Tuberculosis-associated hemophagocytic syndrome. A systemic process

Tuberculosis-Associated Hemophagocytic Lymphohistiocytosis: A Review of Current Literature

Hemophagocytic lymphohistiocytosis (HLH) is a condition of immune dysregulation and hyperinflammation, leading to organ failure and death. Malignancy, autoimmune conditions, and infections, including Mycobacterium tuberculosis (TB), are all considered triggers of HLH. The aim of this study was to review all reported cases of TB-associated HLH in English literature, and to summarize the epidemiology, diagnostics, treatment, and mortality in patients with concomitant HLH and TB. A systematic review of described cases with TB-associated HLH, via a structured literature search in the medical database PubMed, is presented. Additional articles were included through cross-referencing with existing review articles. Articles were reviewed based on a predetermined set of criteria. A total of 116 patients with TB-associated HLH were identified with a male:female ratio of about 3:2. The age at presentation ranged from 12 days to 83 years. Malignancy, autoimmunity, and renal failure were the most common comorbid conditions. Most patients received both tuberculostatic and specific immunomodulating treatment, which was associated with a 66% (48/73) survival rate compared to 56% (15/27) in those receiving only tuberculostatic treatment, and 0% (0/13) in those receiving only immunomodulating treatment. The survival rate was 55% overall. The overlapping presentation between disseminated TB and HLH poses challenging diagnostics and may delay diagnosis and treatment, leading to increased mortality. TB should be considered as a potential trigger of HLH; clinicians' knowledge and awareness of this may result in the appropriate investigations needed to ensure diagnosis and proper treatment.

Disseminated Mycobacterium tuberculosis: An Unusual Presentation with Associated Hemophagocytic Lymphohistiocytosis

Hemophagocytic lymphohistiocytosis (HLH) is a rare, potentially fatal, and systemic hyperinflammatory syndrome with exacerbated and uncontrolled activation of histiocytes and lymphocytes against mature cells. Secondary HLH can occur in association with a myriad of underlying infections or malignancies. Our patient is a 38-year-old male prisoner with poorly controlled diabetes and no known other medical conditions. He was referred to our emergency department with three-week history of worsening malaise, weight loss, fever, bruising, and shortness of breath; imaging showed pneumomediastinum, lung nodule, and adrenal mass. Biopsy of the lung nodule revealed acid-fast bacilli. Furthermore, bone marrow biopsy showed foci of necrosis with associated acid-fast bacilli and hemophagocytosis highlighted by CD163 stain; consequently, secondary HLH was suggested. Hence, lab results were reviewed and found to satisfy five of the eight secondary HLH criteria. Moreover, ferritin was >10,000 ng/ml, which has been suggested to be highly suspicious for HLH. The patient was started on anti-MAC therapy. Unfortunately, the patient's status declined rapidly; he developed multi-organ failure and succumbed to disease. Later, his culture confirmed Mycobacterium tuberculosis. In conclusion, we presented a rare and challenging case of secondary HLH associated with disseminated Mycobacterium tuberculosis. A high index of suspicion is required for early diagnosis and treatment, and pathologists should be aware of Mycobacterium tuberculosis' association with secondary HLH.

Haemophagocytic lymphohistiocytosis in a patient with familial Mediterranean fever and miliary tuberculosis: a case report

Haemophagocytic lymphohistiocytosis (HLH) is a lethal complication of several infections, especially viral origin. Mycobacterium tuberculosis infection can also lead to HLH, yet it is an uncommon trigger. Considering the role of increased cytokines in HLH, autoinflammatory conditions, such as familial Mediterranean fever (FMF), might contribute to its development. Nevertheless, the possible relationship between FMF and HLH has been suggested only in some case reports. We present a case of FMF who admitted to the hospital with consitutional symptoms and chest pain regarding to recurrent pericarditis. On a blood test, pancytopenia and elevated acute phase reactants were seen. Fluorine-18 fluorodeoxyglucose (FDG) positron emission tomography/computed tomography demonstrated positive FDG uptake sites on both the right and left surrenal glands, the visceral layer of pericard, and reactive lymphadenomegalies at multiple mediastinal regions. Bone marrow biopsy revealed haemophagocytosis. Methylprednisolone treatment was initiated. Despite immunosuppressive treatment, clinical and biochemical parameters deteriorated; thus, a thorax computed tomography was executed. Findings were consistent with miliary tuberculosis infection. M. tuberculosis was detected in blood culture and bronchoalveolar lavage culture material. Also, bone marrow and surrenal biopsy material revealed necrotising caseating granuloma.

Haematological profiles after Intensive phase of Anti Koch Treatment with special emphasis on bone marrow changes

BACKGROUND

Tuberculosis remains a major public health problem in various parts of the world. It leads to various haematological changes. Study of these haematological changes will help better patient management.

OBJECTIVE & METHODS

It is to evaluate haematological changes in tuberculosis patients and compare the result with special emphasis to bone marrow changes as active case search is sharply decreasing the miliary tuberculosis. It is also to evaluate the patients with before and after the Intensive Phase of Anti Koch Treatment. Sputum positive and sputum negative tuberculosis patients confirmed by other ancillary techniques were included into this study. It is conducted at a tertiary level hospital in rural area.

RESULT

In this study bone marrow hypercellularity was of erythroid series with only 1.92% patients showed granuloma in bone marrow aspiration. In addition to bone marrow changes, significant changes were evident in haemoglobin level, Erythrocyte Sedimentation Rate (ESR) Total White Blood Cell count and RBC count.

DISCUSSION

In majority cases this study showed Erythroid Hyperplasia. It is sharp contrast with other study where myeloid hyperplasia was evident. This study also differs from other study where high number of bone marrow granuloma was reported. In this study only 1.92% cases showed bone marrow granuloma. This study also documented higher number of anaemic cases mostly because of the institute serves poor and tribal population.

CONCLUSION

In our study the cases showing granuloma and hyperplasia of myeloid series were limited. With introduction of Directly Observed Treatment and house to house active case search helped to sharply decrease bone marrow granuloma by limiting multi-organ spread. This study showed, ESR level may be considered as prognostic parameters of tuberculosis.

Tuberculosis-associated hemophagocytic lymphohistiocytosis with initial presentation of fever of unknown origin in a general hospital: An analysis of 8 clinical cases

The study aimed to investigate the clinical features and prognoses of patients with tuberculosis (TB) who had secondary hemophagocytic lymphohistiocytosis (HLH).Patients first presenting with fever of unknown origin, who were ultimately diagnosed with TB-associated secondary HLH, were assessed retrospectively. We summarized and analyzed clinical manifestations, laboratory examinations, diagnoses, treatments, and prognoses of patients using clinical data, outpatient follow-up, and telephone follow-up in combination with literature review.Among patients admitted to the hospital with fever of unknown origin in the past 10 years, 371 patients were diagnosed with TB. Among them, 8 cases were diagnosed as tuberculosis-associated HLH (TB-HLH). The proportion of females among TB-HLH patients was higher than the proportion of females among TB patients. Within the same time period, 227 cases met the diagnostic criteria for HLH, among which TB-HLH patients accounted for 3.52% of the cases. None of the 8 TB-HLH patients had underlying diseases, and a majority of them had short symptom durations, rapid progression, along with multisystem and multiorgan dysfunctions. Their clinical manifestations were inconsistent with the typical clinical manifestations and imaging results characteristic of TB. Compared with patients with TB in our hospital during the same period, the 8 TB-HLH patients had a higher proportion of blood-disseminated TB and tuberculous meningitis. Apart from this, the hematological damage in these patients was higher than the common clinical manifestations of TB, and they also had a high proportion of respiratory failure. All 8 TB-HLH patients received antitubercular therapy, and 6 of them were also treated for HLH. However, their morbidity and mortality were significantly higher than that for reported cases of TB-HLH cases, both domestically and abroad, which may be attributed to the fever of unknown origin.Patients with TB-HLH had poor prognoses and no specific clinical manifestations. Therefore, cases of atypical TB and severe TB should be carefully monitored to achieve early diagnosis and early intervention.

Hemophagocytic lymphohistiocytosis: An unusual presentation of tuberculosis in hemodialysis patients

We report a series of three patients with end-stage renal disease on maintenance hemodialysis presenting with hemophagocytic lymphohistiocytosis (HLH) as an unusual manifestation of extrapulmonary tuberculosis. All three patients were middle-aged men. They presented with fever, pancytopenia, varying degrees of hepatosplenomegaly, abnormal liver function tests, coagulopathy, increased serum ferritin, and triglycerides. Tests for fever work-up were negative. Bone marrow examination revealed hemophagocytosis and caseating granuloma. Acid fast bacilli were demonstrated in two patients. The HLH-2004 diagnostic criteria suggested by the histiocytic society were followed to arrive at the diagnosis. All of them succumbed to death even before the definitive diagnosis could be made. We suggest that aggressive diagnostic work-up must be done when hemodialysis patients present with fever and pancytopenia. Priority should be toward early diagnosis and appropriate treatment to improve the prognosis.

Sudden unexpected death due to hemophagocytic lymphohistiocytosis syndrome

The hemophagocytic lymphohistiocytosis (HLH) syndrome is a hyperimmune disorder characterized by lymphohistiocytic infiltrations, elevated cytokine levels in the blood, macrophage activation, and hemophagocytosis, frequently presenting with a febrile septic picture. This unusual disease is more common in infancy and childhood than adulthood. It is classified as primary or familial when a genetic defect is identified and secondary or acquired when triggered by certain infections, autoimmune disorders, or malignancies. If or when such patients expire, they typically do so within a hospital or under a physician's care and so such cases rarely come to the attention of forensic pathologists. We report on the unexpected deaths of two hospitalized adult cases of HLH brought to autopsy without a premortem diagnosis. Postmortem examination demonstrated marked hepatosplenomegaly and lymphadenopathy in association with hemophagocytosis. Although very uncommon HLH must be considered in infants, children, or adults who die unexpectedly with an undiagnosed septic presentation.

Haemophagocytic lymphohistiocytosis: a cause for rare but fatal outcome in tuberculosis

Haemophagocytic lymphohistiocytosis (HLH), also called haemophagocytic syndrome (HPS) is characterised by a dysregulated activation and proliferation of macrophages, leading to uncontrolled phagocytosis of platelets, erythrocytes, lymphocytes and their haematopoietic precursors throughout the reticuloendothelial system. Mycobacterium tuberculosis-associated HPS is a rare and underdiagnosed association. We report a 34-year-old male patient diagnosed with tubercular pleural effusion responding poorly to antitubercular treatment. Patient later developed generalised lymphadenopathy, pancytopaenia and liver dysfunction and was eventually diagnosed as HLH. Despite being treated as per HLH protocol 2004 he could not be saved.

Diagnostic Dilemma in an Adolescent Boy: Hemophagocytic Syndrome in Association with Kala Azar

Leishmaniasis is caused by infection with the hemoparasite Leishmania. The disease is a major public health problem in at least 88 countries, including Turkey. Prolonged fever with anorexia and loss of appetite are the major presenting features of visceral leishmaniasis. It is rarely defined as an etiological cause of hemophagocytic syndrome. The clinical course triggered by leishmania infection and hemophagocytosis may coincide, and this may lead to considerable diagnostic difficulty, especially in young children. In this report, we describe an adolescent boy with visceral leishmaniasis as a rare cause of the hemophagocytic syndrome. This is the first reported association between hemophagocytosis and visceral leishmaniasis in an adolescent.

Tuberculosis-associated haemophagocytic syndrome

Haemophagocytic syndrome is a disorder characterised by fevers, lymphadenopathy, hepatosplenomegaly, cytopenias, and hyperferritinaemia due to dysregulated activation and proliferation of macrophages, leading to uncontrolled phagocytosis of platelets, erythrocytes, lymphocytes, and their haematopoietic precursors throughout the reticuloendothelial system. Primary or familial haemophagocytic syndrome appears to have a genetic aetiology, whereas secondary haemophagocytic syndrome may be associated with malignancy, autoimmune disease, or infection. Epstein-Barr virus is the most common infectious aetiology implicated in haemophagocytic syndrome, but the syndrome has been associated with a variety of other viral, bacterial, and parasitic pathogens. We describe a case of haemophagocytic syndrome associated with disseminated Mycobacterium tuberculosis. We review all cases of M tuberculosis-associated haemophagocytic syndrome reported in the English language literature and discuss important issues pertaining to the epidemiology, diagnosis, and management of this disease.

Pediatric hemophagocytic syndromes: a diagnostic and therapeutic challenge

Pediatric hemophagocytic syndrome (HS) is a severe and often fatal clinical disorder. This syndrome is frequently unrecognized, and thus, affected children may receive suboptimal management, leading to an increase in mortality. The purpose of this review is to provide a clinical guide to (1) the recognition of HS based on clinical, biologic, and pathologic features; (2) the identification of the primary cause of HS in a given affected child; and (3) the initiation of effective treatment in a timely manner.

Infection-associated haemophagocytosis: the tropical spectrum

Reactive proliferation and inappropriate activation of mature histiocytes with haemophagocytosis (HP) may occur in association with a wide variety of infections, neoplasms, collagen vascular diseases, and acquired and inherited immunodeficiency states. The association with infections is particularly important because overwhelming HP can obscure the typical clinical features of the primary disease and negatively affects outcome. A high index of suspicion is required for early recognition of associated HP as the cause of cytopenias. Institution of specific therapy is crucial for survival. This study highlights the wide spectrum of tropical diseases that can have associated reactive HP. Thirty cases with documented prominent HP on bone marrow aspiration smears were reviewed. Twenty-one (69%) of the marrows were from patients who had common tropical infections: malaria, typhoid and visceral leishmaniasis and 11 of 15 patients (73%) who were followed up improved on specific infection-directed and supportive measures. The presence of severe HP in bone marrow smears correlated with marked cytopenias. Recognition of HP in this geographical region should stimulate the search for one of these infections as early institution of specific therapy is crucial for patient survival.

Hypercalcaemia and haemophagocytic syndrome: rare concurrent presentations of disseminated tuberculosis in a dialysis patient

Tuberculosis remains an important cause of infection in chronic haemodialysis patients. Frequent extrapulmonary involvement, non-specific presentation and limited diagnostic tools usually make early diagnosis difficult. Herein, we report on an 83-year-old female patient who had been on regular heamodialysis therapy for 15 years, who presented with asymptomatic hypercalcaemia and pancytopenia. Haemophagocytic syndrome was documented during the admission period. Mycobacterium tuberculosis was cultured from bone marrow 1 month after her demise. This case report highlights the non-specific manifestations of extrapulmonary tuberculosis in dialysis patients and the limited value of conventional diagnostic methods. We would like to recommend aggressive intervention and early tissue aspiration from possible infectious sites when tuberculosis cannot be completely ruled out. Disseminated tuberculosis should be considered as an indication of hypercalcaemia where haemophagocytic syndrome occurs simultaneously.

A successfully treated case of disseminated tuberculosis-associated hemophagocytic syndrome and multiple organ dysfunction syndrome

We report the case of a patient who presented with disseminated tuberculosis-associated hemophagocytic syndrome (HPS). A 40-year-old man was admitted because of fatigue, fever, and renal dysfunction. Chest radiograph and computed tomography scan showed diffuse reticulonodular shadow, and Mycobacterium tuberculosis was identified. Peripheral blood counts decreased rapidly, and bone marrow aspiration revealed hemophagocytosis by macrophages. Despite antituberculous and steroid pulse therapy, multiple organ dysfunction syndrome developed. After plasma exchange and continuous hemodiafiltration were started, hypercytokinemia and vital signs improved dramatically. Although disseminated tuberculosis-associated HPS carries a poor prognosis, acute blood purification may be an effective means of treating HPS involving multiple organ dysfunction syndrome.

A clinical analysis of 52 adult patients with hemophagocytic syndrome: the prognostic significance of the underlying diseases

We retrospectively analyzed 52 adult patients with hemophagocytic syndrome (HPS). The underlying diseases were heterogeneous, including malignant lymphoma (lymphoma-associated hemophagocytic syndrome [LAHS]) in 26 patients, systemic lupus erythematosus in 3 patients, viral infections in 7 patients, and bacteria] or fungal infections in 6 patients. More than 83% of patients received prednisolone as an initial treatment. Multiple-agent chemotherapies (cyclophosphamide, doxorubicin, and vincristine) were administered to 96% of LAHS patients after a histopathological diagnosis of lymphoma. HPSs were controllable and remissions were achieved except for those patients with LAHS, fulminant Epstein-Barr virus-associated HPS, and an immunosuppressive state. Twenty-one (81%) of the LAHS patients had uncontrollable HPS and died of multiple organ failure and disseminated intravascular coagulation. The median survival time of LAHS patients was 83 days. In contrast, 3 (12%) of the other HPS patients died of multiple organ failure within 44 days.The clinical manifestations and the laboratory findings of LAHS and the other HPSs were too variable to establish the prognosis based only on the findings at the onset of HPS. The prognostic factors of adult HPS were found to be the underlying diseases, notably malignant lymphoma and infections, accompanied by the immunosuppressive state.

Reactive hemophagocytic syndrome presenting as a component of multiple organ dysfunction syndrome

OBJECTIVE

To report two cases of severe reactive hemophagocytic syndrome (RHS), to discuss their impact, and to present evidence that RHS may be a constitutive part of multiple organ dysfunction syndrome (MODS).

DESIGN

Case-report.

SETTING

Pediatric intensive care unit (PICU).

PATIENTS

Two patients with RHS and MODS.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Case #1: A 3 yr-old boy with Mucha-Haberman syndrome (pityriasis lichenoides) was admitted to the PICU for septic shock, acute respiratory distress syndrome, capillary leak, acute renal failure, liver dysfunction, and RHS (pancytopenia and hemophagocytosis on bone marrow aspirate). The pancytopenia was severe (white blood cell count, 0.9 x 10(9)/L; hemoglobin, 59 g/L; platelets, 36 x 10(9)/L), required many transfusions, and resolved 2 months later. The patient needed mechanical ventilation for 6 wks. Length of stay in PICU was 2 months. Case #2: A previously healthy 4 yr-old girl was admitted to the PICU for respiratory failure. She developed acute respiratory distress syndrome, cardiomyopathy with complete atrioventricular block, shock, capillary leak, liver dysfunction, and RHS (pancytopenia and hemophagocytosis on bone marrow aspirate). The pancytopenia was severe (white blood cell count, 1.92 x 10(9)/L; hemoglobin, 65 g/L; platelets, 58 x 10(9)/L) and necessitated transfusional support. Serology for respiratory syncytial virus was positive. RHS duration was 20 days; the patient recovered completely. Length of mechanical ventilation was 16 days and length of stay in PICU was 3 wks.

CONCLUSIONS

These cases show that RHS may be a significant cause of pancytopenia in the PICU. It needs to be recognized as a clinical entity because it can be reversible and nonneoplastic. RHS and MODS share some pathophysiologic elements and could be related to each other.

Haemophagocytic syndrome associated with infections

Haemophagocytic syndromes (HS) are the clinical manifestation of an increased macrophagic activity with haemophagocytosis. Pathophysiology is related to a deregulation of T-lymphocytes and excessive production of cytokines. The main clinicobiological features are fever, hepatosplenomegaly, adenopathies, skin rash, neurological features, cytopenias, hypertriglyceridaemia, hyperferritinaemia and coagulopathy. Diagnosis is based on examination of the bone marrow which shows benign histiocytes actively phagocytosing haemopoietic cells. Acquired HS are mostly associated with an underlying disease such as immunodeficiency, haematological neoplasias and autoimmune diseases. Infection-associated HS was originally described by Risdall in 1979, in viral disease. Since the initial description HS has also been documented in patients with bacterial, parasitic or fungal infections. Epstein-Barr virus (EBV) is the causative agent in most cases. In EBV-associated HS, which sometimes has a fatal course, unregulated T-cell reaction or uncontrolled B-cell proliferation may release cytokines. Management of HS consists of early diagnosis, careful screening for, and prompt treatment of, infections and detection and therapy of any underlying disease. Prognosis of infection-associated haemophagocytic syndrome (IAHS) is better than that in other types of secondary HS. Management of cytokine imbalance should be useful to improve the outcome and reduce the mortality rate in these cases.

Hemophagocytic lymphohistiocytosis

Hemophagocytic lymphohistiocytosis (HLH) is a rare condition in children associated with immunodeficiency, life threatening infections and malignancy. Infection associated hemophagocytosis responds well to appropriate antimicrobioal therapy and rarely to steroids when the infective agent is suspected to be of viral origin.

Polymerase chain reaction amplification of archival material for Epstein-Barr virus, cytomegalovirus, human herpesvirus 6, and parvovirus B19 in children with bone marrow hemophagocytosis

Bone marrow hemophagocytosis may occur as an incidental finding, or it may be a manifestation of a systemic and potentially lethal disorder. When systemic, the proliferation is termed hemophagocytic lymphohistiocytosis (HLH), a clinicopathologic entity characterized by a widespread proliferation of benign hemophagocytic histiocytes, fever, pancytopenia, deranged liver function, and frequently coagulopathy and hepatosplenomegaly. A variety of infectious agents, including Epstein-Barr virus (EBV), cytomegalovirus (CMV), human herpesvirus 6 (HHV6), and parvovirus B19 (PVB19), have been associated with HLH, but the relative frequency of each using one technique has not been evaluated. In addition, infectious causes of incidental bone marrow hemophagocytosis, not occurring in the setting of HLH, have not been evaluated. Review of bone marrow reports from bone marrow examinations done between December 1986 and June 1997 showed that 20 children aged 2 months to 15 years had bone marrow examinations that indicated hemophagocytosis. Archival materials from 19 patients were successfully retrieved, and DNA was extracted from archived unstained coverslips with subsequent polymerase chain reaction for EBV, CMV, HHV6, and PVB19 genomic DNA. DNA extracted from 16 bone marrow specimens of age-matched children was used as negative controls. Eleven of the 19 patients fulfilled the clinical and pathological criteria for HLH; the remaining eight patients had isolated hemophagocytosis without a systemic presentation. Viral DNA was detected in 8 of 11 patients with HLH but in none of eight patients with isolated hemophagocytosis. EBV was present in five of the bone marrows, followed in frequency by HHV6, CMV, and PVB19. Infection with more than one agent was present in three patients. Only one control patient was positive for HHV6 DNA; the remaining control patients were negative for all viruses. Viral infection, detected by PCR analysis of bone marrow, is a common finding in patients with HLH but not in patients with isolated bone marrow hemophagocytosis. This technique may provide another marker to aid in the diagnosis of HLH and suggests a different cause of hemophagocytosis occurring in patients with and without HLH.

Hemophagocytic syndrome associated with hematological neoplasias

Hemophagocytic syndrome (HPS) is a reactive process that complicates several diseases including hematological neoplasias (HN). It has been suggested that HPS may be a negative prognosis factor for neoplastic diseases. In this retrospective analysis, 13 cases with HPS associated to HN were compared with two age, sex, diagnosis, disease stage and treatment matched controls in order to determine the impact of this syndrome on the survival. Cases with HPS were adult patients with a male:female ratio of 1:1 and their clinical picture was characterized by fever, lymphadenopathy, hepatosplenomegaly, and pancytopenia. Median survival since HN diagnosis was 7 and 48 months for the HPS and control groups, respectively (P = 0.0001). In ten patients who died, median survival after HPS presentation was 1 month. These results suggest that the presence of HPS is a negative prognosis factor in patients with HN. Due to its high mortality rate, an individualized, early, and intensive chemotherapeutic regimen may be required for HN complicated with this syndrome.

[Etiological aspects of reactive hemophagocytoses: retrospective study in 99 patients]

We describe the causes of reactive hemophagocytic process in a retrospective study including 99 patients. The main diagnosis were: lymphomas (18 cases), pyogenic bacteria infections (15 cases), herpes virus infections (12 cases), other infections (multiple, parasitic, fungal, mycobacterial, unidentified) (11 cases), acute hepatitis (five cases), systemic lupus erythematosus (three cases). We also found numerous other diseases involving the reticuloendothelial system. The cause remained undetermined in 16 cases. Lymphoma accounted for 64% of the cases in previously healthy patients who had been febrile for more than 10 days at the time of the diagnosis of reactive hemophagocytic process, and for 31% in HIV-positive patients. Lymphomas were rare (5%) in non HIV-positive, immunosuppressed patients. In this setting and in previously healthy patients who had been febrile for less than 10 days, infectious diseases were widely dominant (respectively 60% and 86% of the cases). Those were mainly due to pyogenic bacteria and to herpes virus. A rapidly fatal evolution occurred in some cases of lymphomas-related hemophagocytic process. These data support the choice of aggressive investigations in order to diagnose lymphoma in previously healthy patients presenting with reactive hemophagocytic process who have been febrile for more than 10 days, and in selected HIV-patients. Such a procedure is not recommended in the other cases.

Thrombocytopenia in the sepsis syndrome: role of hemophagocytosis and macrophage colony-stimulating factor

BACKGROUND

Thrombocytopenia is frequently encountered in critically ill patients with the sepsis syndrome, but its mechanisms frequently remain undetermined. Hemophagocytosis has been reported as a cause of thrombocytopenia in various diseases. This prospective study was designed to assess: (1) the incidence of hemophagocytosis in patients suffering from both the sepsis syndrome and unexplained thrombocytopenia, and (2) the circulating level of the macrophage-colony-stimulating factor (M-CSF) according to the presence or absence of hemophagocytosis.

METHODS

Fifty consecutive patients diagnosed with both the sepsis syndrome and thrombocytopenia of undetermined origin were studied. Hemophagocytosis was diagnosed based on microscopical examination of sternal bone marrow aspiration by two independent observers. Serum M-CSF concentrations were measured in each patient and compared with levels of a normal population (n = 59). Causes and severity of sepsis syndromes as well as serum M-CSF levels were compared between patients with and without hemophagocytosis.

RESULTS

Hemophagocytosis was diagnosed in 32 patients (64%). Mean serum M-CSF levels were increased in patients when compared with normal subjects (539 +/- 141 versus 208 +/- 82 IU/mL: P < 0.001), and higher in patients with than without hemophagocytosis (580 +/- 145 versus 457 +/- 89 IU/mL: P = 0.01). Multiorgan dysfunction and infection were independent risk factors of hemophagocytosis (odds ratio = 31.3 and 6.8, 95% confidence interval (CI) = 5.4 to 177.6 and 1.0 to 47.4, P <0.0001 and P = 0.03, respectively).

CONCLUSIONS

Hemophagocytosis is a frequent cause of unexplained thrombocytopenia in patients with severe sepsis syndrome. Our results suggest that M-CSF is overproduced in the sepsis syndrome, particularly when hemophagocytosis is present. The role of M-CSF in the initiation and development of hemophagocytosis remains to be determined.

Haemophagocytic lymphohistiocytosis: experience at two U.K. centres

Haemophagocytic lymphohistiocytosis (HLH) is a rare disorder of inappropriate macrophage activation. Both familial and sporadic forms, which may be infection-associated, are recognized. Between 1985 and 1991 we treated 23 cases of HLH (12 male, 11 female). There were eight familial cases, defined by a previously affected sibling and/or history of consanguinity, age 3 d to 15 months at presentation. The age of the remaining 15 cases varied from 1 month to 9.5 years. A potential viral trigger was identified in four cases (EBV, two; parvovirus B19, one; echovirus II, one) including one familial case. Six of eight (75%) patients who received supportive care alone, including all four familial cases, died within 6 months of presentation. Both long-term survivors in this group presented at an older age (7.5 and 8 years) and had proven or suspected virus-associated HLH. 15 patients were treated with etoposide (150-250 mg/m2 days 1-3 every 21 d) and methylprednisolone; 10 patients received intrathecal methotrexate in addition. In nine (60%) of these cases a complete (six) or partial (three) response was achieved, though one child suffered a fatal 'tumour lysis' syndrome. Overall mortality in the treated group was 66.6%, being highest (75%) in patients under 2 years at presentation compared to 33% in those over 2 years. Two of three familial and one of five sporadic cases relapsed and died 3 d to 20 months from diagnosis. Only one familial case survives at follow-up of 11 months. Of the five remaining survivors, two received allogeneic bone marrow transplantation (one matched related, one haploidentical) and are alive at 11 and 29 months. Three cases aged 2.5, 7.5 and 9.5 years remain in remission at 11, 20 and 25 months respectively. The high mortality of HLH supports a role for allogeneic BMT in selected cases, particularly those with a familial basis or under 2 years at presentation.

Miliary tuberculosis with splenic rupture: a fatal case with hemophagocytic syndrome and possible association with long standing sarcoidosis

A fatal case of miliary tuberculosis complicated by splenic rupture and reactive hemophagocytic syndrome is presented. A 42 yr old Indian patient with a 7 yr history of sarcoidosis developed miliary tuberculosis and hemophagocytic syndrome after steroid therapy. A ruptured enlarged spleen with hemoperitoneum was detected at autopsy. This case highlights the need to consider the occurrence of tuberculosis in patients with sarcoidosis, especially after steroid therapy. Yellow bodies (Hamazaki-Wesenberg bodies), commonly but not exclusively found in sarcoidosis, were identified within the retroperitoneal lymph nodes in this case.

Intravenously administered immune globulin for the treatment of infection-associated hemophagocytic syndrome

Infection-associated hemophagocytic syndrome is an unusual disease with a high mortality rate. A variety of treatment modalities have been used with limited success. We report three patients with infection-associated hemophagocytic syndrome successfully treated with intravenously administered immune globulin.

Pancytopaenia associated with disseminated tuberculosis, reactive histiocytic haemophagocytic syndrome and tuberculous hypersplenism

A 38-year-old black male is reported with a rare combination of disseminated tuberculosis together with a reactive histiocytic haemophagocytic syndrome and tuberculosis hypersplenism. Tuberculosis and histiocytic haemophagocytosis were diagnosed on bone marrow examination. The pancytopaenia and splenomegaly which were present on admission did not resolve despite adequate anti-tuberculosis chemotherapy. Prior to splenectomy the patient continued to have a marked thrombocytopenia which resulted in recurrent bouts of epistaxis; splenectomy together with tuberculostatic therapy was curative for the condition. The patient remains well with normal blood counts 1 year later.

Miliary tuberculosis with acute respiratory failure and histiocytic hemophagocytosis. Successful treatment with extracorporeal lung support and epipodophyllotoxin VP 16-213

A 14-year-old girl with high fever, dyspnea and bilateral miliary nodules on chest X-ray, developed a rapidly progressive respiratory failure associated with histiocytic hemophagocytosis. Histologic examination of bone marrow biopsy revealed tuberculous granulomas with caseating necrosis. We report a pediatric case in which treatment with extracorporeal lung support and epipodophyllotoxin VP 16-213 was successful.

Peripheral T-cell lymphoma presenting as hemophagocytic syndrome

Three patients with peripheral T-cell lymphoma presenting with pyrexia, wasting, hepatosplenomegaly and pancytopenia in the absence of myelophthisic lymphomatous involvement are reported. Early in the course of the disease when there was no significant lymphadenopathy, these cases created enormous diagnostic confusion. Although the clinical features were suggestive of malignant histiocytosis (MH), marrow findings showed phagocytic histiocytes which did not appear atypical, and the criteria for diagnosis of MH could not be satisfied. Lymph node enlargement was detected only after 14, 5, and 8 weeks from the onset of symptoms, and the diagnosis of T-lymphoma was then made on lymph node biopsies. Treatment with multiple agent chemotherapy was attempted. Two patients died 3 days and 11 weeks after treatment was started and the third was lost to follow-up. In contrast with most of the cases reported in the literature, our cases show that a reactive hemophagocytic syndrome can be an early and prominent manifestation of an underlying T-cell lymphoma. Differentiation from other causes of hemophagocytic syndrome can be difficult and lack of histological proof of malignancy in the initial stage often delays definitive diagnosis and treatment.

Histiocytic hemophagocytosis in the bone marrow in children with sepsis and disseminated intravascular coagulation

Two children with systemic E. coli and candidial infections developed disseminated intravascular coagulation (DIC). Bone marrow examination in both cases showed histiocytic hemophagocytosis, consistent with the diagnosis of the hemophagocytic syndrome. Histiocytic hemophagocytosis in the bone marrow, one of the markers of the activated mononuclear phagocyte system, might be common in patients with severe sepsis and DIC, especially in immunodeficiency.

Histiocytic cytophagic panniculitis

Nineteen cases of histiocytic cytophagic panniculitis from our institution and from the literature were reviewed for their clinical and histopathologic features. All patients had cutaneous involvement consisting of cutaneous nodules and plaques that occasionally were ecchymotic and ulcerated and were characterized by infiltration of the subcutaneous tissue by large, benign histiocytes with cytophagic features. Thirteen of the patients had died (nine with hemorrhagic complications), four patients had a benign course with remission of the disease, and two patients responded to aggressive polychemotherapy. Immunohistochemical studies of paraffin-embedded tissue, performed in five cases, revealed a large number of infiltrating T cells in the subcutaneous inflammatory lesions.

Reactive histiocytic hyperplasia with hemophagocytosis in hematopoietic organs: a reevaluation of the benign hemophagocytic proliferations

Histiocytic hyperplasia with hemophagocytosis (HHH) is a relatively rare condition that has often been mistaken for a neoplastic disorder, but which most frequently represents a secondary reactive phenomenon whose associated risk factors have not yet been clearly defined. Histologic sections of hematopoietic organs (bone marrow, lymph nodes, and spleen) from 230 consecutive adults autopsies were reviewed to identify cases of HHH and to correlate them with clinical and autopsy findings. Moderate to severe HHH was present in the bone marrow in 102 and 230 cases, in the lymph nodes in 79 of 191 cases, and in the spleens of 16 of 209 cases. Recent blood transfusions, bacterial sepsis, major surgery, underlying disseminated malignancy, Candida sepsis, and viral infection were studied as potential risk factors. Both crude and adjusted analyses indicated a strong association between recent blood transfusions and the development of HHH in the bone marrow (P less than .0001). There was a marked dose-response relationship between number of units and the risk of HHH, with an adjusted risk ratio of 59.9 for five or more units compared with no transfusions. Bacterial sepsis was also associated with a significantly increased risk of HHH in the bone marrow in both the crude and adjusted analyses (adjusted risk ratio, 4.10; P = .0002). Major surgery and viral infection were only marginally associated with an increased risk for HHH (P = .03 and P = 0.06, respectively), and underlying disseminated malignancy and Candida sepsis did not appear to contribute any risk. Analyses for HHH in lymph nodes and spleen were similar to analysis for the bone marrow, but were somewhat less marked. The results of this study suggest that reactive HHH in hematopoietic organs may be far more common than has previously been acknowledged, and is most often multifactorial rather than related to a single underlying condition, with transfusions and bacterial sepsis constituting the most significant risk factors. Therefore, reactive HHH may represent a frequent secondary phenomenon in critically ill patients undergoing transfusions and should not be mistaken for an ominous sign or for the development of a superimposed malignancy.

Weber-Christian panniculitis with systemic cytophagic histiocytosis

A 49-year-old woman suffered from Weber-Christian panniculitis with a typically periodic course. Subsequently, the attacks of the disease developed to a severe state: high fever, endotoxinemia, pancytopenia, and clotting disorder, in addition to the cutaneous manifestations. One and a half years after the outbreak of the disease the patient died in a septic shock. At autopsy all three stages of Weber-Christian panniculitis were found. In addition, an immense proliferation of benign cytophagic histiocytes could be observed in the bone marrow, spleen, lymph nodes and, less distinctly, in the fatty and interstitial tissues of the visceral organs. As a nosologic entity, the Weber-Christian disease is frequently questioned. Some authors consider the lobular, histiocytic, cytophagic panniculitis a unique syndrome. On the other hand, it must be emphasized that benign, cytophagic histiocytosis may exist associated with infections or may accompany different diseases. Furthermore, the Weber-Christian panniculitis is clinically and morphologically well defined.