; East Melbourne, VIC, Australia
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288
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Sankhyan N, Saptharishi LG, Sasidaran K, Kanga A, Singhi SC. Clinical profile of scrub typhus in children and its association with hemophagocytic lymphohistiocytosis. Indian Pediatr 2015; 51:651-3. [PMID: 25129000 DOI: 10.1007/s13312-014-0470-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To study the clinical profile of children with scrub typhus and its association with hemophagocytic lymphohistiocytosis. METHODS Children presenting with unexplained fever and multi-systemic involvement between May to December 2011 were tested for scrub typhus using IgM ELISA kits. Occurrence of Hemophagocytic lymphohistiocytosis in IgM positive cases of scrub typhus was studied. RESULTS Of the 35 children with unexplained fever and multi-systemic involvement, 15 children (9 boys) tested positive for scrub typhus. Thrombocytopenia, hypoalbuminemia and raised hepatic transaminases were observed in all children. Out of seven children evaluated for hemophagocytic lymphohistiocytosis. 3 met the criteria for hemophagocytosis. Two children (one with hemophagocytic lymphohistiocytosis) died. CONCLUSIONS Scrub typhus is a common cause of unexplained fever in children in northern India. Hemophagocytic lymphohistiocytosis can occasionally complicate scrub typhus in children.
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Affiliation(s)
- Naveen Sankhyan
- Department of Pediatrics, PGIMER, Chandigarh; and *Department of Microbiology, Indira Gandhi Medical College, Shimla, India. Correspondence to: Prof. Sunit C Singhi, Professor and Head, Department of Pediatrics, Advanced Pediatric Centre, Post Graduate Institute of Medical Education and Research, Chandigarh 160 012, India.
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289
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Park M, Yun YJ, Woo SI, Lee JW, Chung NG, Cho B. Rotavirus-associated hemophagocytic lymphohistiocytosis (HLH) after hematopoietic stem cell transplantation for familial HLH. Pediatr Int 2015; 57:e77-80. [PMID: 25712613 DOI: 10.1111/ped.12567] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2014] [Revised: 09/22/2014] [Accepted: 10/30/2014] [Indexed: 01/02/2023]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening disorder of immune regulation. HLH consists of two forms: familial and acquired, the latter which occurs in association with infection, malignancy, rheumatic disease and acquired immune deficiency. Herein, we report a case of acquired HLH in a child who had received allogeneic hematopoietic stem cell transplantation for familial HLH with UNC13D mutation. Based on microbiology, only rotavirus was identified as a possible organism triggering HLH. The patient's fulminant clinical course included acute respiratory failure, a sepsis-like pattern, disseminated intravascular coagulopathy, and rhabdomyolysis, leading to multiorgan failure and death from septic shock.
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Affiliation(s)
- Meerim Park
- Department of Pediatrics, Chungbuk National University College of Medicine, Cheongju, Korea
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290
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Kodan P, Chakrapani M, Shetty M, Pavan R, Bhat P. Hemophagocytic lymphohistiocytosis secondary to infections: a tropical experience! J Postgrad Med 2015; 61:112-5. [PMID: 25766345 PMCID: PMC4943449 DOI: 10.4103/0022-3859.150904] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2014] [Revised: 06/09/2014] [Accepted: 11/06/2014] [Indexed: 11/04/2022] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a potentially fatal hyper inflammatory condition, if not recognized and treated in time. A high index of suspicion can help identify the condition early. This condition can occur in the primary or secondary form. Secondary HLH or hemophagocytic syndrome (HPS) secondary to infections is an important clinical entity especially in tropical world. In this article, we share our experience with this entity and make an attempt to explore literature about ravenous macrophages which occurs secondary to infections. It is a series of six cases of HLH secondary to infectious disease in our center in a coastal city in South India over last one year with follow up.
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Affiliation(s)
| | - M Chakrapani
- Department of Medicine, Kasturba Medical College, Manipal University, Mangalore, India
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291
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Collins LE, DeCourcey J, Soledad di Luca M, Rochfort KD, Loscher CE. An Emerging Role for SNARE Proteins in Dendritic Cell Function. Front Immunol 2015; 6:133. [PMID: 25873919 PMCID: PMC4379939 DOI: 10.3389/fimmu.2015.00133] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2014] [Accepted: 03/10/2015] [Indexed: 12/21/2022] Open
Abstract
Dendritic cells (DCs) provide an essential link between innate and adaptive immunity. At the site of infection, antigens recognized by DCs via pattern-recognition receptors, such as Toll-like receptors (TLRs), initiate a specific immune response. Depending on the nature of the antigen, DCs secrete distinct cytokines with which they orchestrate homeostasis and pathogen clearance. Dysregulation of this process can lead to unnecessary inflammation, which can result in a plethora of inflammatory diseases. Therefore, the secretion of cytokines from DCs is tightly regulated and this regulation is facilitated by highly conserved trafficking protein families. These proteins control the transport of vesicles from the Golgi complex to the cell surface and between organelles. In this review, we will discuss the role of soluble n-ethylmaleimide-sensitive factor attachment protein receptor proteins (SNAREs) in DCs, both as facilitators of secretion and as useful tools to determine the pathways of secretion through their definite locations within the cells and inherent specificity in opposing binding partners on vesicles and target membranes. The role of SNAREs in DC function may present an opportunity to explore these proteins as novel targets in inflammatory disease.
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Affiliation(s)
- Laura E. Collins
- Immunomodulation Research Group, School of Biotechnology, Dublin City University, Dublin, Ireland
| | - Joseph DeCourcey
- Immunomodulation Research Group, School of Biotechnology, Dublin City University, Dublin, Ireland
| | - Mariana Soledad di Luca
- Immunomodulation Research Group, School of Biotechnology, Dublin City University, Dublin, Ireland
| | - Keith D. Rochfort
- Immunomodulation Research Group, School of Biotechnology, Dublin City University, Dublin, Ireland
| | - Christine E. Loscher
- Immunomodulation Research Group, School of Biotechnology, Dublin City University, Dublin, Ireland
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292
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Put K, Avau A, Brisse E, Mitera T, Put S, Proost P, Bader-Meunier B, Westhovens R, Van den Eynde BJ, Orabona C, Fallarino F, De Somer L, Tousseyn T, Quartier P, Wouters C, Matthys P. Cytokines in systemic juvenile idiopathic arthritis and haemophagocytic lymphohistiocytosis: tipping the balance between interleukin-18 and interferon-γ. Rheumatology (Oxford) 2015; 54:1507-17. [PMID: 25767156 DOI: 10.1093/rheumatology/keu524] [Citation(s) in RCA: 106] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2014] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVES To study the role of IFN-γ in the pathogenesis of systemic JIA (sJIA) and haemophagocytic lymphohistiocytosis (HLH) by searching for an IFN-γ profile, and to assess its relationship with other cytokines. METHODS Patients with inactive (n = 10) and active sJIA (n = 10), HLH [n = 5; of which 3 had sJIA-associated macrophage activation syndrome (MAS)] and healthy controls (n = 16) were enrolled in the study. Cytokines and IFN-γ-induced genes and proteins were determined in plasma, in patient peripheral blood mononuclear cells (PBMCs) and in lymph node biopsies of one patient during both sJIA and MAS episodes. IFN-γ responses were investigated in healthy donor PBMCs, primary fibroblasts and endothelial cells. RESULTS Plasma IFN-γ, IL-6 and IL-18 were elevated in active sJIA and HLH. Levels of IFN-γ and IFN-γ-induced proteins (IP-10/CXCL-10, IL-18BP and indoleamine 2,3-dioxygenase) in HLH were much higher than levels in active sJIA. Free IL-18 and ratios of IL-18/IFN-γ were higher in active sJIA compared with HLH. HLH PBMCs showed hyporesponsiveness to IFN-γ in vitro when compared with control and sJIA PBMCs. Endothelial cells and fibroblasts expressed IFN-γ-induced proteins in situ in lymph node staining of a MAS patient and in vitro upon stimulation with IFN-γ. CONCLUSION Patients with active sJIA and HLH/MAS show distinct cytokine profiles, with highly elevated plasma levels of IFN-γ and IFN-γ-induced proteins typically found in HLH/MAS. In addition to PBMCs, histiocytes, endothelial cells and fibroblasts may contribute to an IFN-γ profile in plasma. Increasing levels of IFN-γ compared with IL-18 may raise suspicion about the development of MAS in sJIA.
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Affiliation(s)
| | | | | | | | | | - Paul Proost
- Laboratory of Molecular Immunology, Rega Institute, University of Leuven, Leuven, Belgium
| | - Brigitte Bader-Meunier
- IMAGINE Institute, Hôpital Necker-Enfants Malades, Assistance Publique Hôpitaux de Paris, Université Paris-Descartes, Paris, France
| | - René Westhovens
- Skeletal Biology and Engineering Research Center, Department of Development and Regeneration, University of Leuven, Department of Rheumatology, University Hospital Leuven, Leuven, Belgium
| | - Benoit J Van den Eynde
- Ludwig Institute for Cancer Research and de Duve Institute, Université Catholique de Louvain, Brussels, Belgium
| | - Ciriana Orabona
- Department of Experimental Medicine and Biochemical Sciences, University of Perugia, Perugia, Italy
| | - Francesca Fallarino
- Department of Experimental Medicine and Biochemical Sciences, University of Perugia, Perugia, Italy
| | - Lien De Somer
- Laboratory of Pediatric Immunology, University Hospital Leuven, University of Leuven and
| | - Thomas Tousseyn
- Department of Imaging and Pathology, University of Leuven, Leuven, Belgium
| | - Pierre Quartier
- IMAGINE Institute, Hôpital Necker-Enfants Malades, Assistance Publique Hôpitaux de Paris, Université Paris-Descartes, Paris, France
| | - Carine Wouters
- IMAGINE Institute, Hôpital Necker-Enfants Malades, Assistance Publique Hôpitaux de Paris, Université Paris-Descartes, Paris, France, Laboratory of Pediatric Immunology, University Hospital Leuven, University of Leuven and
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293
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Kim SB, Shrivastava MS, Strakhan M. A rare cause of acquired immune deficiency syndrome related pancytopenia. Hematol Rep 2015; 7:5475. [PMID: 25852844 PMCID: PMC4378201 DOI: 10.4081/hr.2015.5475] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2014] [Accepted: 02/18/2015] [Indexed: 11/22/2022] Open
Abstract
A 21-year-old male with acquired immune deficiency syndrome, not on highly active antiretroviral treatment (HAART) was admitted after complaining of headache and intermittent diarrhea, found to have Cryptococcal meningitis. During the course of his hospitalization, patient developed pancytopenia. Anemia panel, serologies including Epstein barr virus, cytomegalovirus, and parvovirus were negative. Patient then developed high grade fever with elevated liver enzymes. Blood cultures, urine cultures, stool cultures, and repeat cerebrospinal fluid cultures remained negative. Patient subsequently developed skin lesions which on biopsy showed Kaposi’s sarcoma, and upon endoscopy, noted to have gastrointestinal Kaposi’s sarcoma involvement. Human herpes virus 8 was positive. Bone marrow biopsy revealed hemophagocytic lymphohistiocytosis. Despite having a concern for patient developing immune reconstitution syndrome which may worsen his meningitis, HAART was initiated and patient’s symptoms improved including resolution of fevers and hematological as well as liver abnormalities. Kaposi’s sarcoma improved as well.
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Affiliation(s)
- Su Bin Kim
- Department of Medicine, Albert Einstein College of Medicine , Jacobi Medical Center, Bronx, NY, USA
| | | | - Marianna Strakhan
- Department of Hematology/Oncology, Albert Einstein College of Medicine , Jacobi Medical Center, Bronx, NY, USA
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294
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A female patient with incomplete hemophagocytic lymphohistiocytosis caused by a heterozygous XIAP mutation associated with non-random X-chromosome inactivation skewed towards the wild-type XIAP allele. J Clin Immunol 2015; 35:244-8. [PMID: 25744037 DOI: 10.1007/s10875-015-0144-6] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2014] [Accepted: 02/13/2015] [Indexed: 10/23/2022]
Abstract
X-linked lymphoproliferative disease (XLP) is a rare inherited immunodeficiency that often leads to hemophagocytic lymphohistiocytosis (HLH). XLP can be classified as XLP1 or XLP2, caused by mutations in SH2D1A and XIAP, respectively. In women, X-chromosome inactivation (XCI) of most X-linked genes occurs on one of the X chromosomes in each cell. The choice of which X chromosome remains activated is generally random, although genetic differences and selective advantage may cause one of the X chromosomes to be preferentially inactivated. Here we describe three patients with pancytopenia, including one female patient, in a Japanese family with a novel XIAP mutation. All three patients exhibited deficient XIAP protein expression, impaired NOD2/XIAP signaling, and augmented activation-induced cell death. In the female patient, the paternally derived X chromosome was non-randomly and exclusively inactivated in her peripheral blood and hair root cells. In contrast to asymptomatic females, this patient exhibied non-random XCI skewed towards the wild-type XIAP allele. This is the first report of a female patient with incomplete HLH resulting from a heterozygous XIAP mutation in association with non-random XCI.
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295
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Boisseau M, Lambotte O, Galicier L, Lerolle N, Marzac C, Aumont C, Coppo P, Fardet L. Epstein-Barr virus viral load in human immunodeficiency virus-positive patients with reactive hemophagocytic syndrome. Infect Dis (Lond) 2015; 47:423-7. [PMID: 25746607 DOI: 10.3109/00365548.2015.1007475] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Because human immunodeficiency virus (HIV)-infected patients control Epstein-Barr virus (EBV) replication poorly, we hypothesized that reactive hemophagocytic syndrome (HS) in these patients may be associated with poor control of EBV. The files of 314 patients with a suspected diagnosis of HS were retrospectively reviewed. EBV viral load at the time of HS was compared between HIV-positive and -negative patients. A confirmed diagnosis of HS was made in 162 patients [109 males, median age 48 (35-62) years]. Among them, 61 (38%) were HIV positive [median HIV viral load 3.2 (1.6-5.5) log/ml, median CD4 count 94 (28-190)/mm(3)]. The median EBV viral load was significantly higher in HIV-positive than in HIV-negative patients [4.0 (2.9-4.6) vs 2.5 (0-4.2) log/ml, p = 0.002]. It was higher both in patients with hematological malignancy-associated HS [4.0 (2.9-4.4) vs 2.9 (0-4.9) log/ml, p = 0.03] and in patients with infection-associated HS [3.9 (0-4.9) vs 0 (0-4.1) log/ml, p = 0.14]. However, EBV viral load was not significantly higher in HIV-infected patients with confirmed HS than in HIV-infected patients for whom HS was unlikely [4.0 (2.9-4.6) vs 3.9 (2.6-4.1) log/ml, p = 0.48].The high EBV viral load observed in HIV-infected patients with HS may be more likely to reflect the chronic HIV infection than to be the direct trigger of HS.
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Affiliation(s)
- Mario Boisseau
- From the AP-HP, Service de Médecine Interne, Hôpital Bichat-Claude Bernard , Paris , France
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296
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Jenkins MR, Rudd-Schmidt JA, Lopez JA, Ramsbottom KM, Mannering SI, Andrews DM, Voskoboinik I, Trapani JA. Failed CTL/NK cell killing and cytokine hypersecretion are directly linked through prolonged synapse time. ACTA ACUST UNITED AC 2015; 212:307-17. [PMID: 25732304 PMCID: PMC4354371 DOI: 10.1084/jem.20140964] [Citation(s) in RCA: 157] [Impact Index Per Article: 17.4] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Jenkins et al. discover that failure of perforin and granzyme cytotoxicity by human and mouse CTLs/NK cells prolongs the immunological synapse, leading to repetitive calcium signaling and hypersecretion of inflammatory mediators that subsequently activate macrophages. Disengagement from target cells is dependent on apoptotic caspase signaling. The findings may provide mechanistic understanding for immunopathology in familial hemophagocytic lymphohistiocytosis. Failure of cytotoxic T lymphocytes (CTLs) or natural killer (NK) cells to kill target cells by perforin (Prf)/granzyme (Gzm)-induced apoptosis causes severe immune dysregulation. In familial hemophagocytic lymphohistiocytosis, Prf-deficient infants suffer a fatal “cytokine storm” resulting from macrophage overactivation, but the link to failed target cell death is not understood. We show that prolonged target cell survival greatly amplifies the quanta of inflammatory cytokines secreted by CTLs/NK cells and that interferon-γ (IFN-γ) directly invokes the activation and secondary overproduction of proinflammatory IL-6 from naive macrophages. Furthermore, using live cell microscopy to visualize hundreds of synapses formed between wild-type, Prf-null, or GzmA/B-null CTLs/NK cells and their targets in real time, we show that hypersecretion of IL-2, TNF, IFN-γ, and various chemokines is linked to failed disengagement of Prf- or Gzm-deficient lymphocytes from their targets, with mean synapse time increased fivefold, from ∼8 to >40 min. Surprisingly, the signal for detachment arose from the dying target cell and was caspase dependent, as delaying target cell death with various forms of caspase blockade also prevented their disengagement from fully competent CTLs/NK cells and caused cytokine hypersecretion. Our findings provide the cellular mechanism through which failed killing by lymphocytes causes systemic inflammation involving recruitment and activation of myeloid cells.
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Affiliation(s)
- Misty R Jenkins
- Cancer Cell Death and Killer Cell Biology Laboratories, Peter MacCallum Cancer Centre, East Melbourne, Victoria 3002, Australia The Sir Peter MacCallum Department of Oncology; Department of Genetics; and Department of Medicine, St. Vincent's Hospital; The University of Melbourne, Parkville, Victoria 3010, Australia
| | - Jesse A Rudd-Schmidt
- Cancer Cell Death and Killer Cell Biology Laboratories, Peter MacCallum Cancer Centre, East Melbourne, Victoria 3002, Australia The Sir Peter MacCallum Department of Oncology; Department of Genetics; and Department of Medicine, St. Vincent's Hospital; The University of Melbourne, Parkville, Victoria 3010, Australia
| | - Jamie A Lopez
- Cancer Cell Death and Killer Cell Biology Laboratories, Peter MacCallum Cancer Centre, East Melbourne, Victoria 3002, Australia The Sir Peter MacCallum Department of Oncology; Department of Genetics; and Department of Medicine, St. Vincent's Hospital; The University of Melbourne, Parkville, Victoria 3010, Australia
| | - Kelly M Ramsbottom
- Cancer Cell Death and Killer Cell Biology Laboratories, Peter MacCallum Cancer Centre, East Melbourne, Victoria 3002, Australia The Sir Peter MacCallum Department of Oncology; Department of Genetics; and Department of Medicine, St. Vincent's Hospital; The University of Melbourne, Parkville, Victoria 3010, Australia
| | - Stuart I Mannering
- The Sir Peter MacCallum Department of Oncology; Department of Genetics; and Department of Medicine, St. Vincent's Hospital; The University of Melbourne, Parkville, Victoria 3010, Australia Immunology and Diabetes Unit, St. Vincent's Institute of Medical Research, Fitzroy, Victoria 3065, Australia
| | - Daniel M Andrews
- The Sir Peter MacCallum Department of Oncology; Department of Genetics; and Department of Medicine, St. Vincent's Hospital; The University of Melbourne, Parkville, Victoria 3010, Australia
| | - Ilia Voskoboinik
- Cancer Cell Death and Killer Cell Biology Laboratories, Peter MacCallum Cancer Centre, East Melbourne, Victoria 3002, Australia The Sir Peter MacCallum Department of Oncology; Department of Genetics; and Department of Medicine, St. Vincent's Hospital; The University of Melbourne, Parkville, Victoria 3010, Australia The Sir Peter MacCallum Department of Oncology; Department of Genetics; and Department of Medicine, St. Vincent's Hospital; The University of Melbourne, Parkville, Victoria 3010, Australia
| | - Joseph A Trapani
- Cancer Cell Death and Killer Cell Biology Laboratories, Peter MacCallum Cancer Centre, East Melbourne, Victoria 3002, Australia The Sir Peter MacCallum Department of Oncology; Department of Genetics; and Department of Medicine, St. Vincent's Hospital; The University of Melbourne, Parkville, Victoria 3010, Australia
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297
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Otrock ZK, Eby CS. Clinical characteristics, prognostic factors, and outcomes of adult patients with hemophagocytic lymphohistiocytosis. Am J Hematol 2015; 90:220-4. [PMID: 25469675 DOI: 10.1002/ajh.23911] [Citation(s) in RCA: 213] [Impact Index Per Article: 23.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2014] [Revised: 11/24/2014] [Accepted: 11/28/2014] [Indexed: 12/24/2022]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a rare clinical syndrome characterized by the activation of the mononuclear phagocytic system. The diagnosis of HLH in adults is challenging not only because the majority of the reported data are from pediatric patients, but also because HLH occurs in many disease entities. This study reports the clinical and laboratory findings and prognostic factors of adult HLH in a large cohort managed at a single medical center from 2003 to 2014. Seventy-three patients met the HLH-2004 diagnostic criteria. The median age was 51 years (range, 18-82 years); 41 (56.2%) were male. Patients manifested fever, cytopenias, and elevated ferritin in >85% of cases. Likely causes of HLH were as follows: 30 (41.1%) infections, 21 (28.8%) malignancies, 5 (6.8%) attributed to autoimmune disorders, 1 (1.4%) primary immunodeficiency, 2 (2.7%) post solid organ transplantation, and 13 (17.8%) idiopathic. The median overall survival was 7.67 months. Patients with malignancy-associated HLH had a markedly worse survival compared with patients with non-malignancy-associated HLH (median overall survival 1.13 vs. 46.53 months, respectively; P < 0.0001). In a multivariable analysis, malignancy (hazard ratio = 12.22; 95% CI: 2.53-59.02; P = 0.002) correlated with poor survival. Ferritin >50,000 µg/L correlated with 30-day mortality. Survival after a diagnosis of HLH is dismal, especially among those with malignancy-associated HLH. The development of a registry for adults with HLH would improve our understanding of this syndrome, validate diagnostic criteria, and help develop effective treatment strategies.
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Affiliation(s)
- Zaher K. Otrock
- Department of Pathology and Immunology; Washington University School of Medicine; St. Louis Missouri
| | - Charles S. Eby
- Department of Pathology and Immunology; Washington University School of Medicine; St. Louis Missouri
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298
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XIAP deficiency syndrome in humans. Semin Cell Dev Biol 2015; 39:115-23. [DOI: 10.1016/j.semcdb.2015.01.015] [Citation(s) in RCA: 90] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2014] [Revised: 01/29/2015] [Accepted: 01/30/2015] [Indexed: 01/15/2023]
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299
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Epstein-barr virus-related hemophagocytic lymphohistiocytosis: hematologic emergency in the critical care setting. Case Rep Hematol 2015; 2015:491567. [PMID: 25755898 PMCID: PMC4338404 DOI: 10.1155/2015/491567] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2014] [Revised: 01/23/2015] [Accepted: 01/23/2015] [Indexed: 01/17/2023] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a rare and potential life-threatening clinical syndrome that results from uncontrolled activation of the immune system. Secondary HLH, more commonly observed in adult patients, is seen in the context of underlying triggering conditions. Epstein-Barr virus (EBV) has been recognized as the leading infectious cause and is associated with a poor outcome. As clinical and laboratory features of HLH could overlap with septic shock syndrome in most patients, the diagnosis of HLH, especially in adults, is the most challenging aspect of the disease that results in delayed recognition and treatment of rapidly progressive multiorgan system failure. We report a case of Hemophagocytic lymphohistiocytosis in a patient who presented with signs of septic shock syndrome and we review the literature on the topic.
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300
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Cytokine balance and cytokine-driven natural killer cell dysfunction in systemic juvenile idiopathic arthritis. Cytokine Growth Factor Rev 2015; 26:35-45. [DOI: 10.1016/j.cytogfr.2014.05.005] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2014] [Revised: 05/13/2014] [Accepted: 05/15/2014] [Indexed: 01/14/2023]
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