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Orth HM, Wiemer D, Schneitler S, Schönfeld A, Holtfreter MC, Gliga S, Fuchs A, Pfäfflin F, Denkinger CM, Kalbitz S, Fritzsche C, Hübner MP, Trauth J, Jensen BEO, Luedde T, Feldt T. Hemophagocytic lymphohistiocytosis-how common and how severe is it as a complication of malaria? Retrospective case series and review of the literature. Infection 2024; 52:471-482. [PMID: 37875775 PMCID: PMC10955030 DOI: 10.1007/s15010-023-02104-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 09/27/2023] [Indexed: 10/26/2023]
Abstract
BACKGROUND Infection-associated secondary hemophagocytic lymphohistiocytosis (sHLH) is a potentially life-threatening hyperinflammatory condition caused by various infectious diseases. Malaria has rarely been described as trigger. The aim of this study is to collect data on frequency, clinical spectrum, and outcome of sHLH induced by malaria. METHODS We collected case numbers on malaria and malaria-associated sHLH from specialized centers in Germany from 2015 to 2022. In addition, we conducted a literature search on published cases of malaria-associated sHLH and systematically analyzed the literature regarding clinical and diagnostic criteria. RESULTS We obtained data from 13 centers treating 1461 malaria cases with different Plasmodium species, of which 5 patients (0.34%) also were diagnosed with sHLH. The literature search revealed detailed case reports from further 51 patients and case series comprising the description of further 24 patients with malaria-associated sHLH. Most cases (48/80; 60%) were reported from Asia. The median time interval between onset of malaria symptoms and hospital admission was 7 days. Severe complications of sHLH were documented in 36% (20/56) of patients, including two patients with multiple organ failure in our case series. Only 41% (23/56) of patients received specific treatment for sHLH, nevertheless the mortality rate (CFR) of 5% is lower compared to the CFR reported for sHLH triggered by other infectious diseases (e.g., 25% in sHLH due to EBV infection). CONCLUSION Malaria-associated sHLH appears to have a comparatively good prognosis but may still represent an underdiagnosed and potentially fatal complication of malaria, especially in resource-poor settings.
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Affiliation(s)
- Hans Martin Orth
- Department of Gastroenterology, Hepatology and Infectious Diseases, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University, Düsseldorf, Germany.
| | - Dorothea Wiemer
- Department of Tropical Medicine and Infectious Diseases at the Bernhard Nocht Institute, Bundeswehr Hospital Hamburg, Hamburg, Germany
| | - Sophie Schneitler
- Institute of Medical Microbiology and Hygiene, Saarland University, Homburg/Saar, Germany
| | - Andreas Schönfeld
- Department of Infectious Diseases, West German Centre of Infectious Diseases, University Hospital Centre Essen, University of Duisburg-Essen DE, Essen, Germany
| | - Martha Charlotte Holtfreter
- Department of Gastroenterology, Hepatology and Infectious Diseases, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University, Düsseldorf, Germany
| | - Smaranda Gliga
- Department of Gastroenterology, Hepatology and Infectious Diseases, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University, Düsseldorf, Germany
| | - Andre Fuchs
- Internal Medicine III-Gastroenterology and Infectious Diseases, Augsburg University Hospital, Augsburg, Germany
| | - Frieder Pfäfflin
- Department for Infectious Diseases and Respiratory Medicine, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Claudia Maria Denkinger
- Division of Infectious Disease and Tropical Medicine, Heidelberg University Hospital, Heidelberg, Germany
- German Center for Infection Research (DZIF), partner site Heidelberg University Hospital, Heidelberg, Germany
| | - Sven Kalbitz
- Department of Infectious Diseases/Tropical Medicine, Nephrology and Rheumatology, Hospital St. Georg, Leipzig, Germany
| | - Carlos Fritzsche
- Department of Tropical Medicine and Infectious Diseases, Center for Internal Medicine, University of Rostock, Rostock, Germany
| | - Marc P Hübner
- Institute for Medical Microbiology, Immunology and Parasitology, University Hospital Bonn, Bonn, Germany
- German Center for Infection Research (DZIF), Partner Site Bonn-Cologne, Bonn, Germany
| | - Janina Trauth
- Division of Infectious Diseases, Department of Internal Medicine II, University Hospital Giessen and Marburg, Justus Liebig University Giessen, Giessen, Germany
| | - Björn-Erik Ole Jensen
- Department of Gastroenterology, Hepatology and Infectious Diseases, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University, Düsseldorf, Germany
| | - Tom Luedde
- Department of Gastroenterology, Hepatology and Infectious Diseases, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University, Düsseldorf, Germany
| | - Torsten Feldt
- Department of Gastroenterology, Hepatology and Infectious Diseases, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University, Düsseldorf, Germany
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Deng R, Yuan G, Ye Y, Luo W, Zhong J, Wang H, Wei X, Luo X, Xiong A. Qualitative evaluation of connective tissue disease with cytomegalovirus infection: A meta-analysis of case reports. Semin Arthritis Rheum 2024; 65:152396. [PMID: 38340610 DOI: 10.1016/j.semarthrit.2024.152396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Revised: 01/24/2024] [Accepted: 01/26/2024] [Indexed: 02/12/2024]
Abstract
BACKGROUND The primary therapies for connective tissue disease include glucocorticoids and immunosuppressants. However, their prolonged usage can precipitate opportunistic infections, such as cytomegalovirus infection. When managing connective tissue disease complicated by cytomegalovirus infection, judicious selection of treatment modalities is crucial. This involves assessing the necessity for antiviral therapy and contemplating the reduction or cessation of glucocorticoids and immunosuppressants. OBJECTIVE This investigation sought to methodically review existing literature regarding treating connective tissue disease patients with cytomegalovirus infection. METHODS On July 5, 2023, an exhaustive literature search was conducted. Data analysis utilized the Kruskal-Wallis test or one-way analysis of variance, supplemented by Bonferroni post hoc testing. RESULTS Our meta-analysis incorporated 88 studies encompassing 146 connective tissue disease patients with CMV infections. The results indicated that patients with connective tissue disease and cytomegalovirus disease benefitted more from antiviral therapy than those not receiving such treatment (P = 0.003, P < 0.005). Furthermore, the strategic reduction of glucocorticoids and/or immunosuppressants was beneficial (P = 0.037, P < 0.05). Poor clinical outcomes with glucocorticoid-immunosuppressant combination therapy compared to other treatment modalities. The findings also suggested that CMV infection patients fare better without Cyclosporine A than using it (P = 0.041, P < 0.05). CONCLUSION Antiviral therapy is a viable treatment option in cases of connective tissue disease co-occurring with cytomegalovirus disease. Additionally, when connective tissue disease is stable, there is potential merit in reducing glucocorticoids and/or immunosuppressants, especially avoiding the combination of these drugs. For all cytomegalovirus infection patients, Cyclosporine A may be avoided wherever possible for selecting immunosuppressive agents if its use is not deemed essential in the treatment regimen.
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Affiliation(s)
- Ruiting Deng
- Department of Rheumatology and Immunology, Nanchong Central Hospital, The Affiliated Nanchong Central Hospital of North Sichuan Medical College, Nanchong Hospital of Beijing Anzhen Hospital Capital Medical University, Nanchong, Sichuan, China
| | - Gaodi Yuan
- Department of Rheumatology and Immunology, Nanchong Central Hospital, The Affiliated Nanchong Central Hospital of North Sichuan Medical College, Nanchong Hospital of Beijing Anzhen Hospital Capital Medical University, Nanchong, Sichuan, China
| | - Yiman Ye
- Department of Rheumatology and Immunology, Nanchong Central Hospital, The Affiliated Nanchong Central Hospital of North Sichuan Medical College, Nanchong Hospital of Beijing Anzhen Hospital Capital Medical University, Nanchong, Sichuan, China
| | - Wenxuan Luo
- Department of Rheumatology and Immunology, Nanchong Central Hospital, The Affiliated Nanchong Central Hospital of North Sichuan Medical College, Nanchong Hospital of Beijing Anzhen Hospital Capital Medical University, Nanchong, Sichuan, China
| | - Jiaxun Zhong
- Department of Rheumatology and Immunology, Nanchong Central Hospital, The Affiliated Nanchong Central Hospital of North Sichuan Medical College, Nanchong Hospital of Beijing Anzhen Hospital Capital Medical University, Nanchong, Sichuan, China
| | - Haolan Wang
- Department of Rheumatology and Immunology, Nanchong Central Hospital, The Affiliated Nanchong Central Hospital of North Sichuan Medical College, Nanchong Hospital of Beijing Anzhen Hospital Capital Medical University, Nanchong, Sichuan, China
| | - Xin Wei
- Department of Ophthalmology, West China Hospital, Sichuan University, Chengdu, China.
| | - Xiongyan Luo
- Department of Rheumatology and Immunology, West China Hospital, Sichuan University, Chengdu, China.
| | - Anji Xiong
- Department of Rheumatology and Immunology, Nanchong Central Hospital, The Affiliated Nanchong Central Hospital of North Sichuan Medical College, Nanchong Hospital of Beijing Anzhen Hospital Capital Medical University, Nanchong, Sichuan, China; Inflammation and Immunology Key Laboratory of Nanchong City, Nanchong, Sichuan, China; Nanchong Central Hospital, (Nanchong Clinical Research Center), Nanchong, Sichuan, China.
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Xu S, He K. Hemophagocytic lymphohistiocytosis after solid organ transplantation: A challenge for clinicians. Transpl Immunol 2024; 83:102007. [PMID: 38307154 DOI: 10.1016/j.trim.2024.102007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 01/29/2024] [Accepted: 01/30/2024] [Indexed: 02/04/2024]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a rare inflammatory disorder with a high mortality rate and a wide range of symptoms. Solid organ transplantation, which provides patients with a unique immunosuppressive state, is a less common predisposing factor for HLH. HLH after solid organ transplantation (HLH-SOT) is very rare and fatal. It is hard to diagnose and treat and extremely understudied. The use of immunosuppressants makes the situation of HLH-SOT more complex. This review summarizes the existing literature on HLH after solid organ transplantation and describes its triggers and symptoms, focusing on its diagnosis and treatment. We performed a literature search of case reports, case series, letters to the editor, and clinical quizzes describing patients with HLH after solid organ transplantation (HLH-SOT). We provide recommendations on the diagnosis protocol and treatment strategy based on the existing evidence.
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Affiliation(s)
- Shanshan Xu
- Department of Liver Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China; Shanghai Engineering Research Center of Transplantation and Immunology, Shanghai, China; Shanghai Institute of Transplantation, Shanghai, China
| | - Kang He
- Department of Liver Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China; Shanghai Engineering Research Center of Transplantation and Immunology, Shanghai, China; Shanghai Institute of Transplantation, Shanghai, China.
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Jordan MB. Hemophagocytic lymphohistiocytosis: A disorder of T cell activation, immune regulation, and distinctive immunopathology. Immunol Rev 2024; 322:339-350. [PMID: 38100247 DOI: 10.1111/imr.13298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2023]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a disorder that has been recognized since the middle of the last century. In recent decades, increasing understanding of the genetic roots and pathophysiology of HLH has led to improved diagnosis and treatment of this once universally fatal disorder. HLH is best conceptualized as a maladaptive state of excessive T cell activation driving life-threatening myeloid cell activation, largely via interferon-gamma (IFN-γ). In familial forms of HLH (F-HLH), inherited defects of lymphocyte cytotoxic biology underlie excessive T cell activation, demonstrating the importance of the perforin/granzyme pathway as a negative feedback loop limiting acute T cell activation in response to environmental factors. HLH occurring in other contexts and without apparent inherited genetic predisposition remains poorly understood, though it may share some downstream aspects of pathophysiology including excessive IFN-γ action and activation of innate immune effectors. Iatrogenic forms of HLH occurring after immune-activating therapies for cancer are providing new insights into the potential toxicities of inadequately controlled T cell activation. Diagnosing HLH increasingly relies on context-specific measures of T cell activation, IFN-γ activity, and inflammation. Treatment of HLH largely relies on cytotoxic chemotherapy, though targeted therapies against T cells, IFN-γ, and other cytokines are increasingly utilized.
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Affiliation(s)
- Michael B Jordan
- Division of Immunobiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Division of Bone Marrow Transplantation and Immune Deficiency, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
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Sugisaki K, Uchida T, Iwama S, Okihara M, Akashi I, Kihara Y, Konno O, Kuroda M, Koike J, Iwamoto H, Oda T. Glomerular lipidosis as a feature of renal-limited macrophage activation syndrome in a transplanted kidney: a case report. BMC Nephrol 2023; 24:329. [PMID: 37936128 PMCID: PMC10631159 DOI: 10.1186/s12882-023-03380-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Accepted: 10/27/2023] [Indexed: 11/09/2023] Open
Abstract
BACKGROUND Glomerular lipidosis is a rare histological feature presenting the extensive glomerular accumulation of lipids with or without histiocytic infiltration, which develops under various conditions. Among its various etiologies, macrophage activation syndrome (MAS) is a condition reported to be associated with histiocytic glomerular lipidosis. Here we describe the first case of glomerular lipidosis observed in a renal allograft that histologically mimicked histiocytic glomerulopathy owing to MAS. CASE PRESENTATION A 42-year-old man underwent successful living-donor kidney transplantation. However, middle-grade proteinuria and increased serum triglyceride levels indicative of type V hyperlipidemia developed rapidly thereafter. An allograft biopsy performed 6 months after the transplantation showed extensive glomerular infiltration of CD68+ foam cells (histiocytes) intermingled with many CD3+ T-cells (predominantly CD8+ cells). Furthermore, frequent contact between glomerular T-cells and histiocytes, and the existence of activated CD8+ cells (CD8+, HLA-DR+ cells) were observed by double immunostaining. There was no clinicopathological data suggesting lipoprotein glomerulopathy or lecithin cholesterol acyltransferase deficiency, both of which are well-known causes of glomerular lipidosis. The histological findings were relatively similar to those of histiocytic glomerulopathy caused by MAS. As systemic manifestations of MAS, such as fever, pancytopenia, coagulation abnormalities, hyperferritinemia, increased liver enzyme levels, hepatosplenomegaly, and lymphadenopathy were minimal, this patient was clinicopathologically diagnosed as having renal-limited MAS. Although optimal treatment strategies for MAS in kidney transplant patients remains unclear, we strengthened lipid-lowering therapy using pemafibrate, without modifying the amount of immunosuppressants. Serum triglyceride levels were normalized with this treatment; however, the patient's extensive proteinuria and renal dysfunction did not improve. Biopsy analysis at 1 year after the transplantation demonstrated the disappearance of glomerular foamy changes, but the number of glomerular infiltrating cells remained similar. CONCLUSION To our knowledge, this is the first reported case of glomerular lipidosis in a transplanted kidney. Increased interaction-activation of histiocytes (macrophages) and CD8+ T-cells, the key pathogenic feature of MAS, was observed in the glomeruli of this patient, who did not demonstrate overt systemic manifestations, suggesting a pathological condition of renal-limited MAS. The clinical effects of triglyceride-lowering therapy were limited, suggesting that hypertriglyceridemia was not the cause of but rather may be a consequence of renal-limited MAS.
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Affiliation(s)
- Kentaro Sugisaki
- Department of Nephrology and Blood Purification, Kidney Disease Center, Tokyo Medical University Hachioji Medical Center, 1163 Tatemachi, Hachioji, Tokyo, 193-0998, Japan
| | - Takahiro Uchida
- Department of Nephrology and Blood Purification, Kidney Disease Center, Tokyo Medical University Hachioji Medical Center, 1163 Tatemachi, Hachioji, Tokyo, 193-0998, Japan
| | - Sachiko Iwama
- Department of Nephrology and Blood Purification, Kidney Disease Center, Tokyo Medical University Hachioji Medical Center, 1163 Tatemachi, Hachioji, Tokyo, 193-0998, Japan
| | - Masaaki Okihara
- Department of Kidney Transplantation Surgery, Kidney Disease Center, Tokyo Medical University Hachioji Medical Center, Hachioji, Tokyo, Japan
| | - Isao Akashi
- Department of Kidney Transplantation Surgery, Kidney Disease Center, Tokyo Medical University Hachioji Medical Center, Hachioji, Tokyo, Japan
| | - Yu Kihara
- Department of Kidney Transplantation Surgery, Kidney Disease Center, Tokyo Medical University Hachioji Medical Center, Hachioji, Tokyo, Japan
| | - Osamu Konno
- Department of Kidney Transplantation Surgery, Kidney Disease Center, Tokyo Medical University Hachioji Medical Center, Hachioji, Tokyo, Japan
| | - Masayuki Kuroda
- Center for Advanced Medicine, Chiba University, Chiba City, Chiba, Japan
| | - Junki Koike
- Department of Pathology, St. Marianna University School of Medicine, Kawasaki, Kanagawa, Japan
| | - Hitoshi Iwamoto
- Department of Kidney Transplantation Surgery, Kidney Disease Center, Tokyo Medical University Hachioji Medical Center, Hachioji, Tokyo, Japan
| | - Takashi Oda
- Department of Nephrology and Blood Purification, Kidney Disease Center, Tokyo Medical University Hachioji Medical Center, 1163 Tatemachi, Hachioji, Tokyo, 193-0998, Japan.
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Chinnici A, Beneforti L, Pegoraro F, Trambusti I, Tondo A, Favre C, Coniglio ML, Sieni E. Approaching hemophagocytic lymphohistiocytosis. Front Immunol 2023; 14:1210041. [PMID: 37426667 PMCID: PMC10324660 DOI: 10.3389/fimmu.2023.1210041] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Accepted: 06/08/2023] [Indexed: 07/11/2023] Open
Abstract
Hemophagocytic Lymphohistiocytosis (HLH) is a rare clinical condition characterized by sustained but ineffective immune system activation, leading to severe and systemic hyperinflammation. It may occur as a genetic or sporadic condition, often triggered by an infection. The multifaceted pathogenesis results in a wide range of non-specific signs and symptoms, hampering early recognition. Despite a great improvement in terms of survival in the last decades, a considerable proportion of patients with HLH still die from progressive disease. Thus, prompt diagnosis and treatment are crucial for survival. Faced with the complexity and the heterogeneity of syndrome, expert consultation is recommended to correctly interpret clinical, functional and genetic findings and address therapeutic decisions. Cytofluorimetric and genetic analysis should be performed in reference laboratories. Genetic analysis is mandatory to confirm familial hemophagocytic lymphohistiocytosis (FHL) and Next Generation Sequencing is increasingly adopted to extend the spectrum of genetic predisposition to HLH, though its results should be critically discussed with specialists. In this review, we critically revise the reported laboratory tools for the diagnosis of HLH, in order to outline a comprehensive and widely available workup that allows to reduce the time between the clinical suspicion of HLH and its final diagnosis.
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Affiliation(s)
- Aurora Chinnici
- Department of Neurosciences, Psychology, Drug Research and Child Health (NEUROFARBA), University of Florence, Florence, Italy
- Department of Pediatric Hematology Oncology, Meyer Children’s Hospital IRCCS, Florence, Italy
| | - Linda Beneforti
- Department of Neurosciences, Psychology, Drug Research and Child Health (NEUROFARBA), University of Florence, Florence, Italy
- Department of Pediatric Hematology Oncology, Meyer Children’s Hospital IRCCS, Florence, Italy
| | - Francesco Pegoraro
- Department of Pediatric Hematology Oncology, Meyer Children’s Hospital IRCCS, Florence, Italy
- Department of Health Sciences, University of Florence, Florence, Italy
| | - Irene Trambusti
- Department of Pediatric Hematology Oncology, Meyer Children’s Hospital IRCCS, Florence, Italy
| | - Annalisa Tondo
- Department of Pediatric Hematology Oncology, Meyer Children’s Hospital IRCCS, Florence, Italy
| | - Claudio Favre
- Department of Pediatric Hematology Oncology, Meyer Children’s Hospital IRCCS, Florence, Italy
| | - Maria Luisa Coniglio
- Department of Pediatric Hematology Oncology, Meyer Children’s Hospital IRCCS, Florence, Italy
| | - Elena Sieni
- Department of Pediatric Hematology Oncology, Meyer Children’s Hospital IRCCS, Florence, Italy
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Jeyakanthan T, Ladel L, Khandpur B, Tan WY, Nasir SA. Coronavirus Does It Again: Post-COVID-19 Hemophagocytic Lymphohistiocytosis (HLH). Cureus 2023; 15:e35275. [PMID: 36968874 PMCID: PMC10036136 DOI: 10.7759/cureus.35275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/20/2023] [Indexed: 02/23/2023] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a hematological disorder that results from an uncontrolled activation of the immune system, which can then lead to multisystem organ failure. Given the nonspecific nature of this illness, it can go undetected for too long, thereby causing permanent damage to organ systems. In adults, HLH has been associated with a number of infectious etiologies, particularly viral infections. Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has led to a global pandemic and has been associated with acute respiratory distress syndrome (ARDS). Among its other manifestations, COVID-19 has also been linked to HLH. In this report, we describe a case of a male patient who presented with multisystem organ failure and was found to have HLH. Since no clear etiology for his HLH could be elicited, it was determined to be a result of his recent COVID-19 infection.
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Chevalier K, Schmidt J, Coppo P, Galicier L, Noël N, Lambotte O. Hemophagocytic Lymphohistiocytosis Associated With Cytomegalovirus Infection: 5 Cases and a Systematic Review of the Literature. Clin Infect Dis 2023; 76:351-358. [PMID: 35974465 DOI: 10.1093/cid/ciac649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 07/30/2022] [Accepted: 08/09/2022] [Indexed: 01/18/2023] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a rare, life-threatening disorder characterized by an uncontrolled, persistent, hyperimmune response. It can be triggered by an infectious, neoplastic, or autoimmune event. The involvement of cytomegalovirus (CMV) in the onset of HLH is subject to debate, and the epidemiology of CMV-associated HLH (HLH-CMV) remains poorly characterized. We identified 5 cases of HLH-CMV in our hospital, systematically searched the PubMed database for publications on HLH-CMV, and reviewed 57 publications with a total of 67 cases of HLH-CMV. Only 48 patients (71.6%) were immunodeficient, suggesting that HLH-CMV can occur in immunocompetent patients. The major cause of underlying immunodepression (51%) was inflammatory bowel disease (mainly treated with azathioprine). CMV infection was nearly always symptomatic, and lung involvement was frequent (31 cases). Fifty-five patients recovered. Nineteen patients were treated for CMV infection only and had a good outcome, suggesting that antiviral drugs might be the cornerstone of HLH-CMV treatment.
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Affiliation(s)
- Kevin Chevalier
- Université Paris-Saclay, AP-HP, Hôpital Bicêtre, service de Médecine Interne Immunologie Clinique, Centre de recherche en Immunologie des infections virales et des maladies auto-immunes ImVA, UMR1184, INSERM, CEA, Le Kremlin Bicêtre, France
| | - Julien Schmidt
- Université Paris-Saclay, AP-HP, Hôpital Bicêtre, service de Médecine Interne Immunologie Clinique, Centre de recherche en Immunologie des infections virales et des maladies auto-immunes ImVA, UMR1184, INSERM, CEA, Le Kremlin Bicêtre, France
| | - Paul Coppo
- Sorbonne Université, AP-HP, Hôpital St. Antoine, service d'hématologie clinique et thérapie cellulaire, Paris, France
| | - Lionel Galicier
- Université Paris Cité, AP-HP, Hôpital Saint-Louis, service d'immunologie clinique, Paris, France
| | - Nicolas Noël
- Université Paris-Saclay, AP-HP, Hôpital Bicêtre, service de Médecine Interne Immunologie Clinique, Centre de recherche en Immunologie des infections virales et des maladies auto-immunes ImVA, UMR1184, INSERM, CEA, Le Kremlin Bicêtre, France
| | - Olivier Lambotte
- Université Paris-Saclay, AP-HP, Hôpital Bicêtre, service de Médecine Interne Immunologie Clinique, Centre de recherche en Immunologie des infections virales et des maladies auto-immunes ImVA, UMR1184, INSERM, CEA, Le Kremlin Bicêtre, France
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9
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Paolino J, Berliner N, Degar B. Hemophagocytic lymphohistiocytosis as an etiology of bone marrow failure. Front Oncol 2022; 12:1016318. [PMID: 36387094 PMCID: PMC9647152 DOI: 10.3389/fonc.2022.1016318] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Accepted: 09/27/2022] [Indexed: 11/13/2022] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a syndrome of multiorgan system dysfunction that is caused by hypercytokinemia and persistent activation of cytotoxic T lymphocytes and macrophages. A nearly ubiquitous finding and a diagnostic criterion of HLH is the presence of cytopenias in ≥ 2 cell lines. The mechanism of cytopenias in HLH is multifactorial but appears to be predominantly driven by suppression of hematopoiesis by pro-inflammatory cytokines and, to some extent, by consumptive hemophagocytosis. Recognition of cytopenias as a manifestation of HLH is an important consideration for patients with bone marrow failure of unclear etiology.
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Affiliation(s)
- Jonathan Paolino
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, United States
| | - Nancy Berliner
- Division of Hematology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
| | - Barbara Degar
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, United States,*Correspondence: Barbara Degar,
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Roccatello D, Sciascia S, Barreca A, Naretto C, Alpa M, Quattrocchio G, Radin M, Fenoglio R. Renal involvement as a unique manifestation of hemophagocytic syndrome. Front Med (Lausanne) 2022; 9:796121. [PMID: 36275824 PMCID: PMC9579315 DOI: 10.3389/fmed.2022.796121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Accepted: 08/25/2022] [Indexed: 11/21/2022] Open
Abstract
Renal-limited hemophagocytic syndrome (HPS) is a rare clinical setting characterized by abnormal activation of the immune system. Fever associated with pancytopenia, hepatosplenomegaly with liver dysfunction, and hypofibrinogenemia are usually observed in HPS. From a histological level, the presence of non-malignant macrophages infiltrating bone marrow and organs represents the hallmark of this condition. Non-malignant macrophages are associated with phagocytizing activities involving other blood cells. While primary HPS is usually associated with inherited dysregulation of the immune system, secondary HPS usually occurs in the context of infection or is linked to a neoplastic process. Clinical presentation varies and can potentially lead to life-threatening settings. While renal involvement has frequently been reported, however, detailed descriptions of the kidney manifestations of HPS are lacking. More critically, the diagnosis of HPS is rarely supported by renal biopsy specimens. We report four rare cases of biopsy-proven renal-limited HPS in patients presenting with acute kidney injury (AKI). The available evidence on this topic is critically discussed in light of the possible emergence of an autonomous entity characterized by an isolated kidney involvement.
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Affiliation(s)
- Dario Roccatello
- University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) With Nephrology and Dialysis Unit, Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley (North-West Italy), Department of Clinical and Biological Sciences, San Giovanni Bosco Hub Hospital, University of Turin, Turin, Italy,*Correspondence: Dario Roccatello
| | - Savino Sciascia
- University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) With Nephrology and Dialysis Unit, Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley (North-West Italy), Department of Clinical and Biological Sciences, San Giovanni Bosco Hub Hospital, University of Turin, Turin, Italy
| | | | - Carla Naretto
- University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) With Nephrology and Dialysis Unit, Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley (North-West Italy), Department of Clinical and Biological Sciences, San Giovanni Bosco Hub Hospital, University of Turin, Turin, Italy
| | - Mirella Alpa
- University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) With Nephrology and Dialysis Unit, Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley (North-West Italy), Department of Clinical and Biological Sciences, San Giovanni Bosco Hub Hospital, University of Turin, Turin, Italy
| | - Giacomo Quattrocchio
- University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) With Nephrology and Dialysis Unit, Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley (North-West Italy), Department of Clinical and Biological Sciences, San Giovanni Bosco Hub Hospital, University of Turin, Turin, Italy
| | - Massimo Radin
- University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) With Nephrology and Dialysis Unit, Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley (North-West Italy), Department of Clinical and Biological Sciences, San Giovanni Bosco Hub Hospital, University of Turin, Turin, Italy
| | - Roberta Fenoglio
- University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) With Nephrology and Dialysis Unit, Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley (North-West Italy), Department of Clinical and Biological Sciences, San Giovanni Bosco Hub Hospital, University of Turin, Turin, Italy
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11
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Orth HM, Fuchs A, Lübke N, Jensen BEO, Luedde T. Recurrent parvovirus B19 viremia resulting in two episodes of hemophagocytic lymphohistiocytosis. Virol J 2022; 19:107. [PMID: 35752863 PMCID: PMC9233783 DOI: 10.1186/s12985-022-01841-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Accepted: 05/27/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Hemophagocytic lymphohistiocytosis (HLH) is a hyperinflammatory condition with uncontrolled activation of lymphocytes and macrophages. Besides a primary (genetic) form, HLH can also be triggered by malignant, autoimmune and infectious diseases. HLH recurrences are rarely described, usually only in primary HLH. Parvovirus B19 (PVB19) Infection is one of the rare and rather benign causes of HLH. Since the infection usually results in long-lasting immunity, recurrent viremia is very uncommon. CASE PRESENTATION We report an unusual case of a young female with recurrent PVB19 infection that led to repeated episodes of HLH. The first episode occurred at the age of 25 years with a three-week history of high fever and nonspecific accompanying symptoms. The diagnosis of HLH was confirmed by HLH-2004 criteria and HScore, PVB19 viremia was detected as underlying cause. Following guideline-based therapy, the patient was symptom-free for one year, before similar symptoms recurred in a milder form. Again, PVB19 was detected and HLH was diagnosed according to HScore. After successful treatment and a nine-month symptom-free interval, a third phase of hyperinflammation with low PVB19 viremia occurred; this time, treatment with a corticosteroid and intravenous immunoglobulin was initiated before the presence of clear diagnostic criteria for HLH. No further events occurred in the following three years. CONCLUSIONS In the case of our patient, the recurrent viremia triggered three episodes of hyperinflammation, two of which were clearly diagnosed as HLH. To our knowledge, this is the first published case of recurrent HLH due to PVB19 infection. Therefore, the case gives new insights in triggering mechanisms for HLH.
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Affiliation(s)
- Hans Martin Orth
- Department of Gastroenterology, Hepatology and Infectious Diseases, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University, Düsseldorf, Germany.
| | - Andre Fuchs
- Internal Medicine III - Gastroenterology and Infectious Diseases, Augsburg University Hospital, Augsburg, Germany
| | - Nadine Lübke
- Department of Virology, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University, Düsseldorf, Germany
| | - Björn-Erik Ole Jensen
- Department of Gastroenterology, Hepatology and Infectious Diseases, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University, Düsseldorf, Germany
| | - Tom Luedde
- Department of Gastroenterology, Hepatology and Infectious Diseases, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University, Düsseldorf, Germany
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12
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Núñez-Torrón C, Ferrer-Gómez A, Moreno Moreno E, Pérez-Mies B, Villarrubia J, Chamorro S, López-Jiménez J, Palacios J, Piris-Villaespesa M, García-Cosío M. Secondary haemophagocytic lymphohistiocytosis in COVID-19: correlation of the autopsy findings of bone marrow haemophagocytosis with HScore. J Clin Pathol 2022; 75:383-389. [PMID: 33722841 PMCID: PMC7970658 DOI: 10.1136/jclinpath-2020-207337] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Revised: 01/19/2021] [Accepted: 02/15/2021] [Indexed: 01/08/2023]
Abstract
BACKGROUND Secondary haemophagocytic lymphohistiocytosis (sHLH) is characterised by a hyper activation of immune system that leads to multiorgan failure. It is suggested that excessive immune response in patients with COVID-19 could mimic this syndrome. Some COVID-19 autopsy studies have revealed the presence of haemophagocytosis images in bone marrow, raising the possibility, along with HScore parameters, of sHLH. AIM Our objective is to ascertain the existence of sHLH in some patients with severe COVID-19. METHODS We report the autopsy histological findings of 16 patients with COVID-19, focusing on the presence of haemophagocytosis in bone marrow, obtained from rib squeeze and integrating these findings with HScore parameters. CD68 immunohistochemical stains were used to highlight histiocytes and haemophagocytic cells. Clinical evolution and laboratory parameters of patients were collected from electronic clinical records. RESULTS Eleven patients (68.7%) displayed moderate histiocytic hyperplasia with haemophagocytosis (HHH) in bone marrow, three patients (18.7%) displayed severe HHH and the remainder were mild. All HScore parameters were collected in 10 patients (62.5%). Among the patients in which all parameters were evaluable, eight patients (80%) had an HScore >169. sHLH was not clinically suspected in any case. CONCLUSIONS Our results support the recommendation of some authors to use the HScore in patients with severe COVID-19 in order to identify those who could benefit from immunosuppressive therapies. The presence of haemophagocytosis in bone marrow tissue, despite not being a specific finding, has proved to be a very useful tool in our study to identify these patients.
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Affiliation(s)
| | | | | | - Belen Pérez-Mies
- Pathology, Hospital Ramón y Cajal, Madrid, Spain
- Faculty of Medicine, University of Alcalá de Henares, Madrid, Spain
- CIBER-ONC, Instituto de Salud Carlos III, Madrid, Spain
| | | | | | - Javier López-Jiménez
- Hematology, Hospital Ramón y Cajal, Madrid, Spain
- Faculty of Medicine, University of Alcalá de Henares, Madrid, Spain
| | - J Palacios
- Pathology, Hospital Ramón y Cajal, Madrid, Spain
- Faculty of Medicine, University of Alcalá de Henares, Madrid, Spain
- CIBER-ONC, Instituto de Salud Carlos III, Madrid, Spain
| | | | - Mónica García-Cosío
- Pathology, Hospital Ramón y Cajal, Madrid, Spain
- Faculty of Medicine, University of Alcalá de Henares, Madrid, Spain
- CIBER-ONC, Instituto de Salud Carlos III, Madrid, Spain
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13
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Outcome of Viral-associated Hemophagocytic Lymphohistiocytosis at a Tertiary Hospital. Pediatr Infect Dis J 2022; 41:330-334. [PMID: 34845149 DOI: 10.1097/inf.0000000000003401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Little is known about viral-associated hemophagocytic lymphohistiocytosis (HLH) in Oman. This study was done to assess the epidemiology, clinical features and outcome of viral-associated HLH in our setting. METHODS We retrospectively reviewed children (0-18 years) managed for viral-associated HLH at the Sultan Qaboos University Hospital, Oman, over a 15-year period (2006-2020). Patients' medical records were used to describe their demographic, clinical and laboratory features, management and outcome. RESULTS Fifty-six children were managed for HLH at Sultan Qaboos University Hospital over the last 15 years (2006-2020) of whom a third (19; 34%) had a viral trigger. The median age at the time of diagnosis of viral-associated HLH was 83 (13-96) months. Fever, cytopenia, hyperferritinemia and evidence of hemophagocytosis in bone marrow were the most consistent findings. Most of these children had either genetic predisposition to HLH (8/19; 42%) or underlying immunodeficiency secondary to malignant conditions or chemotherapy/hematopoietic stem cell transplantation (6/19; 32%). Epstein-Barr virus (9; 47%) followed by cytomegalovirus (6; 31%) was the most common viral trigger in our setting. Treatment included antivirals (8; 42%), HLH 2004 protocol (4; 21%), rituximab (4; 21%) and hematopoietic stem cell transplantation (3; 16%). Fourteen children (74%) had full recovery. CONCLUSIONS In our small cohort, viral-associated HLH was more frequently encountered in children with genetic predisposition to HLH or children with underlying immunodeficiency. In addition, we found that the outcome is overall good for children who have no genetic predisposition to HLH and children with genetic predisposition who underwent hematopoietic stem cell transplantation.
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14
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Cytokine Profile and Anti-Inflammatory Activity of a Standardized Conditioned Medium Obtained by Coculture of Monocytes and Mesenchymal Stromal Cells (PRS CK STORM). Biomolecules 2022; 12:biom12040534. [PMID: 35454123 PMCID: PMC9029939 DOI: 10.3390/biom12040534] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 03/27/2022] [Accepted: 03/29/2022] [Indexed: 02/01/2023] Open
Abstract
Intercellular communication between monocytes/macrophages and cells involved in tissue regeneration, such as mesenchymal stromal cells (MSCs) and primary tissue cells, is essential for tissue regeneration and recovery of homeostasis. Typically, in the final phase of the inflammation-resolving process, this intercellular communication drives an anti-inflammatory immunomodulatory response. To obtain a safe and effective treatment to counteract the cytokine storm associated with a disproportionate immune response to severe infections, including that associated with COVID-19, by means of naturally balanced immunomodulation, our group has standardized the production under GMP-like conditions of a secretome by coculture of macrophages and MSCs. To characterize this proteome, we determined the expression of molecules related to cellular immune response and tissue regeneration, as well as its possible toxicity and anti-inflammatory potency. The results show a specific molecular pattern of interaction between the two cell types studied, with an anti-inflammatory and regenerative profile. In addition, the secretome is not toxic by itself on human PBMC or on THP-1 monocytes and prevents lipopolysaccharide (LPS)-induced growth effects on those cell types. Finally, PRS CK STORM prevents LPS-induced TNF-A and IL-1Β secretion from PBMC and from THP-1 cells at the same level as hydrocortisone, demonstrating its anti-inflammatory potency.
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15
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Wilson C, Lee WI, Cook MC, Smyth L, Talaulikar D. Correlation of haemophagocytosis with clinical criteria of haemophagocytic lymphohistiocytosis and recommendations for bone marrow reporting. Pathology 2021; 54:434-441. [PMID: 34711415 DOI: 10.1016/j.pathol.2021.07.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 07/18/2021] [Accepted: 07/28/2021] [Indexed: 10/20/2022]
Abstract
Haemophagocytic lymphohistiocytosis (HLH) is a rare condition resulting from a dysregulated inflammatory response. Currently there are no guidelines on the reporting of haemophagocytosis on bone marrow biopsy (BM) and lack of evidence on correlation between haemophagocytosis with the clinical diagnostic criteria for HLH. We aimed to assess if the amount of haemophagocytosis identified in the BM correlates with HLH-2004 criteria. Secondary aims were to evaluate inter-observer variability in reporting haemophagocytosis, and to formulate recommendations for screening in bone marrow specimens. A retrospective review of bone marrow biopsies from adult patients under investigation for HLH was undertaken independently by two haematopathologists who were blinded to the original biopsy report. The average number of actively haemophagocytic cells in each slide were quantified. Cases with discordance pertaining to the degree of haemophagocytosis were reviewed by both assessors to reach a consensus. Sixty-two specimens from 59 patients were available for assessment. An underlying haematological condition was identified in 34 cases (58%). There was a significant association between the amount of haemophagocytosis identified on the aspirate samples and the number of HLH-2004 criteria met (p<0.0001). In patients where haemophagocytosis was present (n=31), there was a correlation between the amount of haemophagocytosis and ferritin (p=0.041). Based on our review, we have made recommendations for the reporting of BM haemophagocytosis. Our findings indicate that the amount of haemophagocytosis present on BM samples correlates with the number of HLH-2004 criteria. We found marked interobserver variability which we anticipate can be rectified with our recommendations for reporting.
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Affiliation(s)
- C Wilson
- Haematology Department, Canberra Hospital, Garran, ACT, Australia
| | - W I Lee
- Immunology Department, Canberra Hospital, Garran, ACT, Australia
| | - M C Cook
- Immunology Department, Canberra Hospital, Garran, ACT, Australia; Australian National University Medical School, Acton, ACT, Australia
| | - L Smyth
- Australian National University Medical School, Acton, ACT, Australia
| | - D Talaulikar
- Haematology Department, Canberra Hospital, Garran, ACT, Australia; Australian National University Medical School, Acton, ACT, Australia.
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16
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Valdés Francí E, Perez Flores I, Candel FJ, Moreno de la Higuera MA, Romero NC, Rodríguez Cubillo B, Lucena Valverde R, Sánchez Fructuoso AI. Hemophagocytic syndrome triggered by donor-transmitted toxoplasmosis as a complication in same-donor recipients of renal transplantation: Case report and review of the literature. Transpl Infect Dis 2021; 23:e13732. [PMID: 34533259 DOI: 10.1111/tid.13732] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 07/16/2021] [Accepted: 09/05/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND Hemophagocytic syndrome (HPS) is an infrequent complication of transplantation caused by an inflammatory response with a benign proliferation of macrophages and defective lytic capability of T lymphocytes and NK cells that can lead to multiorgan failure. Transplant patients are particularly exposed as a result of the increased risk of both infections and malignancies derived from immunosuppressive drugs. There is no consensus for therapy or immunosuppression; mortality is high. We report a case and present a review of all cases of HPS occurring in solid organ transplant recipients. CASE REPORT: We report two cases of infection by Toxoplasma gondii transmitted by the kidney allograft. One of the recipients was seronegative before transplantation and developed disseminated primary toxoplasmosis. An immune reaction compatible with an HPS ensued. Both were treated with Trimethoprim/sulfamethoxazole, immunosuppression was tapered, and after a 2-week period a complete response was obtained. CONCLUSION HPS presents therapeutic challenges in the context of transplantation. If HPS is suspected, the search of a very likely underlying infection should be central to the management.
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Affiliation(s)
- Elena Valdés Francí
- Nephrology Department, Clínico San Carlos University Hospital, Madrid, Spain
| | - Isabel Perez Flores
- Nephrology Department, Clínico San Carlos University Hospital, Madrid, Spain
| | - Francisco Javier Candel
- Department of Clinical Microbiology and Infectious Diseases, Clínico San Carlos University Hospital, Madrid, Spain
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17
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Ponnatt TS, Lilley CM, Mirza KM. Hemophagocytic Lymphohistiocytosis. Arch Pathol Lab Med 2021; 146:507-519. [PMID: 34347856 DOI: 10.5858/arpa.2020-0802-ra] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/08/2021] [Indexed: 11/06/2022]
Abstract
CONTEXT.— Hemophagocytic lymphohistiocytosis (HLH) is a rare, life-threatening disorder of immune regulation that can eventually result in end-organ damage and death. HLH is characterized by uncontrolled activation of cytotoxic T lymphocytes, natural killer cells, and macrophages that can lead to a cytokine storm. The diagnosis of HLH is often challenging due to the diverse clinical manifestations and the presence of several diagnostic mimics. The prognosis is generally poor, warranting rapid diagnosis and aggressive management. OBJECTIVE.— To provide a comprehensive review of the pathogenesis, clinical features, diagnosis, and management of HLH. DATA SOURCES.— Peer-reviewed literature. CONCLUSIONS.— HLH is a condition where a complete understanding of the pathogenesis, early diagnosis, and proper management has an important role in determining patient outcome. Genetic mutations causing impairment in the function of cytotoxic T lymphocytes and natural killer cells have been identified as the root cause of familial HLH; however, the specific pathogenesis of acquired HLH is unclear. The HLH-2004 protocol used in the diagnosis of HLH was originally developed for the pediatric population. The HLH-2004 protocol still forms the basis of the diagnosis of HLH in adults, although its use in adults has not been formally validated yet. Treatment of HLH is primarily based on the HLH-94 protocol, which involves suppressing the inflammatory response, but the treatment needs to be modified in adults depending on the underlying cause and comorbidities.
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Affiliation(s)
- Tanya Sajan Ponnatt
- From the Department of Pathology, Loyola University Chicago, Health Sciences Campus, Maywood, Illinois
| | - Cullen M Lilley
- From the Department of Pathology, Loyola University Chicago, Health Sciences Campus, Maywood, Illinois
| | - Kamran M Mirza
- From the Department of Pathology, Loyola University Chicago, Health Sciences Campus, Maywood, Illinois
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18
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Bendari M, Delsa H, Bouanani N, Jabouri R, Darouich S, Nejjari S, Guessous F, Doghmi K. Hemophagocytic lymphohistiocytosis associated with HBV-HCV coinfection in adult: Case report. Clin Case Rep 2021; 9:e04328. [PMID: 34401150 PMCID: PMC8346598 DOI: 10.1002/ccr3.4328] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 04/21/2021] [Accepted: 04/29/2021] [Indexed: 11/12/2022] Open
Abstract
The case reported is the first case in Morocco to our knowledge. The reason for sharing this case is to facilitate knowledge transfer between physicians, caring for adult patients with HLH, with the aim to improve the outcome of these patients.
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Affiliation(s)
- Mounia Bendari
- Hematology DepartmentCheikh Khalifa International University HospitalCasablancaMorocco
- Mohammed VI University of Health SciencesCasablancaMorocco
| | - Hanane Delsa
- Mohammed VI University of Health SciencesCasablancaMorocco
- Gastroenterology and Hepatology DepartmentCheikh Khalifa International University HospitalCasablancaMorocco
| | - Nouama Bouanani
- Hematology DepartmentCheikh Khalifa International University HospitalCasablancaMorocco
- Mohammed VI University of Health SciencesCasablancaMorocco
| | - Rajaa Jabouri
- Mohammed VI University of Health SciencesCasablancaMorocco
- Internal Medicine DepartmentCheikh Khalifa International University HospitalCasablancaMorocco
| | - Safaa Darouich
- Hematology DepartmentCheikh Khalifa International University HospitalCasablancaMorocco
- Mohammed VI University of Health SciencesCasablancaMorocco
| | - Sara Nejjari
- Hematology DepartmentCheikh Khalifa International University HospitalCasablancaMorocco
- Mohammed VI University of Health SciencesCasablancaMorocco
| | - Fadila Guessous
- Mohammed VI University of Health SciencesCasablancaMorocco
- Department of Biological SciencesFaculty of MedicineCasablancaMorocco
| | - Kamal Doghmi
- Hematology DepartmentCheikh Khalifa International University HospitalCasablancaMorocco
- Mohammed VI University of Health SciencesCasablancaMorocco
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19
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Line-selective macrophage activation with an anti-CD40 antibody drives a hemophagocytic syndrome in mice. Blood Adv 2021; 4:2751-2761. [PMID: 32559293 DOI: 10.1182/bloodadvances.2020001624] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Accepted: 05/18/2020] [Indexed: 11/20/2022] Open
Abstract
Hemophagocytic syndromes comprise a cluster of hyperinflammatory disorders, including hemophagocytic lymphohistiocytosis and macrophage activation syndrome. Overwhelming macrophage activation has long been considered a final common pathway in the pathophysiology of hemophagocytic syndromes leading to the characteristic cytokine storm, laboratory abnormalities, and organ injuries that define the clinical spectrum of the disease. So far, it is unknown whether primary macrophage activation alone can induce the disease phenotype. In this study, we established a novel mouse model of a hemophagocytic syndrome by treating mice with an agonistic anti-CD40 antibody (Ab). The response in wild-type mice is characterized by a cytokine storm, associated with hyperferritinemia, high soluble CD25, erythrophagocytosis, secondary endothelial activation with multiple organ vaso-occlusion, necrotizing hepatitis, and variable cytopenias. The disease is dependent on a tumor necrosis factor-α-interferon-γ-driven amplification loop. After macrophage depletion with clodronate liposomes or in mice with a macrophage-selective deletion of the CD40 gene (CD40flox/flox/LysMCre), the disease was abolished. These data provide a new preclinical model of a hemophagocytic syndrome and reinforce the key pathophysiological role of macrophages.
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20
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Bérar A, Ardois S, Walter-Moraux P, Jegonday MA, Henriot B. Primary varicella-zoster virus infection of the immunocompromised associated with acute pancreatitis and hemophagocytic lymphohistiocytosis: A case report. Medicine (Baltimore) 2021; 100:e25351. [PMID: 33879665 PMCID: PMC8078430 DOI: 10.1097/md.0000000000025351] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Accepted: 03/11/2021] [Indexed: 01/04/2023] Open
Abstract
RATIONALE Primary varicella-zoster virus (VZV) infection may be associated with hemophagocytic lymphohistiocytosis (HLH), as well as with acute pancreatitis. However, there is few data concerning the evolution and the optimal treatment of these rare associations. PATIENT CONCERNS A 57-year-old immunocompromised woman, who was treated for chronic lymphocytic leukemia 3 years prior to admission, was hospitalized with abdominal pain revealing severe acute pancreatitis. The day after admission, a pruritic rash appeared on her face, trunk, and limbs, sparing the palmoplantar regions. At the same time, fever, thrombocytopenia (27 × 109/L), major hyperferritinemia (11,063 μg/mL), hypertriglyceridemia (2.56 mmol/L) and elevated lactate dehydrogenase levels (1441 IU/L) suggested HLH. DIAGNOSIS The diagnosis of chickenpox (varicella) was established. Primary VZV infection was then confirmed: cutaneous and plasma VZV polymerase chain reactions were positives, VZV serology was negative for IgG. INTERVENTIONS Treatment with aciclovir was started intravenously after the onset of the rash, for a total of 10 days. A 48-h surveillance in intensive care was carried out. OUTCOMES Acute pancreatitis and biological abnormalities evolved favorably under aciclovir. Platelet count was normalized 6 days after admission to hospital. LESSONS A favorable outcome of primary VZV infection associated with severe acute pancreatitis and probable HLH in an immunocompromised patient is possible with aciclovir alone.
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Affiliation(s)
- Antoine Bérar
- CHU Rennes, Department of Internal Medicine and Clinical Immunology, Rennes
| | - Samuel Ardois
- CHU Rennes, Department of Internal Medicine and Clinical Immunology, Rennes
| | | | | | - Basile Henriot
- CH René Pleven, Department of Internal Medicine, Dinan
- CH Broussais, Department of Internal Medicine, Saint-Malo, France
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21
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Choi EJ, Lee SH, Oh CK, Kim YB, Bang JB. Cytomegalovirus-Associated Hemophagocytic Syndrome Diagnosed by Liver Biopsy in a Kidney Transplant Recipient. Yonsei Med J 2021; 62:274-277. [PMID: 33635018 PMCID: PMC7934097 DOI: 10.3349/ymj.2021.62.3.274] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Revised: 12/21/2020] [Accepted: 12/28/2020] [Indexed: 11/27/2022] Open
Abstract
Hemophagocytic syndrome (HPS) is a rare but potentially life-threatening disease in kidney transplant recipients, and is caused by systemic proliferation of macrophages actively phagocytizing other blood cells in the bone marrow, lymph nodes, and the spleen. Here, we report a 40-year-old male kidney transplant recipient who presented with fever, bicytopenia, and elevated liver enzymes 2 months after transplantation. Given that cytomegalovirus antigenemia and real-time polymerase chain reaction tests were positive, liver biopsy was performed under an assumption of cytomegalovirus-induced hepatitis. Hepatic histology revealed multifocal microabscess with cytomegalovirus inclusion bodies, marked Kupffer cell hyperplasia, and erythrophagocytosis by activated macrophages. As laboratory findings such as hyperferritinemia, elevated serum lactate dehydrogenase, low natural killer cell activity, and high soluble interleukin-2 receptor were also compatible with HPS, the recipient was diagnosed as having cytomegalovirus-induced hepatitis combined with reactive HPS. Following intravenous ganciclovir therapy with continuous administration of tacrolimus and corticosteroid, the symptoms resolved and laboratory findings were normalized. As far as we know, this is the first report of cytomegalovirus-induced hepatitis combined with reactive HPS in a kidney transplant recipient that is diagnosed by liver biopsy.
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Affiliation(s)
- Eun Ji Choi
- Department of Surgery, Ajou University School of Medicine, Suwon, Korea
| | - Su Hyung Lee
- Department of Surgery, Ajou University School of Medicine, Suwon, Korea
| | - Chang Kwon Oh
- Department of Surgery, Ajou University School of Medicine, Suwon, Korea
| | - Young Bae Kim
- Department of Pathology, Ajou University School of Medicine, Suwon, Korea
| | - Jun Bae Bang
- Department of Surgery, Ajou University School of Medicine, Suwon, Korea.
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22
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Hattori N, Sato M, Uesugi Y, Nakata A, Sasaki Y, Shimada S, Watanuki M, Fujiwara S, Kawaguchi Y, Arai N, Uto Y, Matsui T, Yanagisawa K, Tahara S, Koeffler HP, Iezumi K, Nakamaki T. Characteristics and predictors of post-transplant-associated hemophagocytic lymphohistiocytosis in adults. Int J Hematol 2021; 113:693-702. [PMID: 33385294 DOI: 10.1007/s12185-020-03067-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 12/14/2020] [Accepted: 12/15/2020] [Indexed: 11/28/2022]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is an uncontrolled hyperinflammatory disorder driven by an overactive immune system that results in high mortality. Post-transplant-associated hemophagocytic lymphohistiocytosis (PT-HLH) is a type of secondary HLH that occurs following allogeneic hematopoietic stem cell transplantation (allo-HSCT). The clinical features of PT-HLH remain unclear and diagnostic and prognostic tools have not yet been established. Here, we retrospectively evaluated the clinical manifestations and outcomes of PT-HLH in 94 patients who underwent allo-HSCT. According to our PT-HLH criteria (hyperferritinemia and increased macrophage count in bone marrow), PT-HLH occurred in 12 patients (12.8%). The PT-HLH patients showed splenomegaly (P = .001), a higher risk of engraftment failure (P = .013), and an increased percentage of macrophages and hemophagocytes in bone marrow aspirates (P = .0009 and P = .0006, respectively). Moreover, univariate and multivariate analyses revealed that the survival rate was lower in PT-HLH patients than non-PT-HLH patients (P = .0017 and P = .034, respectively). This study defines the clinical features of PT-HLH and PT-HLH criteria that could be useful tools for diagnosing PT-HLH.
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Affiliation(s)
- Norimichi Hattori
- Division of Hematology, Department of Medicine, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa-Ku, Tokyo, 142-8666, Japan.
| | - Misuzu Sato
- Department of Pathology and Laboratory Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Yuka Uesugi
- Division of Hematology, Department of Medicine, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa-Ku, Tokyo, 142-8666, Japan
| | - Ayaka Nakata
- Division of Hematology, Department of Medicine, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa-Ku, Tokyo, 142-8666, Japan
| | - Yohei Sasaki
- Division of Hematology, Department of Medicine, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa-Ku, Tokyo, 142-8666, Japan
| | - Shotaro Shimada
- Division of Hematology, Department of Medicine, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa-Ku, Tokyo, 142-8666, Japan
| | - Megumi Watanuki
- Division of Hematology, Department of Medicine, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa-Ku, Tokyo, 142-8666, Japan
| | - Shun Fujiwara
- Division of Hematology, Department of Medicine, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa-Ku, Tokyo, 142-8666, Japan
| | - Yukiko Kawaguchi
- Division of Hematology, Department of Medicine, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa-Ku, Tokyo, 142-8666, Japan
| | - Nana Arai
- Division of Hematology, Department of Medicine, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa-Ku, Tokyo, 142-8666, Japan
| | - Yui Uto
- Division of Hematology, Department of Medicine, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa-Ku, Tokyo, 142-8666, Japan
| | - Tomoharu Matsui
- Division of Hematology, Department of Medicine, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa-Ku, Tokyo, 142-8666, Japan
| | - Kouji Yanagisawa
- Division of Hematology, Department of Medicine, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa-Ku, Tokyo, 142-8666, Japan
| | - Sachiko Tahara
- Department of Pathology and Laboratory Medicine, Showa University School of Medicine, Tokyo, Japan
| | - H Phillip Koeffler
- Division of Hematology/Oncology, Cedars-Sinai Medical Center, School of Medicine at University of California Los Angeles, Los Angeles, CA, USA
| | - Keiichi Iezumi
- Department of Pathology and Laboratory Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Tsuyoshi Nakamaki
- Division of Hematology, Department of Medicine, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa-Ku, Tokyo, 142-8666, Japan
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23
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Schenk T, Birndt S, Rosée PL. Hämophagozytische Syndrome beim Erwachsenen. AKTUEL RHEUMATOL 2020. [DOI: 10.1055/a-1252-2287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
ZusammenfassungDie Hämophagozytische Lymphohistiozytose (HLH) ist ein Zytokinsturm-Syndrom, das bei Erwachsenen in der Regel durch Malignome, Infektionen oder autoinflammatorische/autoimmunologische Erkrankungen ausgelöst wird. In der Rheumatologie ist das Erkrankungsbild besser als Makrophagenaktivierungs-Syndrom bekannt (MAS-HLH). Die HLH entsteht auf dem Boden eines genetisch bedingten und/oder erworbenen dysfunktionalen Immunsystems. Im Unterschied zur hereditären primären HLH (pHLH) bei Kindern findet sich bei der adulten, zumeist sekundären HLH (sHLH) nur sehr selten eine monogenetische Ursache. In Einzelfällen kann sich aber eine „late onset“-genetische HLH auch erst im Erwachsenenalter manifestieren. Die Diagnose von HLH und MAS wird verzögert durch die unspezifische Symptomatik (Fieber, Zytopenie, Ferritinanstieg, Splenomegalie, Multiorganversagen), die sich mit der Grunderkrankung oder einem SIRS überlagern kann. Die namengebende Hämophagozytose lässt sich nur bei einem Teil der Patienten nachweisen. sHLH und MAS-HLH weisen unbehandelt eine hohe Mortalität auf. Diagnosekriterien für pHLH und MAS sowie das standardisierte HLH-2004-Therapieprotokoll wurden in der Pädiatrie kontinuierlich in klinischen Studien entwickelt. In angepasster Form werden Kriterien und Substanzen des pädiatrischen HLH-Protokolls auch bei Erwachsenen angewendet. Zunehmend kommen neue Therapien zum Einsatz, welche die Hyperzytokinämie und deren Auswirkungen bei HLH und MAS bremsen (z. B. Ruxolitinib oder Anakinra). Der folgende Artikel soll eine Übersicht zu Epidemiologie, Diagnostik und Therapie von HLH und MAS bei Erwachsenen geben.
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Affiliation(s)
- Thomas Schenk
- Hämatologie/Onkologie, Klinik für Innere Medizin II, Universitätsklinikum Jena, Jena
| | - Sebastian Birndt
- Hämatologie/Onkologie, Klinik für Innere Medizin II, Universitätsklinikum Jena, Jena
| | - Paul La Rosée
- Hämatologie/Onkologie/Infektiologie/Immunologie/Palliativmedizin, Schwarzwald Baar Klinikum, Klinik für Innere Medizin II, Villingen-Schwenningen
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24
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Cabler SS, Hogan PG, Fritz SA, Bednarski JJ, Hunstad DA. Incidence and treatment of hemophagocytic lymphohistiocytosis in hospitalized children with Ehrlichia infection. Pediatr Blood Cancer 2020; 67:e28436. [PMID: 32706439 DOI: 10.1002/pbc.28436] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 05/06/2020] [Accepted: 05/07/2020] [Indexed: 12/23/2022]
Abstract
We report a large cohort of pediatric patients with human monocytic ehrlichiosis (HME), enabling an estimated incidence of secondary hemophagocytic lymphohistiocytosis (HLH) in hospitalized children with HME. Among 49 children with PCR-confirmed Ehrlichia infection, 8 (16%) met current criteria for HLH. Those with HLH had more significant hematologic abnormalities and longer durations from symptom onset to admission and definitive anti-infective therapy. Among these eight, three received chemotherapy plus doxycycline, one of whom died; the other five were treated with doxycycline without chemotherapy, and all survived without HLH recurrence. Our findings demonstrate that antimicrobial therapy alone can successfully resolve Ehrlichia-associated HLH.
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Affiliation(s)
- Stephanie S Cabler
- Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri
| | - Patrick G Hogan
- Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri
| | - Stephanie A Fritz
- Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri
| | - Jeffrey J Bednarski
- Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri
| | - David A Hunstad
- Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri
- Department of Molecular Microbiology, Washington University School of Medicine, St. Louis, Missouri
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25
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Abstract
The clinical and laboratory features of COVID-19 are reviewed with attention to the immunologic manifestations of the disease. Recent COVID-19 publications describe a variety of clinical presentations including an asymptomatic state, pneumonia, a hemophagocytic lymphohistiocytosis like syndrome, Multisystem Inflammatory Syndrome in Children (MIS-C) but, also called Pediatric Inflammatory Multisystem Syndrome-Toxic Shock (PIMS-TS), Kawasaki Disease, and myocarditis. A common theme amongst multiple reports suggests an overexuberant autoimmune component of the disease but a common pathophysiology to explain the variations in clinical presentation has been elusive. Review of the basic science of other viral induced autoimmune disorders may give clues as to why immunosuppressive and immunomodulating regimens now appear to have some efficacy in COVID-19. Review of the immunopathology also reveals other therapies that have yet to be explored. There is potential use of T cell depleting therapies and possibly anti-CD20 therapy for COVID-19 and clinical research using these medications is warranted.
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26
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Prilutskiy A, Kritselis M, Shevtsov A, Yambayev I, Vadlamudi C, Zhao Q, Kataria Y, Sarosiek SR, Lerner A, Sloan JM, Quillen K, Burks EJ. SARS-CoV-2 Infection-Associated Hemophagocytic Lymphohistiocytosis. Am J Clin Pathol 2020; 154:466-474. [PMID: 32681166 PMCID: PMC7454285 DOI: 10.1093/ajcp/aqaa124] [Citation(s) in RCA: 82] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
OBJECTIVES A subset of coronavirus disease 2019 (COVID-19) patients exhibit clinical features of cytokine storm. However, clinicopathologic features diagnostic of hemophagocytic lymphohistiocytosis (HLH) have not been reported. We studied the reticuloendothelial organs of 4 consecutive patients who died of COVID-19 and correlated with clinical and laboratory parameters to detect HLH. METHODS Autopsies were performed on 4 patients who died of COVID-19. Routine H&E staining and immunohistochemical staining for CD163 were performed to detect hemophagocytosis. Clinical and laboratory results from premortem blood samples were used to calculate H-scores. RESULTS All 4 cases demonstrated diffuse alveolar damage within the lungs. Three of the 4 cases had histologic evidence of hemophagocytosis within pulmonary lymph nodes. One case showed hemophagocytosis in the spleen but none showed hemophagocytosis in liver or bone marrow. Lymphophagocytosis was the predominant form of hemophagocytosis observed. One patient showed diagnostic features of HLH with an H-score of 217, while a second patient likely had HLH with a partial H-score of 145 due to a missing triglyceride level. The remaining 2 patients had H-scores of 131 and 96. CONCLUSIONS This is the first report of severe acute respiratory syndrome coronavirus 2-associated HLH. Identification of HLH in a subset of patients with severe COVID-19 will inform clinical trials of therapeutic strategies.
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Affiliation(s)
| | | | - Artem Shevtsov
- Department of Pathology and Laboratory Medicine, Boston, MA
| | - Ilyas Yambayev
- Department of Pathology and Laboratory Medicine, Boston, MA
| | | | - Qing Zhao
- Department of Pathology and Laboratory Medicine, Boston, MA
| | | | - Shayna R Sarosiek
- Department of Hematology and Oncology, Boston University School of Medicine, Boston Medical Center, Boston, MA
| | - Adam Lerner
- Department of Hematology and Oncology, Boston University School of Medicine, Boston Medical Center, Boston, MA
| | - J Mark Sloan
- Department of Hematology and Oncology, Boston University School of Medicine, Boston Medical Center, Boston, MA
| | - Karen Quillen
- Department of Hematology and Oncology, Boston University School of Medicine, Boston Medical Center, Boston, MA
| | - Eric J Burks
- Department of Pathology and Laboratory Medicine, Boston, MA
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27
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Almalky MA, Saleh SHA, Baz EG, Fakhr AE. Clinico-laboratory profile and perforin gene mutations of pediatric hemophagocytic lymphohistiocytosis cases: a five-year single center study. Pan Afr Med J 2020; 36:354. [PMID: 33224420 PMCID: PMC7664152 DOI: 10.11604/pamj.2020.36.354.25079] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Accepted: 07/31/2020] [Indexed: 12/16/2022] Open
Abstract
Introduction hemophagocytic lymphohistiocytosis (HLH) is an immunological disease characterized by hemophagocytosis of blood cells and proliferation of T-cells and histiocytes in the spleen and bone marrow then infiltration into body organs. Familial HLH (FHL) is a fatal disorder and determining gene mutations is a good guide for predicting the prognosis and choosing treatment options. This study aimed to illustrate the clinical, laboratory characteristics, including perforin gene mutation screening, treatment and survival outcome of pediatric HLH patients. Methods we conducted this cross-sectional study on pediatric patients who were diagnosed with HLH using the revised HLH-2004 criteria, from January 2014 to February 2019 at Zagazig University Children's Hospital, Egypt. We collected demographic, clinical and laboratory data and screened for the presence of mutations in perforin (PRF1) gene by polymerase chain reaction (PCR) amplification. We treated the patients according to HLH-2004 treatment protocol and documented their survival outcome. Results the total number of cases were 18; eight males and ten females, the age range was between three months and 12 years. Of the eight HLH-2004 diagnostic criteria, all patients met at least five criteria. We detected PRF1 gene mutation in 38.9% (7 patients) with nine previously unreported mutations. Sixteen patients (88.9%) received HLH-2004 treatment protocol and the remaining two patients died before initiation of treatment. The overall mortality was 72.2% (13 patients). Conclusion our results increase the awareness of clinical and laboratory characterizations of pediatric HLH patients and the prevalence of PRF1 gene mutations among those patients.
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Affiliation(s)
| | | | - Eman Gamal Baz
- Pediatric Department, Faculty of Medicine, Zagazig University, Sharkia, Egypt
| | - Ahmed Elsadek Fakhr
- Microbiology and Immunology Department, Faculty of Medicine, Zagazig University, Sharkia, Egypt.,Pathology Laboratory and Blood Bank, International Medical Center, Jeddah, Saudi Arabia
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28
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Alsaid HM, Wahdan AAM, Tahboub IN, Almakadma NM. Hemophagocytic Lymphohistiocytosis and Relapsing Polychondritis with Acute Myelogenous Leukemia: Case Report and Review of the Literature. AMERICAN JOURNAL OF CASE REPORTS 2020; 21:e925287. [PMID: 32812531 PMCID: PMC7458697 DOI: 10.12659/ajcr.925287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Patient: Female, 16-year-old Final Diagnosis: Hemophagocytic lymphohistiocytosis • relapsing polychondritis Symptoms: Fever • joint pain • leukopenia Medication: — Clinical Procedure: — Specialty: Cardiology • Critical Care Medicine • Hematology • General and Internal Medicine • Pediatrics and Neonatology • Rheumatology
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Affiliation(s)
- Hamza M Alsaid
- Department of Medicine, Hadassah University Hospital, Al-Quds School of Medicine, Jerusalem, Israel
| | - Adnan A M Wahdan
- Department of Internal Medicine, Palestine Medical Complex, Ramallah, West Bank, Palestinian Territory, Occupied
| | - Ihab N Tahboub
- Department of Medicine, College of Medicine and Health Sciences, An-Najah National University, Nablus, West Bank, Palestinian Territory, Occupied
| | - Nour M Almakadma
- Department of Internal Medicine, Palestine Medical Complex, Ramallah, West Bank, Palestinian Territory, Occupied
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29
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Griffin G, Shenoi S, Hughes GC. Hemophagocytic lymphohistiocytosis: An update on pathogenesis, diagnosis, and therapy. Best Pract Res Clin Rheumatol 2020; 34:101515. [PMID: 32387063 DOI: 10.1016/j.berh.2020.101515] [Citation(s) in RCA: 136] [Impact Index Per Article: 34.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a rare, life-threatening state of immune hyperactivation that arises in the setting of genetic mutations and infectious, inflammatory, or neoplastic triggers. Sustained, aberrant activation of cytotoxic CD8+ T cells and resultant inflammatory cytokine release are core pathogenic mechanisms. Key clinical features include high persistent fever, hepatosplenomegaly, blood cytopenia, elevated aminotransferase and ferritin levels, and coagulopathy. HLH is likely under-recognized, and mortality remains high, especially in adults; thus, prompt diagnosis and treatment are essential. Familial forms of HLH are currently treated with chemotherapy as a bridge to hematopoietic stem cell transplantation. HLH occurring in rheumatic disease (macrophage activation syndrome) is treated with glucocorticoids, IL-1 blockade, or cyclosporine A. In other forms of HLH, addressing the underlying trigger is essential. There remains a pressing need for more sensitive, context-specific diagnostic tools. Safer, more effective therapies will arise with improved understanding of the cellular and molecular mechanisms of HLH.
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Affiliation(s)
- Georgia Griffin
- Division of Rheumatology, Seattle Children's Hospital, Seattle, WA, USA.
| | - Susan Shenoi
- Division of Rheumatology, Seattle Children's Hospital, Seattle, WA, USA
| | - Grant C Hughes
- Division of Rheumatology, University of Washington, Seattle, WA, USA
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30
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Mizuta H, Nakano E, Takahashi A, Koyama T, Namikawa K, Yamazaki N. Hemophagocytic lymphohistiocytosis with advanced malignant melanoma accompanied by ipilimumab and nivolumab: A case report and literature review. Dermatol Ther 2020; 33:e13321. [PMID: 32191382 DOI: 10.1111/dth.13321] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Revised: 03/10/2020] [Accepted: 03/16/2020] [Indexed: 01/22/2023]
Abstract
Combination therapy with nivolumab + ipilimumab was recently approved for treating unresectable cases of malignant melanoma. In spite of the high response rate, it is associated with a high incidence of serious adverse events, including immune-related hemophagocytic syndrome/hemophagocytic lymphohistiocytosis (irHPS/HLH), a difficult to diagnose rare disease. This is the first report of this disease in an Asian malignant melanoma patient treated with nivolumab + ipilimumab. A 69-year-old Japanese woman with unresectable malignant melanoma was treated with nivolumab + ipilimumab. Following the combined therapy, her fever and symptoms of malaise occurred, and she visited to our hospital's emergency department. Blood tests revealed significant liver dysfunction, anemia, and thrombocytopenia. We suspected irHPS/HLH, based on tests revealing decreased fibrinogen and significantly increased ferritin. Bone marrow biopsy revealed numerous macrophages and high hemophagocytosis levels. After 50 mg prednisolone (1 mg/kg per day) was administered, fever and cytopenia markedly improved. irHPS/HLH has a high rate of coagulation abnormalities accompanied by hypertriglyceridemia and hypofibrinogenemia, which are unlikely to occur in adult HPS/HLHs. Because irHPS/HLH responds better to steroids than other secondary HPS/HLHs, we expect a complete cure with steroids. Quick diagnosis and appropriate treatment based on clinical symptoms and laboratory tests are needed in suspected cases.
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Affiliation(s)
- Haruki Mizuta
- Department of Dermatologic Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Eiji Nakano
- Department of Dermatologic Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Akira Takahashi
- Department of Dermatologic Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Takafumi Koyama
- Department of Experimental Therapeutics, National Cancer Center Hospital, Tokyo, Japan
| | - Kenjiro Namikawa
- Department of Dermatologic Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Naoya Yamazaki
- Department of Dermatologic Oncology, National Cancer Center Hospital, Tokyo, Japan
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31
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Kalmuk J, Matar S, Feng G, Kilb E, Lim MY. Parvovirus B19-induced hemophagocytic lymphohistiocytosis: Case report and review of the literature. Clin Case Rep 2019; 7:2076-2081. [PMID: 31788255 PMCID: PMC6878072 DOI: 10.1002/ccr3.2401] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2019] [Revised: 05/27/2019] [Accepted: 05/28/2019] [Indexed: 12/21/2022] Open
Abstract
HLH is a catastrophic and likely underdiagnosed pathology with multiple triggers including infection. PVB19 can cause persistent marrow infection leading to HLH despite negative acute serologic markers making timely diagnosis difficult. Increased awareness of PVB19-HLH is warranted given its potentially lethal nature and the careful interpretation required with serologic markers.
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Affiliation(s)
- James Kalmuk
- Department of Internal MedicineMedical University of South CarolinaCharlestonSCUSA
| | - Sara Matar
- Department of Hematology/OncologyMedical University of South CarolinaCharlestonSCUSA
| | - Gong Feng
- Department of Pathology and Laboratory MedicineMedical University of South CarolinaCharlestonSCUSA
| | - Edward Kilb
- Department of Pulmonary and Critical Care MedicineMedical University of South CarolinaCharlestonSCUSA
| | - Ming Y. Lim
- Department of Hematology/OncologyMedical University of South CarolinaCharlestonSCUSA
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32
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Jordan MB, Allen CE, Greenberg J, Henry M, Hermiston ML, Kumar A, Hines M, Eckstein O, Ladisch S, Nichols KE, Rodriguez-Galindo C, Wistinghausen B, McClain KL. Challenges in the diagnosis of hemophagocytic lymphohistiocytosis: Recommendations from the North American Consortium for Histiocytosis (NACHO). Pediatr Blood Cancer 2019; 66:e27929. [PMID: 31339233 PMCID: PMC7340087 DOI: 10.1002/pbc.27929] [Citation(s) in RCA: 196] [Impact Index Per Article: 39.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Revised: 06/10/2019] [Accepted: 06/28/2019] [Indexed: 12/15/2022]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a syndrome of pathologic immune activation, often associated with genetic defects of lymphocyte cytotoxicity. Though a distinctive constellation of features has been described for HLH, diagnosis remains challenging as patients have diverse presentations associated with a variety of triggers. We propose two concepts to clarify how HLH is diagnosed and treated: within the broader syndrome of HLH, "HLH disease" should be distinguished from "HLH disease mimics" and HLH subtypes should be categorized by specific etiologic associations, not the ambiguous dichotomy of "primary" and "secondary." We provide expert-based advice regarding the diagnosis and initiation of treatment for patients with HLH, rooted in improved understanding of its pathophysiology.
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Affiliation(s)
- Michael B. Jordan
- Division of Immunobiology, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
- Division of Bone Marrow Transplantation and Immune Deficiency, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Carl E. Allen
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Jay Greenberg
- Division of Hematology, Children’s National Medical Center, Washington, DC
| | - Michael Henry
- Center for Cancer and Blood Disorders, Phoenix Children’s Hospital, University of Arizona College of Medicine, Tucson, Arizona
| | - Michelle L. Hermiston
- Department of Pediatrics, UCSF Benioff Children’s Hospital, University of California San Francisco, San Francisco, California
| | - Ashish Kumar
- Cancer and Blood Diseases Institute, Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Melissa Hines
- Division of Critical Care, Department of Pediatric Medicine, St Jude Children’s Research Hospital, Memphis, Tennessee
| | - Olive Eckstein
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Stephan Ladisch
- Center for Cancer and Immunology Research, Children’s National Medical Center and George Washington University School of Medicine, Washington, DC
| | - Kim E. Nichols
- Division of Cancer Predisposition, Department of Oncology, St. Jude Children’s Research Hospital, Memphis, Tennessee
| | - Carlos Rodriguez-Galindo
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, Tennessee
- Department of Global Pediatric Medicine, St. Jude Children’s Research Hospital, Memphis, Tennessee
| | - Birte Wistinghausen
- Division of Oncology, Center for Cancer and Blood Disorders, Children’s National Health System, Washington, DC
| | - Kenneth L. McClain
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, Baylor College of Medicine, Houston, Texas
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, Baylor College of Medicine, Houston, Texas
- Additional corresponding author, Kenneth L. McClain, 6701 Fannin St. Suite 1510, Houston, TX 77030,
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33
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McGinnis E, Medvedev N, Richards MJ, Chen LYC, Wong MP. Post-Transfusion Hemophagocytosis Without Hemophagocytic Lymphohistiocytosis. Mayo Clin Proc Innov Qual Outcomes 2019; 3:517-522. [PMID: 31993572 PMCID: PMC6978597 DOI: 10.1016/j.mayocpiqo.2019.07.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Hemophagocytosis refers to ingestion of hematopoietic elements or mature blood cells by another cell, typically by cells conventionally associated with phagocytic capacity. Although the finding of hemophagocytosis as a prominent feature in a patient’s bone marrow might prompt consideration of a hemophagocytic syndrome (HPS) such as hemophagocytic lymphohistiocytosis (HLH) in a clinician’s or pathologist’s differential diagnosis, this morphologic feature can be nonspecific in the absence of other clinical and laboratory features of pathologic immune activation, which is the sine qua non of HPS/HLH. We describe three patients whose clinical presentations included transfusion-dependent anemia and whose bone marrow aspirates showed unexpectedly brisk hemophagocytosis of mature red blood cells. Despite striking morphologic hemophagocytosis, no patient met criteria for diagnosis of an HPS. Transfusion-associated hemophagocytosis and hyperferritinemia must be carefully distinguished from HLH through clinical and laboratory assessment. Biomarkers of pathologic immune activation are important diagnostic aids.
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Affiliation(s)
- Eric McGinnis
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, Canada
| | - Nadia Medvedev
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, Canada.,Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - Mikhyla J Richards
- Royal Columbian Hospital, New Westminster, Canada.,Division of Hematology, University of British Columbia, Vancouver, Canada
| | - Luke Y C Chen
- Vancouver General Hospital, Vancouver, British Columbia, Canada.,Division of Hematology, University of British Columbia, Vancouver, Canada
| | - Michelle P Wong
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, Canada.,Royal Columbian Hospital, New Westminster, Canada
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34
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Successful Modified Therapy in a Patient with Probable Infection-Associated Hemophagocytic Lymphohistiocytosis. Case Rep Oncol Med 2019; 2019:9781065. [PMID: 31583147 PMCID: PMC6754915 DOI: 10.1155/2019/9781065] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Revised: 07/02/2019] [Accepted: 08/27/2019] [Indexed: 11/17/2022] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a rare, hyperinflammatory syndrome characterized by clinical signs and symptoms of extreme inflammation. In adults, HLH is typically a complication of infections, autoimmune diseases, and malignancies. While the disease is often fatal, classic management of HLH revolves around early diagnosis and initiation of protocolized therapy. We present a case of a previously healthy 56-year-old female who developed distributive shock requiring intubation, vasopressors, and continuous venovenous hemofiltration. In the setting of multiple infectious syndromes, severe cytopenias, and rising direct hyperbilirubinemia, her diagnosis of HLH was confirmed. Therapy was initiated with dexamethasone and two doses of reduced-intensity etoposide based on the patient's clinical course. Over the next few weeks, she continued to improve on dexamethasone monotherapy and has maintained remission up to the present with complete resolution of her cytopenias and return of baseline renal function. Our case highlights the variability in the management of probable infection-associated HLH (IHLH) with a good patient outcome. We demonstrate the potential to treat IHLH with partial protocols and minimal chemotherapeutics.
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35
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Gao F, Zhao H, Chen X, Dong X, Liu T, Fu X. Gallbladder non-Hodgkin's lymphoma: Case report. Int J Surg Case Rep 2019; 61:218-221. [PMID: 31377548 PMCID: PMC6698641 DOI: 10.1016/j.ijscr.2019.07.064] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Revised: 07/19/2019] [Accepted: 07/20/2019] [Indexed: 12/03/2022] Open
Abstract
The patient was hospitalized for “intermittent fever, abdominal pain for 19 days” and then underwent laparoscopic cholecystectomy. After the operation, the patient’s condition deteriorated and eventually died. Postoperative pathological diagnosis confirmed gallbladder non-Hodgkin’s lymphoma. Gallbladder non-Hodgkin’s lymphoma is very rare, and this case also includes hemophagocytic syndrome and bile duct disappearance syndrome, which is rare. This case is described from the onset of the patient to the hospital visit and postoperative conditions. Bile duct disappearance syndrome (VBDS) is a syndrome characterized by reduced intrahepatic bile ducts as a pathological feature and cholestasis as the main clinical manifestation. Hemophagocytic syndrome (HPS) is a group of heterogeneous diseases characterized by over-inflammatory responses due to hereditary or acquired immunodeficiency.
Introduction Extrahepatic biliary non-Hodgkin’s lymphoma (EBNHL) is rare, with a prevalence of 0.6% of malignant biliary tumors. Primary biliary non-Hodgkin’s lymphoma accounts for 0.4% of extranodal non-Hodgkin’s lymphoma (NHL), accounting for approximately 0.016% of all NHL cases. The patient presented with typical bile duct disappearance syndrome. The late performance is a bloodthirsty syndrome. Presentation of case This patient was admitted to the hospital with “intermittent fever, abdominal pain for 19 days”. The relevant laboratory tests showed severe infection. The patients were treated according to abdominal infection, and then laparoscopic cholecystectomy was performed. After the operation, the patient's condition did not relieve and further deteriorated. Postoperative patient performance was not based on preoperative estimates, and surgery did not achieve the desired results. Postoperative pathological diagnosis confirmed gallbladder non-Hodgkin’s lymphoma. The patient eventually died. Discussion Non-calculus inflammation occurs more frequently in the gallbladder. Non-calculus infections are generally caused by bile stasis and ischemia, resulting in bacterial reproduction and reduced blood supply, and gangrene and perforation of the gallbladder are more likely to occur. This patient is also diagnosed and treated according to this idea. The development after surgery completely exceeded our expectations. Gallbladder non-Hodgkin’s lymphoma is very rare, and this case also includes hemophagocytic syndrome and bile duct disappearance syndrome, which is rare. Conclusion Malignant lymphoma of the extrahepatic biliary system is extremely rare, and its clinical manifestations are easily misdiagnosed. At the same time, non-calculous cholecystitis with fever, jaundice and hepatosplenomegaly should be considered.
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Affiliation(s)
- Fei Gao
- Shanxi Academy of Medical Sciences Shanxi Dayi Hospital, Longcheng Street 99, Taiyuan, Shanxi, 030032, China
| | - Haichao Zhao
- Graduate School of Shanxi Medical University, Xinjian South Road 56, Taiyuan, Shanxi, 030032, China.
| | - Xidong Chen
- Graduate School of Shanxi Medical University, Xinjian South Road 56, Taiyuan, Shanxi, 030032, China
| | - Xiushan Dong
- Shanxi Academy of Medical Sciences Shanxi Dayi Hospital, Longcheng Street 99, Taiyuan, Shanxi, 030032, China
| | - Tao Liu
- Shanxi Academy of Medical Sciences Shanxi Dayi Hospital, Longcheng Street 99, Taiyuan, Shanxi, 030032, China
| | - Xifeng Fu
- Shanxi Academy of Medical Sciences Shanxi Dayi Hospital, Longcheng Street 99, Taiyuan, Shanxi, 030032, China
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Liu SS, Wang Y, Xue L, Ma C, Li CH. Hemophagocytic lymphohistiocytosis due to Streptococcus suis in a 12-year-old girl: A case report. Medicine (Baltimore) 2019; 98:e15136. [PMID: 30985681 PMCID: PMC6485824 DOI: 10.1097/md.0000000000015136] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
RATIONALE Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening hyperinflammatory syndrome that can be caused by bacterial infection. Streptococcus suis (S. suis) is a zoonotic pathogen that can cause severe disease in both pigs and humans. We report the first-ever documented case of HLH secondary to S. suis infection. PATIENT CONCERNS A 12-year-old girl presented with fever, rash, hepatosplenomegaly, pancytopenia, and elevated levels of ferritin and soluble CD25. Bone marrow examination revealed hemophagocytosis. Blood culture was positive for S. suis. DIAGNOSIS A diagnosis of hemophagocytic syndrome due to S. suis was established. INTERVENTIONS We treated the patient with intravenous immunoglobulin, intravenous imipenem, and supportive care. OUTCOMES The patient eventually showed complete recovery. LESSONS Inflammatory response plays an important role in S. suis infection. Aberrant inflammatory response to S. suis infection may induce HLH. This case report illustrates that early definitive diagnosis and prompt treatment is a key imperative in patients with suspected S. suis infection.
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Telles JP, de Andrade Perez M, Marcusso R, Correa K, Teixeira RFA, Tobias WM. Hemophagocytic syndrome in patients living with HIV: a retrospective study. Ann Hematol 2018; 98:67-72. [PMID: 30255313 DOI: 10.1007/s00277-018-3500-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2018] [Accepted: 09/16/2018] [Indexed: 01/29/2023]
Abstract
Various infectious diseases can hyper-stimulate the immune system, causing hemophagocytic syndrome (HPS). Little is known regarding the accuracy of diagnostic criteria and epidemiological triggering factors in the acquired immunodeficiency syndrome (AIDS) setting. We investigated the major infectious disease triggers of HPS in patients living with human immunodeficiency virus (HIV)/AIDS and determined the accuracy of bone marrow aspiration (BMA). The inclusion criteria were (i) confirmed HIV diagnosis, (ii) bone marrow aspiration, and (iii) a minimum of four HPS criteria. Patients were further classified into those with four presumed HPS criteria, or ≥ 5 confirmed criteria. The disease triggers, accuracy of bone marrow aspiration, and prognosis markers were examined. Presumed HPS was observed in 15/36 patients (41%), and confirmed HPS in 58% (n = 21). The major etiological triggers were infection with Mycobacterium (34%), Cytomegalovirus (14%), Cryptococcus neoformans (11%), and hematological or tumoral disease (11%). BMA demonstrated 93% specificity on screening diagnosis (odds ratio [OR] 12.7, 95% confidence interval [CI] 1.4-115.1, P = 0.01). Ferritin > 5000 ng/mL correlated with probability of death in univariate analysis (OR 6.00, 95% CI 1.33-27.05, P = 0.02). Ferritin performance as test of death probability presented area under the curve as 0.74 (95% CI 0.56-0.91, P = 0.016). However, neither cluster of differentiation for lymphocyte count nor HIV viral load correlated with patient deaths. Mycobacterium spp. and Cytomegalovirus were the main factors triggering HPS, followed by Cryptococcus neoformans, and hematological and tumoral diseases. High ferritin levels were associated with increased death probability. High specificity was noted with BMA.
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Affiliation(s)
- João Paulo Telles
- Instituto de Infectologia Emílio Ribas, Av. Dr Arnaldo, 165, São Paulo, SP, 01246-900, Brazil.
| | | | - Rosa Marcusso
- Instituto de Infectologia Emílio Ribas, Av. Dr Arnaldo, 165, São Paulo, SP, 01246-900, Brazil
| | - Karina Correa
- Instituto de Infectologia Emílio Ribas, Av. Dr Arnaldo, 165, São Paulo, SP, 01246-900, Brazil
| | | | - Walter Moises Tobias
- Division of Hemathology in Universidade Federal de São Paulo, São Paulo, SP, Brazil
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Karras A. Atteinte rénale du syndrome d’activation macrophagique. MEDECINE INTENSIVE REANIMATION 2018. [DOI: 10.3166/rea-2018-0041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Le syndrome d’activation macrophagique (SAM) ou syndrome hémophagocytaire est une pathologie compliquant soit certains déficits immunitaires d’origine génétique, soit certaines maladies hématologiques (essentiellement des lymphomes non hodgkiniens), infectieuses (herpèsvirus, bactéries, parasites) ou auto-immunes (lupus, maladie de Still). Il se caractérise par une suractivation aiguë du système immunitaire et plus particulièrement des lymphocytes T cytotoxiques et des cellules histiocytaires/macrophagiques, déclenchant une production massive de cytokines pro-inflammatoires avec fièvre, pancytopénie, organomégalie, altérations du bilan hépatique et de la coagulation. Une défaillance multiviscérale est fréquente, nécessitant la prise en charge en réanimation et mettant souvent en jeu le pronostic vital, avec une mortalité qui reste dans certains cas à près de 50 %. Le SAM implique souvent le rein, par le biais d’une nécrose tubulaire aiguë, d’une néphropathie interstitielle inflammatoire ou d’une glomérulopathie sévère, responsable de syndrome néphrotique. La mise en évidence de ce syndrome n’est pas toujours facile chez un patient avec un tableau de sepsis ou de choc septique, mais elle peut guider la prise en charge thérapeutique, notamment l’initiation d’un traitement par chimiothérapie ou immunosuppresseurs, selon l’étiologie identifiée.
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Gars E, Purington N, Scott G, Chisholm K, Gratzinger D, Martin BA, Ohgami RS. Bone marrow histomorphological criteria can accurately diagnose hemophagocytic lymphohistiocytosis. Haematologica 2018; 103:1635-1641. [PMID: 29903767 PMCID: PMC6165820 DOI: 10.3324/haematol.2017.186627] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2017] [Accepted: 06/13/2018] [Indexed: 01/15/2023] Open
Affiliation(s)
| | | | | | - Karen Chisholm
- Seattle Children's Hospital and University of Washington, WA, USA
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Chang Y, Cui M, Fu X, Han L, Zhang L, Li L, Li X, Sun Z, Wu J, Zhang X, Li Z, Nan F, Yan J, Sheng G, Zhang M. Lymphoma associated hemophagocytic syndrome: A single-center retrospective study. Oncol Lett 2018; 16:1275-1284. [PMID: 30061947 DOI: 10.3892/ol.2018.8783] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2016] [Accepted: 04/03/2018] [Indexed: 12/20/2022] Open
Abstract
To improve the understanding of lymphoma associated hemophagocytic syndrome (LAHS) and find an effective treatment for this fatal disease, 57 patients with LAHS were retrospectively reviewed. The most common histopathological type was extranodal natural killer (NK)/T-cell lymphoma, nasal type (ENKL) (45.61%). Patients with B-cell LAHS were significantly older (P<0.001), and exhibited a higher triglyceride level (P=0.012), lower serum ferritin level (P=0.014) and lower plasma Epstein-Barr virus DNA (P<0.001) compared with patients with T/NK-cell LAHS. The median survival time of all patients was 43 days, and patients with B-cell (n=14) and T/NK-cell (n=43) LAHS had a median survival time of 55 and 40 days, respectively (P=0.797). Compared with patients who were treated based on HLH-2004 protocols combined with multidrug chemotherapy, those without chemotherapy had a reduced prognosis (P=0.002). The patients that underwent hematopoietic stem cell transplantation (HSCT) following chemotherapy had a significantly improved overall survival (OS) compared with patients that did not undergo HSCT (P=0.001). Patients with B-cell LAHS treated with rituximab (P=0.015) and patients with ENKL treated with L-asparaginase/pegaspargase (L-asp/peg) (P=0.009) had an improved prognosis compared with patients not treated with these drugs. In the T/NK-cell LAHS group, patients treated with chemotherapy containing gemcitabine did not exhibit an improved OS compared with those not treated with gemcitabine (P=0.326). Furthermore, multivariate analysis demonstrated that long diagnosis time and poor performance status were independent prognosis factors for all patients with LAHS. The present study indicated that survival time does not differ between patients with B-cell LAHS and patients with T/NK-cell LAHS. Early diagnosis and appropriate immunochemotherapy plus HSCT are essential to achieve improved outcomes. The outcome of patients with B-cell LAHS may be significantly improved following treatment with rituximab. L-asp/peg-containing regimens are promising treatments for patients with NK/T-cell LAHS.
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Affiliation(s)
- Yu Chang
- Department of Oncology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan 450052, P.R. China
| | - Meng Cui
- Department of Head and Neck and Thyroid, Henan Cancer Hospital Affiliated to Zhengzhou University, Zhengzhou, Henan 450052, P.R. China
| | - Xiaorui Fu
- Department of Oncology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan 450052, P.R. China
| | - Lijuan Han
- Department of Oncology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan 450052, P.R. China
| | - Lei Zhang
- Department of Oncology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan 450052, P.R. China
| | - Ling Li
- Department of Oncology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan 450052, P.R. China
| | - Xin Li
- Department of Oncology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan 450052, P.R. China
| | - Zhenchang Sun
- Department of Oncology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan 450052, P.R. China
| | - Jingjing Wu
- Department of Oncology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan 450052, P.R. China
| | - Xudong Zhang
- Department of Oncology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan 450052, P.R. China
| | - Zhaoming Li
- Department of Oncology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan 450052, P.R. China
| | - Feifei Nan
- Department of Oncology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan 450052, P.R. China
| | - Jiaqin Yan
- Department of Oncology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan 450052, P.R. China
| | - Guangyao Sheng
- Department of Pediatrics, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan 450052, P.R. China
| | - Mingzhi Zhang
- Department of Oncology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan 450052, P.R. China
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Büchi G, Termine G, Orlassino R, Pagliarino M, Boero R, Zappalà C, Grosso E. Hemophagocytic Syndrome in a Case of Splenic Large B-Cell Lymphoma. TUMORI JOURNAL 2018; 82:621-4. [PMID: 9061078 DOI: 10.1177/030089169608200623] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
A case of splenic large B-cell lymphoma with hemophagocytic syndrome is reported. The difficulties of diagnosis are emphasized especially when peripheral lymph nodes or bone marrow lymphomatous infiltration are not present. Diagnostic criteria for hemophagocytic syndrome and their relationship with the pathogenesis of the disease are also stressed.
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Affiliation(s)
- G Büchi
- Divisione di Medicina Interna, Ospedale Civile di Ivrea, Italy
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Censoplano N, Gorga S, Waldeck K, Stillwell T, Rabah-Hammad R, Flori H. Neonatal Adenovirus Infection Complicated by Hemophagocytic Lymphohistiocytosis Syndrome. Pediatrics 2018; 141:S475-S480. [PMID: 29610175 DOI: 10.1542/peds.2017-2061] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/10/2017] [Indexed: 11/24/2022] Open
Abstract
Two infants with disseminated adenoviral infections are described. Both these infants had a similar clinical course and were also diagnosed with secondary hemophagocytic lymphohistiocytosis (HLH). Previous reports of immunocompromised adults with adenovirus-associated HLH are in the literature; however, this is the first report that we are aware of with this pathology occurring in infants. These cases are used to demonstrate the importance of thinking about HLH in patients who are diagnosed with adenovirus and exhibit prolonged fevers that are unresponsive to antimicrobial agents with hepatosplenomegaly and cytopenias.
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Affiliation(s)
- Nina Censoplano
- Division of Cardiology, University of Colorado Anschutz Medical Campus, Children's Hospital of Colorado, Aurora, Colorado
| | | | | | | | - Raja Rabah-Hammad
- Department of Pathology, C.S. Mott Children's Hospital, Medical School, University of Michigan, Ann Arbor, Michigan; and
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Ragab G, Atkinson TP, Stoll ML. Macrophage Activation Syndrome. THE MICROBIOME IN RHEUMATIC DISEASES AND INFECTION 2018. [PMCID: PMC7123081 DOI: 10.1007/978-3-319-79026-8_14] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Hemophagocytic lymphohistiocytosis (HLH), or termed macrophage activation syndrome (MAS) when associated with rheumatic disorders, is a frequently fatal complication of infections, rheumatic disorders, and hematopoietic malignancies. Clinically, HLH/MAS is a life-threatening condition that is usually diagnosed among febrile hospitalized patients (children and adults) who commonly present with unremitting fever and a shock-like multiorgan dysfunction scenario. Laboratory studies reveal pancytopenia, elevated liver enzymes, elevated markers of inflammation (ESR, CRP), hyperferritinemia, and features of coagulopathy. In about 60% of cases, excess hemophagocytosis (macrophages/histiocytes engulfing other hematopoietic cell types) is noted on biopsy specimens from the bone marrow, liver, lymph nodes, and other organs. HLH/MAS has been hypothesized to occur when a threshold level of inflammation has been achieved, and genetic and environmental risk factors are believed to contribute to the hyperinflammatory state. A broad variety of infections, from viruses to fungi to bacteria, have been identified as triggers of HLH/MAS, either in isolation or in addition to an underlying inflammatory disease state. Certain infections, particularly by members of the herpesvirus family, are the most notorious triggers of HLH/MAS. Treatment for infection-triggered MAS requires therapy for both the underlying infection and dampening of the hyperactive immune response.
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Affiliation(s)
- Gaafar Ragab
- Faculty of Medicine, Cairo University, Cairo, Egypt
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44
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Cutaneous hemophagocytosis: Clinicopathologic features of 21 cases. J Am Acad Dermatol 2018; 78:377-382. [DOI: 10.1016/j.jaad.2017.08.041] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Revised: 08/16/2017] [Accepted: 08/22/2017] [Indexed: 11/19/2022]
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Brisse E, Imbrechts M, Mitera T, Vandenhaute J, Wouters CH, Snoeck R, Andrei G, Matthys P. Lytic viral replication and immunopathology in a cytomegalovirus-induced mouse model of secondary hemophagocytic lymphohistiocytosis. Virol J 2017; 14:240. [PMID: 29258535 PMCID: PMC5738214 DOI: 10.1186/s12985-017-0908-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Accepted: 12/08/2017] [Indexed: 12/28/2022] Open
Abstract
Background Hemophagocytic lymphohistiocytosis (HLH) is a rare immunological disorder caused by unbridled activation of T cells and macrophages, culminating in a life-threatening cytokine storm. A genetic and acquired subtype are distinguished, termed primary and secondary HLH, respectively. Clinical manifestations of both forms are frequently preceded by a viral infection, predominantly with herpesviruses. The exact role of the viral infection in the development of the hemophagocytic syndrome remains to be further elucidated. Methods We utilized a recently developed murine model of cytomegalovirus-associated secondary HLH and dissected the respective contributions of lytic viral replication and immunopathology in its pathogenesis. Results HLH-like disease only developed in cytomegalovirus-susceptible mouse strains unable to clear the virus, but the severity of symptoms was not correlated to the infectious viral titer. Lytic viral replication and sustained viremia played an essential part in the pathogenesis since abortive viral infection was insufficient to induce a full-blown HLH-like syndrome. Nonetheless, a limited set of symptoms, in particular anemia, thrombocytopenia and elevated levels of soluble CD25, appeared less dependent of the viral replication but rather mediated by the host’s immune response, as corroborated by immunosuppressive treatment of infected mice with dexamethasone. Conclusion Both virus-mediated pathology and immunopathology cooperate in the pathogenesis of full-blown virus-associated secondary HLH and are closely entangled. A certain level of viremia appears necessary to elicit the characteristic HLH-like symptoms in the model.
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Affiliation(s)
- Ellen Brisse
- Laboratory of Immunobiology, Rega Institute, Department of Microbiology and Immunology, KU Leuven, Leuven, Belgium
| | - Maya Imbrechts
- Laboratory of Immunobiology, Rega Institute, Department of Microbiology and Immunology, KU Leuven, Leuven, Belgium
| | - Tania Mitera
- Laboratory of Immunobiology, Rega Institute, Department of Microbiology and Immunology, KU Leuven, Leuven, Belgium
| | - Jessica Vandenhaute
- Laboratory of Immunobiology, Rega Institute, Department of Microbiology and Immunology, KU Leuven, Leuven, Belgium
| | - Carine H Wouters
- Laboratory of Pediatric Immunology, Department of Microbiology and Immunology, University Hospital Gasthuisberg, KU Leuven, Leuven, Belgium
| | - Robert Snoeck
- Laboratory of Virology and Chemotherapy, Rega Institute, Department of Microbiology and Immunology, KU Leuven, Leuven, Belgium
| | - Graciela Andrei
- Laboratory of Virology and Chemotherapy, Rega Institute, Department of Microbiology and Immunology, KU Leuven, Leuven, Belgium
| | - Patrick Matthys
- Laboratory of Immunobiology, Rega Institute, Department of Microbiology and Immunology, KU Leuven, Leuven, Belgium.
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Nusshag C, Morath C, Zeier M, Weigand MA, Merle U, Brenner T. Hemophagocytic lymphohistiocytosis in an adult kidney transplant recipient successfully treated by plasmapheresis: A case report and review of the literature. Medicine (Baltimore) 2017; 96:e9283. [PMID: 29390386 PMCID: PMC5815798 DOI: 10.1097/md.0000000000009283] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
RATIONALE Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening disease entity primarily described in children, but not less relevant in adults. It is characterized by a misdirected activation of the immune system, resulting in an uncontrolled cytokine release from macrophages and cytotoxic T-cells (CTLs). Primary HLH relies on a genetic predisposition, whereas secondary HLH develops in the context of infections, malignancies or autoimmune diseases. However, the awareness and therapeutic knowledge for HLH in adulthood is limited. Most therapy protocols are almost exclusively validated in pediatric cohorts and for primary HLH. Their transferability to adult individuals with mostly secondary HLH is doubtful. Especially the high liver and bone marrow toxicity of applied etoposide-based protocols is discussed controversially and connected to overwhelming infections and death. PATIENT CONCERN A 51-year old, male, kidney transplant recipient was admitted to our center suffering from diarrhea, fever, nausea, hyponatremia, kidney graft failure, disorientation, progressive hemodynamic instability, and multiorgan failure. DIAGNOSES Clinical and laboratory findings resembled those of a septic shock. Ferritin and soluble interleukin-2 receptor (sCD25) levels were disproportionally elevated. Only a mild hepatosplenomegaly was diagnosed in a CT scan. A T2-weighted, fluid-attenuated inversion recovery MRI showed marked, bilateral and periventricular white matter hyperintensities. The cerebrospinal fluid (CSF) analysis showed a moderately elevated protein content and cell count. There was no evidence of any bacterial, viral, or parasitic infection. The diagnosis of HLH was made. INTERVENTIONS & OUTCOMES The patient was successfully treated by a combined approach consisting of plasma exchange (PE), corticosteroids, anakinra, and cyclosporine (CsA). LESSONS HLH is an important differential diagnosis in critically ill patients. Its unspecific clinical picture complicates an early diagnosis and may be misclassified as sepsis. A combination of plasma exchange (PE), corticosteroids, anakinra, and cyclosporine (CsA) may be a promising and less toxic approach for HLH therapy in adults.
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Affiliation(s)
| | | | | | | | - Uta Merle
- Departement of Gastroenterology, Heidelberg University Hospital, Germany
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Yabushita T, Yoshioka S, Koba Y, Ono Y, Hiramoto N, Tabata S, Itou M, Shimizu N, Tomii K, Ishikawa T. Successful Treatment of Herpes Simplex Virus (HSV)-1-associated Hemophagocytic Lymphohistiocytosis (HLH) with Acyclovir: A Case Report and Literature Review. Intern Med 2017; 56:2919-2923. [PMID: 28924117 PMCID: PMC5709639 DOI: 10.2169/internalmedicine.8490-16] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) associated with herpes simplex virus (HSV)-1 infection (HSV-1-HLH) is uncommon and is potentially fatal without appropriate treatment. We herein report the case of an adult patient with HSV-1-HLH who was successfully treated with acyclovir. A 69-year-old man developed fever, pancytopenia and liver enzyme elevation after the resolution of pneumonia. These findings and the presence of hemophagocytosis in the patient's bone marrow were consistent with a diagnosis of HLH. The patient was diagnosed with HSV-1-HLH based on the results of a polymerase chain reaction (PCR) for HSV-1. The early administration of acyclovir improved his clinical symptoms and laboratory results within two weeks. In the present case, the rapid and precise diagnosis facilitated the successful treatment of HSV-1-HLH.
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Affiliation(s)
- Tomohiro Yabushita
- Department of Hematology, Kobe City Medical Center General Hospital, Japan
| | - Satoshi Yoshioka
- Department of Hematology, Kobe City Medical Center General Hospital, Japan
| | - Yusuke Koba
- Department of Hematology, Kobe City Medical Center General Hospital, Japan
| | - Yuichirou Ono
- Department of Hematology, Kobe City Medical Center General Hospital, Japan
| | - Nobuhiro Hiramoto
- Department of Hematology, Kobe City Medical Center General Hospital, Japan
| | - Sumie Tabata
- Department of Hematology, Kobe City Medical Center General Hospital, Japan
| | - Munehiro Itou
- Department of Respiratory Medicine, Kobe City Medical Center General Hospital, Japan
| | - Norio Shimizu
- Department of Virology Medical Research Institute, Tokyo Medical and Dental University, Japan
| | - Keisuke Tomii
- Department of Respiratory Medicine, Kobe City Medical Center General Hospital, Japan
| | - Takayuki Ishikawa
- Department of Hematology, Kobe City Medical Center General Hospital, Japan
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Rousselin A, Alavi Z, Le Moigne E, Renard S, Tremouilhac C, Delluc A, Merviel P. Hemophagocytic syndrome in pregnancy: case report, diagnosis, treatment, and prognosis. Clin Case Rep 2017; 5:1756-1764. [PMID: 29152265 PMCID: PMC5676265 DOI: 10.1002/ccr3.1172] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2017] [Revised: 06/28/2017] [Accepted: 08/07/2017] [Indexed: 01/24/2023] Open
Abstract
Diagnosis of hemophagocytic syndrome remains a challenge in particular during pregnancy. Concomitant presence of clinical and biological signs, for example, fever, pancytopenia, hyperferritinemia, and hypertriglyceridemia, should alert clinicians to suspect HPS and proceed to prompt treatments.
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Affiliation(s)
- Aline Rousselin
- Obstetrics and Gynecology Service Brest Medical University Hospital Brest France
| | - Zarrin Alavi
- Inserm CIC 1412 Brest Medical University Hospital Brest France
| | | | - Sarah Renard
- Obstetrics and Gynecology Service Brest Medical University Hospital Brest France
| | | | - Aurélien Delluc
- Department of Internal Medicine Brest Medical University Hospital Brest France
| | - Philippe Merviel
- Obstetrics and Gynecology Service Brest Medical University Hospital Brest France
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Brisse E, Wouters CH, Andrei G, Matthys P. How Viruses Contribute to the Pathogenesis of Hemophagocytic Lymphohistiocytosis. Front Immunol 2017; 8:1102. [PMID: 28936212 PMCID: PMC5594061 DOI: 10.3389/fimmu.2017.01102] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Accepted: 08/22/2017] [Indexed: 11/23/2022] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening, hyperinflammatory syndrome, characterized by the uncontrolled activation of macrophages and T cells, eliciting key symptoms such as persistent fever, hepatosplenomegaly, pancytopenia, hemophagocytosis, hyperferritinemia, and coagulopathy. Viral infections are frequently implicated in the onset of active HLH episodes, both in primary, genetic HLH as in the secondary, acquired form. Infections with herpesviruses such as Epstein-Barr virus and cytomegalovirus are the most common. In autoimmune diseases, a link between viral infections and autoreactive immune responses has been recognized for a considerable time. However, the mechanisms by which viruses contribute to HLH pathogenesis remain to be clarified. In this viewpoint, different factors that may come into play are discussed. Viruses, particularly larger DNA viruses such as herpesviruses, are potent modulators of the immune response. By evading immune recognition, interfering with cytokine balances and inhibiting apoptotic pathways, viruses may increase the host's susceptibility to HLH development. In particular cases, a direct connection between the viral infection and inhibition of natural killer cell or T cell cytotoxicity was reported, indicating that viruses may create immunological deficiencies reminiscent of primary HLH.
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Affiliation(s)
- Ellen Brisse
- Laboratory of Immunobiology, Rega Institute, KU Leuven, Leuven, Belgium
| | - Carine H. Wouters
- Laboratory of Immunobiology, Rega Institute, KU Leuven, Leuven, Belgium
- University Hospital Gasthuisberg, Leuven, Belgium
| | - Graciela Andrei
- Laboratory of Virology and Chemotherapy, Rega Institute, KU Leuven, Leuven, Belgium
| | - Patrick Matthys
- Laboratory of Immunobiology, Rega Institute, KU Leuven, Leuven, Belgium
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Hashmi HRT, Mishra R, Niazi M, Venkatram S, Diaz-Fuentes G. An Unusual Triad of Hemophagocytic Syndrome, Lymphoma and Tuberculosis in a Non-HIV Patient. AMERICAN JOURNAL OF CASE REPORTS 2017; 18:739-745. [PMID: 28669977 PMCID: PMC5507798 DOI: 10.12659/ajcr.903990] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Lymphoma complicated with hemophagocytic syndrome and tuberculosis has been rarely reported. The clinical and radiological presentation of these potentially fatal conditions can be easily confused and there is a potential for misdiagnosis. CASE REPORT We present a 58-year-old Hispanic female who was admitted to the hospital with dizziness and fever. Her initial admission diagnosis was severe sepsis secondary to community acquired pneumonia. She was started on intravenous antibiotics. Due to mediastinal lymphadenopathy, lymphoma was considered as a differential diagnosis for which she underwent bronchoscopy and endobronchial ultrasound-guided sampling of her mediastinal lymph nodes. Lymph node aspirate was suggestive of lymphoma. Initial cultures were negative. Her clinical course was complicated with respiratory failure, cytopenia, and rapidly progressive cervical lymphadenopathy. The patient underwent cervical lymph node excision and bone marrow biopsy. The pathology of the lymph nodes confirmed T cell lymphoma, and bone marrow revealed hemophagocytosis. The patient was started on chemotherapy but she continued to deteriorate and died on day 20 of her hospital admission. Post-mortem results of cultures from a cervical lymph node biopsy and PCR were positive for Mycobacterium tuberculosis. CONCLUSIONS We suggest an aggressive tissue diagnosis with staining for acid-fast bacilli for early diagnosis in patients presenting with hemophagocytic syndrome secondary to lymphoma as coexisting tuberculosis is a consideration. Tuberculosis re-activation should be considered in patients from an endemic region who present with lymphoma and a deteriorating clinical condition.
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Affiliation(s)
| | - Rashmi Mishra
- Division of Pulmonary and Critical Care Medicine, Bronx Lebanon Hospital Center, Bronx, NY, USA
| | - Masooma Niazi
- Department of Pathology, Bronx Lebanon Hospital Center, Bronx, NY, USA
| | - Sindhaghatta Venkatram
- Division of Pulmonary and Critical Care Medicine, Bronx Lebanon Hospital Center, Bronx, NY, USA
| | - Gilda Diaz-Fuentes
- Division of Pulmonary and Critical Care Medicine, Bronx Lebanon Hospital Center, Bronx, NY, USA
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