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Kusontammarat P, Choed-Amphai C, Sathitsamitphong L, Sontichai W, Natesirinilkul R, Charoenkwan P. Predicting relapsed/refractory disease in childhood hemophagocytic lymphohistiocytosis based on clinical features at diagnosis: A 13-year single-institute retrospective study in Thailand. Ann Hematol 2024:10.1007/s00277-024-05879-6. [PMID: 38977464 DOI: 10.1007/s00277-024-05879-6] [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: 03/30/2024] [Accepted: 07/03/2024] [Indexed: 07/10/2024]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening disease. Relapsed/refractory disease is the main cause of death. This study aims to determine the prognostic indicators for relapsed/refractory disease in childhood HLH (R/R HLH). Infants and children under 18 years of age who were diagnosed with HLH according to HLH-2004 criteria, MAS-HLH criteria for rheumatologic diseases, or H-score undergoing treatment in Chiang Mai University hospital between 2010 and 2022 were included. Demographic data, clinical characteristics, and laboratory parameters were retrospectively reviewed. Out of 86 childhood HLH cases, 30 patients (34.9%) experienced R/R HLH. All patients with primary HLH developed R/R HLH. The most common form of secondary HLH was infection-associated hemophagocytic syndrome (IAHS), comprising 43 cases. Of these, 37.2% had relapsed or refractory disease. Univariable analysis identified several potential risk factors for R/R HLH, including younger age, severe disease status, higher HLH-2004 criteria scores, higher H-scores, overt DIC, higher pSOFA scores, and increased levels of aspartate aminotransferase, total bilirubin, and direct bilirubin. Multivariable logistic regression analysis revealed that a pSOFA score of ≥ 8 and age < 3 years were independent risk factors for R/R HLH, with adjusted odds ratios of 6.35 (95% confidence interval [CI], 1.18-34.19; P = 0.032) and 3.62 (95% CI, 1.04-12.63; P = 0.044), respectively. Children with HLH who have a pSOFA score of ≥ 8, or are younger than 3 years, are at a higher risk of relapsed or refractory disease. Further evaluation of management strategies in this context is warranted.
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Affiliation(s)
- Pattranan Kusontammarat
- Department of Pediatrics, Faculty of Medicine, Chiang Mai University, 110 Intawaroros Road, Sriphum, Muang, Chiang Mai, 50200, Thailand
| | - Chane Choed-Amphai
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand.
| | - Lalita Sathitsamitphong
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Watchareewan Sontichai
- Division of Rheumatology, Department of Pediatrics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Rungrote Natesirinilkul
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Pimlak Charoenkwan
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
- Thalassemia and Hematology Center, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
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Kosałka-Węgiel J, Dziedzic R, Siwiec-Koźlik A, Spałkowska M, Milewski M, Żuk-Kuwik J, Zaręba L, Bazan-Socha S, Korkosz M. Clinical and laboratory characteristics of early-onset and delayed-onset lupus nephritis patients: A single-center retrospective study. Rheumatol Int 2024; 44:1283-1294. [PMID: 38546745 PMCID: PMC11178551 DOI: 10.1007/s00296-024-05579-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Accepted: 03/10/2024] [Indexed: 06/15/2024]
Abstract
BACKGROUND Lupus nephritis (LN) manifests systemic lupus erythematosus (SLE) and is characterized by various clinical and laboratory features. This study aimed to comprehensively evaluate the characteristics of LN patients according to the time of LN diagnosis: early-onset (LN diagnosed within one year from SLE diagnosis) vs. delayed-onset (LN diagnosed more than one year after SLE diagnosis). METHODS We conducted a retrospective analysis of medical records from all SLE patients treated at the University Hospital in Kraków, Poland, from 2012 to 2022. We collected data on demographic, clinical, and laboratory characteristics, including histological findings, treatment modalities, and disease outcomes. Statistical analyses were performed to identify factors impacting LN development and prognosis. RESULTS Among 331 LN patients, early-onset was diagnosed in 207 (62.54%) and delayed-onset was documented in 122 cases (36.86%). In 2 (0.6%) LN cases, the time of first kidney manifestation in the SLE course was unknown. Delayed-onset LN had a higher female-to-male ratio and younger age at SLE diagnosis. This group was associated with more severe clinical manifestations. In turn, studied subgroups did not differ in internist comorbidities, kidney histopathology, and family history regarding autoimmune diseases. Delayed-onset LN exhibited a higher frequency of anti-dsDNA, anti-Smith, anti-Ro, anti-RNP, and anti-cardiolipin IgG autoantibodies. During a 14-year follow-up period, 16 patients died. Mortality rate and causes of death were comparable in both analyzed subgroups. CONCLUSIONS More severe clinical manifestations in delayed-onset LN prompt strict monitoring of non-LN SLE patients to diagnose and treat kidney involvement early. Also, recognizing the higher frequency of autoantibodies such as anti-dsDNA or anti-Smith in delayed-onset LN underscores the potential value of autoantibody profiling as a diagnostic and prognostic tool.
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Affiliation(s)
- Joanna Kosałka-Węgiel
- Department of Rheumatology and Immunology, Jagiellonian University Medical College, Jakubowskiego 2, Kraków, 30-688, Poland.
- Department of Rheumatology, Immunology and Internal Medicine, University Hospital, Jakubowskiego 2, Kraków, 30-688, Poland.
| | - Radosław Dziedzic
- Doctoral School of Medical and Health Sciences, Jagiellonian University Medical College, Św. Łazarza 16, Kraków, 31-530, Poland
| | - Andżelika Siwiec-Koźlik
- Department of Rheumatology, Immunology and Internal Medicine, University Hospital, Jakubowskiego 2, Kraków, 30-688, Poland
| | - Magdalena Spałkowska
- Department of Dermatology, Jagiellonian University Medical College, Botaniczna 3, Kraków, 31-501, Poland
| | - Mamert Milewski
- Department of Rheumatology, Immunology and Internal Medicine, University Hospital, Jakubowskiego 2, Kraków, 30-688, Poland
| | - Joanna Żuk-Kuwik
- Department of Hematology, Jagiellonian University Medical College, Jakubowskiego 2, Kraków, 30-688, Poland
| | - Lech Zaręba
- College of Natural Sciences, Institute of Computer Science, University of Rzeszów, Pigonia 1, Rzeszów, 35-310, Poland
| | - Stanisława Bazan-Socha
- Department of Rheumatology, Immunology and Internal Medicine, University Hospital, Jakubowskiego 2, Kraków, 30-688, Poland
- Department of Internal Medicine, Faculty of Medicine, Jagiellonian University Medical College, Jakubowskiego 2, Kraków, 30-688, Poland
| | - Mariusz Korkosz
- Department of Rheumatology and Immunology, Jagiellonian University Medical College, Jakubowskiego 2, Kraków, 30-688, Poland
- Department of Rheumatology, Immunology and Internal Medicine, University Hospital, Jakubowskiego 2, Kraków, 30-688, Poland
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3
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Huang S, Liu Y, Yan W, Zhang T, Wang P, Zhu M, Zhang X, Zhou P, Fan Z, Yu H. Single center clinical analysis of macrophage activation syndrome complicating juvenile rheumatic diseases. Pediatr Rheumatol Online J 2024; 22:58. [PMID: 38783316 PMCID: PMC11112803 DOI: 10.1186/s12969-024-00991-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2023] [Accepted: 04/25/2024] [Indexed: 05/25/2024] Open
Abstract
BACKGROUND Macrophage activation syndrome (MAS), an example of secondary hemophagocytic lymphohistiocytosis, is a potentially fatal complication of rheumatic diseases. We aimed to study the clinical and laboratory characteristics, treatment schemes, and outcomes of different rheumatic disorders associated with MAS in children. Early warning indicators of MAS have also been investigated to enable clinicians to make a prompt and accurate diagnosis. METHODS Fifty-five patients with rheumatic diseases complicated by MAS were enrolled between January 2017 and December 2022. Clinical and laboratory data were collected before disease onset, at diagnosis, and after treatment with MAS, and data were compared between patients with systemic juvenile idiopathic arthritis (sJIA), Kawasaki disease (KD), and systemic lupus erythematosus (SLE). A random forest model was established to show the importance score of each variable with a significant difference. RESULTS Most (81.8%) instances of MAS occurred during the initial diagnosis of the underlying disease. Compared to the active stage of sJIA, the platelet count, erythrocyte sedimentation rate, and fibrinogen level in sJIA-MAS were significantly decreased, whereas ferritin, ferritin/erythrocyte sedimentation rate, aspartate aminotransferase, alanine aminotransferase, lactate dehydrogenase, and D-dimer levels were significantly increased. Ferritin level, ferritin/erythrocyte sedimentation rate, and platelet count had the greatest predictive value for sJIA-MAS. The level of IL-18 in the sJIA-MAS group was significantly higher than in the active sJIA group, whereas IL-6 levels were significantly lower. Most patients with MAS were treated with methylprednisolone pulse combined with cyclosporine, and no deaths occurred. CONCLUSIONS Thrombocytopenia, ferritin levels, the ferritin/erythrocyte sedimentation rate, and elevated aspartate aminotransferase levels can predict the occurrence of MAS in patients with sJIA. Additionally, our analysis indicates that IL-18 plays an important role in the pathogenesis of MAS in sJIA-MAS.
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Affiliation(s)
- Shuoyin Huang
- Department of Rheumatology and Immunology, Children's Hospital of Nanjing Medical University, Nanjing, 210008, China
| | - Yingying Liu
- Department of Rheumatology and Immunology, Children's Hospital of Nanjing Medical University, Nanjing, 210008, China
| | - Wu Yan
- Department of Child Health Care, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Tonghao Zhang
- Department of Rheumatology and Immunology, Children's Hospital of Nanjing Medical University, Nanjing, 210008, China
| | - Panpan Wang
- Department of Rheumatology and Immunology, Children's Hospital of Nanjing Medical University, Nanjing, 210008, China
| | - Meifang Zhu
- Department of Rheumatology and Immunology, Children's Hospital of Nanjing Medical University, Nanjing, 210008, China
| | - Xiaohua Zhang
- Department of Rheumatology and Immunology, Children's Hospital of Nanjing Medical University, Nanjing, 210008, China
| | - Peng Zhou
- Department of Rheumatology and Immunology, Children's Hospital of Nanjing Medical University, Nanjing, 210008, China
| | - Zhidan Fan
- Department of Rheumatology and Immunology, Children's Hospital of Nanjing Medical University, Nanjing, 210008, China.
| | - Haiguo Yu
- Department of Rheumatology and Immunology, Children's Hospital of Nanjing Medical University, Nanjing, 210008, China.
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Yahia Elhassan MA, Hussain Idres RM, Mohamed Elhassan BMS, Banaga Siddiq NS, Osman Mohammed RA, Mahmmoud Fadelallah Eljack M, Mustafa GE, Hemmeda L, Abbasher Hussien Mohamed Ahmed K. Macrophage activation syndrome in a Sudanese child: a case report from Sudan. Ann Med Surg (Lond) 2024; 86:3047-3051. [PMID: 38694344 PMCID: PMC11060311 DOI: 10.1097/ms9.0000000000001900] [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: 12/08/2023] [Accepted: 02/25/2024] [Indexed: 05/04/2024] Open
Abstract
Introduction and importance Macrophage activation syndrome (MAS) is a severe form of hemophagocytic lymphohistiocytosis that is frequently associated with either a flare-up of rheumatologic diseases, or infection and is characterized by intermittent fever, organomegaly, and multisystem dysfunction. Early diagnosis and treatment are crucial for outcome improvement. Case presentation The authors present a 9-year-old male with systemic onset juvenile idiopathic arthritis who presented with fever, vomiting, and nose bleeding, as well as being jaundiced, and having hepatomegaly and ascites. Pancytopenia, hepatic dysfunction, and elevated ferritin levels were discovered, along with negative virological and immunological tests. He was given broad-spectrum antibiotics, and a high-dose steroid showed a good response, and he was discharged about a week later. Clinical discussion It is hypothesized that decreased natural killer cells' function could lead to the inability to clear the infection, and subsequent lymphocytes-induced macrophages activation. Despite being beneficial in this case, steroids led to no improvement in other similar cases. Conclusion MAS is a real life-threatening complication for patients with systemic Juvenile idiopathic arthritis (sJIA), and early diagnosis and prompt initial treatment can both offer a favourable result against such syndrome.
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Abdelfattah AH, Macpherson A, Javed F. Macrophage Activation Syndrome Presents as Initial Manifestation of Lupus in an Adult Female. Cureus 2024; 16:e60567. [PMID: 38894758 PMCID: PMC11184542 DOI: 10.7759/cureus.60567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/18/2024] [Indexed: 06/21/2024] Open
Abstract
Systemic lupus erythematosus (SLE) is an autoimmune disease characterized by the immune system erroneously attacking healthy tissues and organs. SLE has a wide variety of clinical presentations. The signs and symptoms of SLE are very well-known, though rare presentations could occur that require early clinical attention. Macrophage activation syndrome (MAS) is a severe and life-threatening condition in which the immune system becomes overactive, leading to the excessive stimulation and proliferation of immune cells. MAS can occur as a primary immune disorder, which is not very common. It can also happen secondary to a wide variety of pathological conditions, which include infections, malignancies, autoimmune, and rheumatologic disorders. In rare cases, SLE can present with overlapping features of MAS, further complicating the clinical picture, and may require specialized management. Early recognition and intervention of this overlap are essential for improving outcomes, as delayed diagnosis and treatment can lead to significant morbidity and mortality. Here, we present a case of a young adult female who was diagnosed with SLE with the initial presentation of MAS in the form of fever, splenomegaly, cytopenia, and hemophagocytosis.
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Affiliation(s)
- Ahmed H Abdelfattah
- Internal Medicine/Hospital Medicine, University of Kentucky College of Medicine, Lexington, USA
| | - Alexandra Macpherson
- Internal Medicine/Hospital Medicine, University of Kentucky College of Medicine, Lexington, USA
| | - Faiza Javed
- Internal Medicine/Hospital Medicine, University of Kentucky College of Medicine, Lexington, USA
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Kalashnikova E, Isupova E, Gaidar E, Sorokina L, Kaneva M, Masalova V, Dubko M, Kornishina T, Lubimova N, Kuchinskaya E, Chikova I, Raupov R, Kalashnikova O, Kostik M. BCD020 rituximab bioanalog compared to standard treatment in juvenile systemic lupus erythematosus: The data of 12 months case-control study. World J Clin Pediatr 2024; 13:89049. [PMID: 38596443 PMCID: PMC11000064 DOI: 10.5409/wjcp.v13.i1.89049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Revised: 02/02/2024] [Accepted: 01/30/2024] [Indexed: 03/06/2024] Open
Abstract
BACKGROUND Systemic lupus erythematosus (SLE) is the most frequent and serious systemic connective tissue disease. Nowadays there is no clear guidance on its treatment in childhood. There are a lot of negative effects of standard-of-care treatment (SOCT), including steroid toxicity. Rituximab (RTX) is the biological B-lymphocyte-depleting agent suggested as a basic therapy in pediatric SLE. AIM To compare the benefits of RTX above SOCT. METHODS The data from case histories of 79 children from the Saint-Petersburg State Pediatric Medical University from 2012 to 2022 years, were analyzed. The diagnosis of SLE was established with SLICC criteria. We compared the outcomes of treatment of SLE in children treated with and without RTX. Laboratory data, doses of glucocorticosteroids, disease activity measured with SELENA-SLEDAI, and organ damage were assessed at the time of initiation of therapy and one year later. RESULTS Patients, treated with RTX initially had a higher degree of disease activity with prevalence of central nervous system and kidney involvement, compared to patients with SOCT. One year later the disease characteristics became similar between groups with a more marked reduction of disease activity (SELENA-SLEDAI activity index) in the children who received RTX [-19 points (17; 23) since baseline] compared to children with SOCT [-10 (5; 15.5) points since baseline, P = 0.001], the number of patients with active lupus nephritis, and daily proteinuria. During RTX therapy, infectious diseases had three patients; one patient developed a bi-cytopenia. CONCLUSION RTX can be considered as the option in the treatment of severe forms of SLE, due to its ability to arrest disease activity compared to SOCT.
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Affiliation(s)
- Elvira Kalashnikova
- Hospital Pediatry Department, Saint-Petersburg State Pediatric Medical University, Saint-Petersburg 194100, Russia
| | - Eugenia Isupova
- Hospital Pediatry Department, Saint-Petersburg State Pediatric Medical University, Saint-Petersburg 194100, Russia
| | - Ekaterina Gaidar
- Hospital Pediatry Department, Saint-Petersburg State Pediatric Medical University, Saint-Petersburg 194100, Russia
| | - Lyubov Sorokina
- Hospital Pediatry Department, Saint-Petersburg State Pediatric Medical University, Saint-Petersburg 194100, Russia
| | - Maria Kaneva
- Hospital Pediatry Department, Saint-Petersburg State Pediatric Medical University, Saint-Petersburg 194100, Russia
| | - Vera Masalova
- Hospital Pediatry Department, Saint-Petersburg State Pediatric Medical University, Saint-Petersburg 194100, Russia
| | - Margarita Dubko
- Hospital Pediatry Department, Saint-Petersburg State Pediatric Medical University, Saint-Petersburg 194100, Russia
| | - Tatiana Kornishina
- Hospital Pediatry Department, Saint-Petersburg State Pediatric Medical University, Saint-Petersburg 194100, Russia
| | - Natalia Lubimova
- Research Laboratory of Autoimmune and Autoinflammatory Diseases, Almazov National Medical Research Centre, Saint Petersburg 197341, Russia
| | - Ekaterina Kuchinskaya
- Research Laboratory of Autoimmune and Autoinflammatory Diseases, Almazov National Medical Research Centre, Saint Petersburg 197341, Russia
| | - Irina Chikova
- Hospital Pediatry Department, Saint-Petersburg State Pediatric Medical University, Saint-Petersburg 194100, Russia
| | - Rinat Raupov
- Hospital Pediatry Department, Saint-Petersburg State Pediatric Medical University, Saint-Petersburg 194100, Russia
- Department of Rheumatology, Turner National Medical Research Center for Сhildren’s Orthopedics and Trauma Surgery, Saint-Petetrsburg 197136, Russia
| | - Olga Kalashnikova
- Hospital Pediatry Department, Saint-Petersburg State Pediatric Medical University, Saint-Petersburg 194100, Russia
| | - Mikhail Kostik
- Hospital Pediatry Department, Saint-Petersburg State Pediatric Medical University, Saint-Petersburg 194100, Russia
- Research Laboratory of Autoimmune and Autoinflammatory Diseases, Almazov National Medical Research Centre, Saint Petersburg 197341, Russia
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Nguyen TTT, Kim YT, Jeong G, Jin M. Immunopathology of and potential therapeutics for secondary hemophagocytic lymphohistiocytosis/macrophage activation syndrome: a translational perspective. Exp Mol Med 2024; 56:559-569. [PMID: 38448692 PMCID: PMC10984945 DOI: 10.1038/s12276-024-01182-6] [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: 07/15/2023] [Revised: 11/21/2023] [Accepted: 12/19/2023] [Indexed: 03/08/2024] Open
Abstract
Secondary hemophagocytic lymphohistiocytosis/macrophage activation syndrome (sHLH/MAS) is a life-threatening immune disorder triggered by rheumatic disease, infections, malignancies, or medications. Characterized by the presence of hemophagocytic macrophages and a fulminant cytokine storm, sHLH/MAS leads to hyperferritinemia and multiorgan failure and rapidly progresses to death. The high mortality rate and the lack of specific treatments necessitate the development of a new drug. However, the complex and largely unknown immunopathologic mechanisms of sHLH/MAS, which involve dysfunction of various immune cells, diverse etiologies, and different clinical contexts make this effort challenging. This review introduces the terminology, diagnosis, and clinical features of sHLH/MAS. From a translational perspective, this review focuses on the immunopathological mechanisms linked to various etiologies, emphasizing potential drug targets, including key molecules and signaling pathways. We also discuss immunomodulatory biologics, existing drugs under clinical evaluation, and novel therapies in clinical trials. This systematic review aims to provide insights and highlight opportunities for the development of novel sHLH/MAS therapeutics.
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Affiliation(s)
- Tram T T Nguyen
- Department of Health Sciences and Technology, GAIHST, Gachon University, Incheon, Republic of Korea
| | - Yoon Tae Kim
- Department of Health Sciences and Technology, GAIHST, Gachon University, Incheon, Republic of Korea
| | - Geunyeol Jeong
- Department of Health Sciences and Technology, GAIHST, Gachon University, Incheon, Republic of Korea
| | - Mirim Jin
- Department of Health Sciences and Technology, GAIHST, Gachon University, Incheon, Republic of Korea.
- Lee Gil Ya Cancer and Diabetes Institute, Gachon University, Incheon, Republic of Korea.
- Department of Microbiology, College of Medicine, Gachon University, Incheon, Republic of Korea.
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Yu JY, Kim TH, Kim YJ, Kang HM, Yoo IH, Rhim JW, Lee SY, Jeong DC. Macrophage activation syndrome in neonatal lupus presenting with fever and rash. JOURNAL OF RHEUMATIC DISEASES 2024; 31:49-53. [PMID: 38130956 PMCID: PMC10730804 DOI: 10.4078/jrd.2023.0039] [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: 01/01/2020] [Revised: 01/01/2020] [Accepted: 01/01/2020] [Indexed: 12/23/2023]
Abstract
Neonatal lupus can occur in infants born to mother with autoimmune disorders through transplacental auto-antibodies. Clinical manifestations in neonatal lupus include cutaneous lesions and hematologic or hepatobiliary findings resembling those seen in systemic lupus erythematosus. In autoimmune state, macrophage activation syndrome (MAS) represent a critical and potentially fatal complication that can result in mortality if not immediately identified and managed with the appropriate care. Here we present a 33-day-old girl diagnosed with neonatal lupus and serious MAS. She was delivered by a primipara mother who did not exhibit any autoimmune symptoms. The patient visited the hospital due to fever and pancytopenia. Laboratory data were compatible with MAS, including pancytopenia, high level of ferritin, soluble interleukin-2, and decreased natural killer cell activity. In addition, autoimmune study showed positive results for anti-nuclear antibody (ANA), anti-Sjogren syndrome antigen A (SSA), and SSB, The autoimmune study for mother also showed positive results for ANA, anti-SSA, and SSB. The patient recovered after she received high dose steroid and supportive care. Our case indicates that neonatal lupus should be taken into consideration when fever, erythematous skin rash, and pancytopenia are observed in infants, even if their mothers have no prior history of autoimmune conditions.
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Affiliation(s)
- Ji Yoon Yu
- Department of Pediatrics, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Tae Hwan Kim
- Department of Pediatrics, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Ye Ji Kim
- Department of Pediatrics, College of Medicine, The Catholic University of Korea, Seoul, Korea
- Vaccine Bio Research Institute, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hyun Mi Kang
- Department of Pediatrics, College of Medicine, The Catholic University of Korea, Seoul, Korea
- Vaccine Bio Research Institute, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - In Hyuk Yoo
- Department of Pediatrics, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jung Woo Rhim
- Department of Pediatrics, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Soo Young Lee
- Department of Pediatrics, College of Medicine, The Catholic University of Korea, Seoul, Korea
- Vaccine Bio Research Institute, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Dae Chul Jeong
- Department of Pediatrics, College of Medicine, The Catholic University of Korea, Seoul, Korea
- Vaccine Bio Research Institute, College of Medicine, The Catholic University of Korea, Seoul, Korea
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Velayutham B, Padhi S, Devi S, Patra S, Panigrahi C, Ramasubbu MK, Kumar R, Raheman S. Immunohistochemical expression of perforin in adult systemic lupus erythematosus associated macrophage activation syndrome: Clinicohematological correlation and literature review. Lupus 2024; 33:26-39. [PMID: 38069452 DOI: 10.1177/09612033231221414] [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] [Indexed: 12/21/2023]
Abstract
OBJECTIVE To study the bone marrow (BM) immunohistomorphological characteristics in adult systemic lupus erythematosus (SLE) associated macrophage activation syndrome (SLE-MAS). MATERIALS AND METHODS Immunohistochemical (IHC) expression of CD3, CD8, perforin (PFN), and CD163 was studied on BM trephine biopsies from 30 cytopenic adult SLE cases (male: female = 1:5, age; 24 years, range; 19-32) and compared them with ten age matched controls. Clinicopathological parameters were compared among the cases likely (L) or unlikely (U) to have MAS using probability scoring criteria. The best cut off laboratory parameters to discriminate between the two were obtained through receiver operator curve (ROC) analysis. RESULTS MAS occurred in 12/30 (40%) cases and was more commonly associated with prior immunosuppressive therapy (p = .07), ≥ 3 system involvement (p = .09), lower fibrinogen (p < .01), increased triglyceride (p = .002), increased BM hemophagocytosis (p = .002), and higher MAS score [185 (176-203) vs. 105 (77-119), p < .01] than MAS-U subgroup. Although PFN+CD8+ T lymphocytes significantly decreased among cases than controls (p < .05), it was comparable between MAS-L and MAS-U subgroups. Fibrinogen (< 2.4 g/L, AUC; 0.93, p < .01), hemophagocytosis score (> 1.5, AUC; 0.71, p = .03), and an MAS probability score of ≥ 164 (AUC; 1, p < .01) discriminated MAS from those without MAS. CONCLUSION We noted a decrease in perforin mediated CD8 + T cell cytotoxicity in SLE. Immunohistochemical demonstration of the same along with histiocytic hemophagocytosis on BM biopsy may be useful adjunct in early diagnosis and management of MAS in SLE.
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Affiliation(s)
- Bakialakshmi Velayutham
- Department of Pathology with Laboratory Medicine, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
| | - Somanath Padhi
- Department of Pathology with Laboratory Medicine, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
| | - Sujata Devi
- Department of General Medicine, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
| | - Susama Patra
- Department of Pathology with Laboratory Medicine, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
| | - Chinmayee Panigrahi
- Department of Pathology with Laboratory Medicine, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
| | - Mathan Kumar Ramasubbu
- Department of Pharmacology, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
| | - Rajesh Kumar
- Department of General Medicine, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
- Department of General Medicine, All India Institute of Medical Sciences, Deoghar, Jharkhand, India
| | - Samiur Raheman
- Department of Pathology with Laboratory Medicine, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
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Hiyama T, Kurasawa K, Hasegawa A, Miyao T, Tanaka A, Arai S, Arima M, Maezawa R. Differences and similarities in cytokine profiles of macrophage activation syndrome in systemic lupus erythematosus and adult-onset Still's disease. Clin Exp Med 2023; 23:3407-3416. [PMID: 36611087 DOI: 10.1007/s10238-023-00988-4] [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: 12/12/2022] [Accepted: 01/03/2023] [Indexed: 01/08/2023]
Abstract
To clarify the differences and similarities in the cytokine profiles of macrophage activating syndrome (MAS) between systemic lupus erythematosus (SLE) and adult-onset Still's disease (AOSD). The study participants included 9 patients with MAS-SLE, 22 with non-MAS-SLE, 9 with MAS-AOSD, and 13 with non-MAS-AOSD. Serum cytokine levels were measured using a multiplex bead assay. Cytokine levels were compared between patients with SLE and AOSD with/without MAS. Moreover, cytokine patterns were examined using principal component analysis (PCA) and cluster analysis. IL-6, IL-8, IL-18, and TNF-α levels were elevated in patients with SLE and AOSD. IFN-α levels were elevated in SLE, whereas IL-1β and IL-18 levels were elevated in AOSD. In SLE, IFN-α and IL-10 levels were higher in MAS than in non-MAS and controls. PCA revealed distinctive cytokine patterns in SLE and AOSD, SLE with IFN-α and IP-10, AOSD with IL-1β, IL-6, and IL-18, and enhanced cytokine production in MAS. PCA and cluster analysis showed no differences in cytokine patterns between the MAS and non-MAS groups. However, serum ferritin levels were correlated with IFN-α levels in SLE. Cytokine profiles differed between SLE and AOSD but not between MAS and non-MAS. MAS is induced by the enhancement of underlying cytokine abnormalities rather than by MAS-specific cytokine profiles. Type I IFN may be involved in MAS development in patients with SLE.
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Affiliation(s)
- Tomoka Hiyama
- Department of Rheumatology, Dokkyo Medical University, Kita-Kobayashi 880, Mibu, Tochigi, 321-0293, Japan
| | - Kazuhiro Kurasawa
- Department of Rheumatology, Dokkyo Medical University, Kita-Kobayashi 880, Mibu, Tochigi, 321-0293, Japan.
| | - Anna Hasegawa
- Department of Rheumatology, Dokkyo Medical University, Kita-Kobayashi 880, Mibu, Tochigi, 321-0293, Japan
| | - Tomoyuki Miyao
- Department of Rheumatology, Dokkyo Medical University, Kita-Kobayashi 880, Mibu, Tochigi, 321-0293, Japan
| | - Ayae Tanaka
- Department of Rheumatology, Dokkyo Medical University, Kita-Kobayashi 880, Mibu, Tochigi, 321-0293, Japan
| | - Satoko Arai
- Department of Rheumatology, Dokkyo Medical University, Kita-Kobayashi 880, Mibu, Tochigi, 321-0293, Japan
| | - Masafumi Arima
- Department of Rheumatology, Dokkyo Medical University, Kita-Kobayashi 880, Mibu, Tochigi, 321-0293, Japan
| | - Reika Maezawa
- Department of Rheumatology, Dokkyo Medical University, Kita-Kobayashi 880, Mibu, Tochigi, 321-0293, Japan
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Hajji M, Barbouch S, Kaaroud H, Ben Abdelghani K, Ben Hamida F, Harzallah A, Abderrahim E. Uncovering the Spectrum of Hemophagocytic Lymphohistiocytosis: A Nephrology Department's Analysis of 14 Cases. CLINICAL MEDICINE INSIGHTS-CASE REPORTS 2023; 16:11795476231210137. [PMID: 37920369 PMCID: PMC10619340 DOI: 10.1177/11795476231210137] [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: 05/08/2023] [Revised: 10/10/2023] [Indexed: 11/04/2023]
Abstract
Introduction Hemophagocytic lymphohistiocytosis (HLH) is a disease of multi-organ dysfunction due to excessive immune activation causing widespread inflammation and tissue destruction. It is a severe condition associated with high morbidity and mortality. Early identification is crucial for prompt treatment. The objective of this case series is to underscore the intricacy of managing HLH in individuals with renal dysfunction. Methods This is a retrospective study of patients diagnosed with HLH in a nephrology department over a period of 30 years. We retrospectively reviewed the medical files by applying the Revised HLH-2004 criteria. Results Among the 14 female patients included, the mean age was 45.2 years (range 23-78). Nine patients presented with sudden onset of fever and chills. Physical examination revealed purpura in 3 cases, hepatomegaly and splenomegaly in 6 and 5 cases respectively, and peripheral lymphadenopathy in 1 case. Hemorrhagic complications were observed in 5 cases, hypertriglyceridemia in 9 cases, and hyperferritinemia in all cases. Hypothyroidism was observed in all cases, and impaired renal function was detected in 11 of them, with 5 experiencing it as a result of lupus nephritis, and 1 case attributed to pre-eclampsia. Hemophagocytosis was confirmed through sternal puncture in 11 cases. Treatment involved etiological therapy with corticosteroids and immunosuppressants and/or anti-infectives. Intravenous immunoglobulins were administered in 6 cases, while 2 cases required coagulation factor transfusions. Unfortunately, 9 patients did not survive. Conclusion The study highlights the need for increased awareness and prompt recognition of HLH, particularly in patients with associated renal complications.
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Affiliation(s)
- Meriam Hajji
- Department of Medecine A, Charles Nicolle Hospital, Tunis, Tunisia
- Laboratory of Nephropathology LR00SP01, Tunis, Tunisia
- Faculty of Medicine of Tunisia, Tunis University El Manar, Tunis, Tunisia
| | - Samia Barbouch
- Department of Medecine A, Charles Nicolle Hospital, Tunis, Tunisia
- Laboratory of Nephropathology LR00SP01, Tunis, Tunisia
- Faculty of Medicine of Tunisia, Tunis University El Manar, Tunis, Tunisia
| | - Hayet Kaaroud
- Department of Medecine A, Charles Nicolle Hospital, Tunis, Tunisia
- Laboratory of Nephropathology LR00SP01, Tunis, Tunisia
- Faculty of Medicine of Tunisia, Tunis University El Manar, Tunis, Tunisia
| | - Khaoula Ben Abdelghani
- Department of Medecine A, Charles Nicolle Hospital, Tunis, Tunisia
- Faculty of Medicine of Tunisia, Tunis University El Manar, Tunis, Tunisia
| | - Fethi Ben Hamida
- Department of Medecine A, Charles Nicolle Hospital, Tunis, Tunisia
- Laboratory of Nephropathology LR00SP01, Tunis, Tunisia
- Faculty of Medicine of Tunisia, Tunis University El Manar, Tunis, Tunisia
| | - Amel Harzallah
- Department of Medecine A, Charles Nicolle Hospital, Tunis, Tunisia
- Laboratory of Nephropathology LR00SP01, Tunis, Tunisia
- Faculty of Medicine of Tunisia, Tunis University El Manar, Tunis, Tunisia
| | - Ezzeddine Abderrahim
- Department of Medecine A, Charles Nicolle Hospital, Tunis, Tunisia
- Faculty of Medicine of Tunisia, Tunis University El Manar, Tunis, Tunisia
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Shao D, Pena O, Sekulic M, Valdez Imbert R, Vegivinti CTR, Jim B. Secondary haemophagocytic lymphohistiocytosis in a patient with new-onset systemic lupus erythematosus: the challenges of timely diagnosis and successful treatment. BMJ Case Rep 2023; 16:e252938. [PMID: 37429644 PMCID: PMC10335589 DOI: 10.1136/bcr-2022-252938] [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] [Indexed: 07/12/2023] Open
Abstract
Haemophagocytic lymphohistiocytosis (HLH) is an immune-mediated disease driven by abnormal macrophage activation and regulatory cell dysfunction. HLH can be primary due to genetic mutations or secondary due to infection, malignancy or autoimmune conditions. We describe a woman in her early 30s who developed HLH while being treated for newly diagnosed systemic lupus erythematosus (SLE) complicated by lupus nephritis as well as concomitant cytomegalovirus (CMV) reactivation from a dormant infection. The trigger for this secondary form of HLH may have been either aggressive SLE and/or CMV reactivation. Despite prompt treatment with immunosuppressive therapies for SLE consisting of high-dose corticosteroids, mycophenolate mofetil, tacrolimus, etoposide for HLH and ganciclovir for CMV infection, the patient developed multiorgan failure and passed away. We demonstrate the difficulty in identifying a specific cause for secondary HLH when multiple conditions are present (SLE and CMV) and the fact that, despite aggressive treatment for both conditions, the mortality for HLH remains high.
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Affiliation(s)
- Daming Shao
- Medicine, Jacobi Medical Center, Bronx, New York, USA
| | - Oscar Pena
- Medicine, Jacobi Medical Center, Bronx, New York, USA
| | - Miroslav Sekulic
- Department of Pathology and Cell Biology, Columbia University Medical Center, New York, New York, USA
| | | | | | - Belinda Jim
- Medicine, Jacobi Medical Center, Bronx, New York, USA
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13
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Noboa MER, Lopez-Arevalo H, Patel AR, Arora S, Manadan AM. Nationwide analysis of adult hospitalizations with hemophagocytic lymphohistiocytosis and systemic lupus erythematosus. Clin Rheumatol 2023:10.1007/s10067-023-06594-9. [PMID: 37081184 DOI: 10.1007/s10067-023-06594-9] [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: 10/02/2022] [Revised: 04/03/2023] [Accepted: 04/05/2023] [Indexed: 04/22/2023]
Abstract
INTRODUCTION Hemophagocytic lymphohistiocytosis (HLH) is a well-recognized complication of systemic lupus erythematosus (SLE). This study aims to characterize HLH with and without SLE in the US adult inpatient population. METHODS We performed a retrospective study of HLH with and without SLE from the 2016-2019 National Inpatient Sample (NIS) database. We described the demographic characteristics of HLH with and without SLE. Multivariable analysis was performed to calculate odds ratios (OR) for in-hospital death. RESULTS A total of 8690 hospitalizations had HLH. Of those 605 (7%) had SLE, and 8085 (93%) did not have SLE. Relative to the non-SLE group, the SLE group was younger, had more females, less whites, more African Americans, more Hispanics, and more Asian/Pacific Islanders. Over 60% of HLH with or without SLE had a concurrent infection. Sixty (9.9%) of HLH hospitalizations with SLE died compared to 1735 (21.5%) of those without SLE. Among HLH hospitalizations, multivariable analysis showed that age (OR 1.02; 95% C.I. 1.016-1.031), Charlson Comorbidity Index (OR 1.15; 95% C.I. 1.091-1.213), infections (OR 3.35; 95% C.I. 2.467-4.557), and leukemia/lymphoma (OR 1.46; 95% C.I. 1.112-1.905) had higher odds of in-hospital death. SLE did not increase the odds of death. CONCLUSIONS Inpatients with both HLH and SLE were younger, had a higher proportion of racial/ethnic minorities, and were predominately female. One out of every 10 hospitalizations for HLH ended in death but SLE itself was not an independent risk factor for death. Concurrent infection was the variable most associated with HLH death. Key Points • HLH and SLE group were younger and had higher proportions of female and racial/ethnic minorities. • SLE was not an independent risk factor for death in HLH patients.
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Affiliation(s)
| | - Hugo Lopez-Arevalo
- Department of Internal Medicine, Cook County Hospital, 1950 W. Polk, Chicago, IL, 60612, USA
| | - Axi R Patel
- Department of Internal Medicine, Cook County Hospital, 1950 W. Polk, Chicago, IL, 60612, USA
| | - Shilpa Arora
- Department of Internal Medicine, Cook County Hospital, 1950 W. Polk, Chicago, IL, 60612, USA
- Division of Rheumatology, Rush University Medical Center, 1611 West Harrison Street, Suite 510, Chicago, IL, 60612, USA
| | - Augustine M Manadan
- Department of Internal Medicine, Cook County Hospital, 1950 W. Polk, Chicago, IL, 60612, USA
- Division of Rheumatology, Rush University Medical Center, 1611 West Harrison Street, Suite 510, Chicago, IL, 60612, USA
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14
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Stoian M, Procopiescu B, Șeitan S, Scarlat G. Post-COVID-19 syndrome: Insights into a novel post-infectious systemic disorder. J Med Life 2023; 16:195-202. [PMID: 36937488 PMCID: PMC10015558 DOI: 10.25122/jml-2022-0329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Accepted: 01/17/2023] [Indexed: 03/21/2023] Open
Abstract
Coronavirus disease 2019 (COVID-19) is currently considered a complex systemic infectious and inflammatory disease, determined by the infection with severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), and the cause of one of the most important epidemiological phenomena in the last century - the COVID-19 pandemic. This infectious-inflammatory disease may generate a wide range of clinical manifestations and biological modifications, explained by the ubiquitous nature of the SARS-CoV-2 receptors, represented by the angiotensin-converting enzyme-2 (ACE-2), and by the host's violent immune and proinflammatory reaction to the viral infection. These manifestations include immunological disturbances, which, according to certain clinical findings, may persist post-infection, in the form of a presumed systemic inflammatory entity, defined by several clinical concepts with a common pathological significance: post-COVID-19 multisystem (or systemic) inflammatory syndrome, post-COVID syndrome or long-COVID. Although the pathophysiological mechanisms of the post-COVID-19 syndrome are elusive at the present moment, there are currently several studies that describe a systemic inflammatory or autoimmune phenomenon following the remission of the COVID-19 infection in some patients, which suggests the existence of molecular and cellular immune abnormalities, most probably due to the host's initial violent immune response to the viral infection, in the form of three overlapping entities: secondary hemophagocytic lymph histiocytosis (HLH), macrophage activation syndrome (MAS) and cytokine release syndrome (CRS). Thus, this is reminiscent of different classic autoimmune diseases, in which various infections are risk factors in developing the autoimmune process.
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Affiliation(s)
- Marilena Stoian
- Department of Internal Medicine, Dr. Ion Cantacuzino Clinical Hospital, Bucharest, Romania
- Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
- Corresponding Author: Marilena Stoian, Department of Internal Medicine, Dr. Ion Cantacuzino Clinical Hospital, Bucharest, Romania. Carol Davila University of Medicine and Pharmacy, Bucharest, Romania. E-mail:
| | - Bianca Procopiescu
- Department of Internal Medicine, Dr. Ion Cantacuzino Clinical Hospital, Bucharest, Romania
| | - Silviu Șeitan
- Department of Internal Medicine, Dr. Ion Cantacuzino Clinical Hospital, Bucharest, Romania
| | - Gabriel Scarlat
- Department of Internal Medicine, Dr. Ion Cantacuzino Clinical Hospital, Bucharest, Romania
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15
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Rituximab, Intravitreal Bevacizumab and Laser Photocoagulation for Treatment of Macrophage Activation Syndrome and Retinal Vasculitis in Lupus: A Case Report. Int J Mol Sci 2023; 24:ijms24032594. [PMID: 36768956 PMCID: PMC9916420 DOI: 10.3390/ijms24032594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2022] [Revised: 01/21/2023] [Accepted: 01/25/2023] [Indexed: 01/31/2023] Open
Abstract
Systemic lupus erythematosus (SLE) most commonly manifests as mild to moderate disease with severe manifestations such as diffuse alveolar hemorrhage, central nervous system vasculitis, macrophage activation syndrome (MAS) or retinal vasculitis (RV) with visual disturbances occurring in a significantly smaller proportion of patients, most of whom have a poor outcome. Macrophage activation syndrome and RV are insufficiently early and rarely recognized presentations of lupus-consequently there are still no treatment recommendations. Here we present the course of diagnosis and treatment of a patient with an SLE flare that resulted in both life-threatening disease (MAS) and vision-threatening disease (RV). The patient was successfully treated with systemic immunosuppressives, a high dose of glucocorticoids and rituximab (RTX), in parallel with intraocular therapy, intravitreal bevacizumab (BEV) and laser photocoagulation.
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16
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Tharwat S, Hamdy F, Abdelzaher MG, Bakr L, El Hassany A, Abdelsattar M, Eldesoky RT, Ibrahim EM. Life threatening macrophage activation syndrome as the initial presentation of systemic lupus erythematosus: A case report and review of the literature. THE EGYPTIAN RHEUMATOLOGIST 2023. [DOI: 10.1016/j.ejr.2022.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Egyptian evidence-based consensus on clinical practice guidelines for the diagnosis and treat-to-target management of macrophage activation syndrome in children. EGYPTIAN RHEUMATOLOGY AND REHABILITATION 2022. [PMCID: PMC9191532 DOI: 10.1186/s43166-022-00135-z] [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: 11/10/2022] Open
Abstract
Abstract
Background
Macrophage activation syndrome (MAS) is a severe life-threatening hyperinflammatory state with uncontrolled activation and proliferation of macrophages and T-lymphocytes. MAS has variable causes and risk factors. Early diagnosis and optimum management could be lifesaving.
Our aim was to develop a consensus, evidence-based recommendations for the diagnosis, evaluation, and treat-to-target management of pediatric MAS.
This study was carried out to achieve an Egyptian expert consensus on a treat-to-target management strategy for MAS using the Delphi technique. The multistep process strategy was used in developing a consensus, evidence-based treatment guidelines for MAS, started by developing 7 key clinical questions by a scientific committee according to the Patient/Population, Intervention, Comparison, and Outcomes (PICO) approach. The core leadership team identified pediatric rheumatology clinicians and researchers throughout Egypt. To generate evidence for MAS management, an evidence-based, systematic literature review was done. To obtain a consensus, the Delphi procedure (3 rounds) was used.
Results
Twenty-three expert panel participated in the 3 rounds with a response rate of 100%. A total of 19 recommendations, categorized into 2 sections (11 in the diagnosis section and 8 in management), were obtained. The agreement with the recommendations (ranks 7–9) ranged from 86.9 to 95.7%. The consensus was reached (i.e., ≥75% of respondents strongly agreed or agreed) on all the clinical standards. Algorithms for management have been also developed.
Conclusion
This was an expert, consensus recommendation for the diagnosis and treat to target of MAS, based on the best available evidence and expert opinion. The guidelines fill a gap in the literature as it presents a T2T approach for MAS.
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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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Schulert GS. The Big Bad Wolf: Macrophage Activation Syndrome in Childhood-Onset Systemic Lupus Erythematosus. J Rheumatol 2022; 49:1082-1084. [PMID: 36271722 DOI: 10.3899/jrheum.220780] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Affiliation(s)
- Grant S Schulert
- G.S. Schulert, MD, PhD, Associate Professor, Division of Rheumatology, Cincinnati Children's Hospital Medical Center and Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.
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Dey S, Roongta R, Mondal S, Haldar S, Sircar G, Ghosh B, Ghosh A. Recurrent macrophage activation syndrome as the initial manifestation of paediatric systemic lupus erythematosus. Lupus 2022; 31:1132-1137. [PMID: 35713230 DOI: 10.1177/09612033221108852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Introduction: Macrophage Activation Syndrome (MAS) is a rare but potentially fatal complication in rheumatic diseases. Here, we report the case of a 14-year-old girl with MAS as the primary manifestation of Systemic Lupus Erythematosus (SLE). She had three episodes of MAS during the course of her treatment. This case is unique as recurrent MAS in pediatric SLE is rare.Methods: Demographic, clinical, laboratory features and outcomes of our patient was noted. We also reviewed the two reported cases of recurrent MAS in pediatric SLE. Literature review was performed on PubMed search forum. Search items included Macrophage activation syndrome, pediatric systemic lupus erythematosus, recurrent MAS.Conclusion: The diagnosis and management of MAS are challenging as it can simulate an infectious complication or can be the exacerbation of the underlying disease. Early detection and prompt treatment can reduce morbidity in these patients.
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Affiliation(s)
- Sonali Dey
- Department of Clinical Immunology and Rheumatology, 30164Institute of Postgraduate Medical Education and Research, Kolkata, India
| | - Rashmi Roongta
- Department of Clinical Immunology and Rheumatology, 30164Institute of Postgraduate Medical Education and Research, Kolkata, India
| | - Sumantro Mondal
- Department of Clinical Immunology and Rheumatology, 30164Institute of Postgraduate Medical Education and Research, Kolkata, India
| | - Subhankar Haldar
- Department of Clinical Immunology and Rheumatology, 30164Institute of Postgraduate Medical Education and Research, Kolkata, India
| | - Geetabali Sircar
- Department of Clinical Immunology and Rheumatology, 30164Institute of Postgraduate Medical Education and Research, Kolkata, India
| | - Biswadip Ghosh
- Department of Clinical Immunology and Rheumatology, 30164Institute of Postgraduate Medical Education and Research, Kolkata, India
| | - Alakendu Ghosh
- Department of Clinical Immunology and Rheumatology, 30164Institute of Postgraduate Medical Education and Research, Kolkata, India
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Nam SH, Ahn SM, Oh JS, Hong S, Lee CK, Yoo B, Kim YG. Macrophage activation syndrome in rheumatic disease: Clinical characteristics and prognosis of 20 adult patients. PLoS One 2022; 17:e0267715. [PMID: 35522672 PMCID: PMC9075640 DOI: 10.1371/journal.pone.0267715] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 04/13/2022] [Indexed: 11/18/2022] Open
Abstract
Objectives
Macrophage activation syndrome (MAS) is a hyperinflammatory condition that is known to be secondary hemophagocytic lymphohistiocytosis (HLH) in patients with rheumatic disease. The aim of study was to evaluate the clinical manifestations and outcomes in patients with MAS with rheumatic disease.
Materials and methods
We performed a retrospective study of 20 adult patients who were diagnosed with MAS from 2012 to 2020. MAS was classified according to the HLH-2004 criteria. Patients’ information, including clinical features, laboratory findings, and treatment regimens, was collected, and the overall survival rate was estimated by the Kaplan–Meier method.
Results
Twenty patients (18 women, 35.6 ± 18.3 years) who met the HLH-2004 criteria also fulfilled the 2016 EULAR/ACR/PRINTO classification criteria for MAS, and HScore was higher than 169 (mean, 241.1). Fourteen patients with systemic lupus erythematosus and 6 patients with adult-onset Still’s disease were included. All patients were treated initially with corticosteroids, and 16 patients required additional immunosuppressants. The overall survival at 3 and 6 months was 75.2% and 64.3%. In survivors, renal impairment was less common (7.7% versus 71.4%, p = 0.007), the levels of AST (364.0 versus 81.0 IU/L, p = 0.019) and LDH (1346.0 versus 343.0IU/L, p = 0.014), and platelet count (90.0 versus 43.0 × 109/L, p = 0.02) were higher in compared to non-survivors. Nine patients had opportunistic infections, five of whom died during admission.
Conclusion
The mortality of patients with MAS associated with rheumatic disease remains high. Renal impairment, levels of AST and LDH, and platelet count might be associated with prognosis.
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Affiliation(s)
- So Hye Nam
- Division of Rheumatology, Department of Internal Medicine, Eulji University School of Medicine, Uijeongbu Eulji Medical Center, Uijeongbu, Gyeonggi-do, Korea
| | - Soo Min Ahn
- Division of Rheumatology, Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Ji Seon Oh
- Department of Information Medicine, Asan Medical Center, Seoul, Korea
| | - Seokchan Hong
- Division of Rheumatology, Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Chang-Keun Lee
- Division of Rheumatology, Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Bin Yoo
- Division of Rheumatology, Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Yong-Gil Kim
- Division of Rheumatology, Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
- * E-mail:
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22
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Demir BK, Kanık A, Köse M, Hişmi BÖ, Baran M. A surprising cause of proteinuria: Answers. Pediatr Nephrol 2022; 37:1033-1039. [PMID: 34999986 DOI: 10.1007/s00467-021-05363-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Accepted: 11/15/2021] [Indexed: 10/19/2022]
Affiliation(s)
- Belde Kasap Demir
- Department of Pediatrics, Division of Nephrology and Rheumatology, İzmir Katip Çelebi University, İzmir, Turkey. .,Department of Pediatrics, Health Sciences University, Tepecik Training and Research Hospital, İzmir, Turkey.
| | - Ali Kanık
- Department of Pediatrics, Health Sciences University, Tepecik Training and Research Hospital, İzmir, Turkey.,Department of Pediatrics, İzmir Katip Çelebi University, İzmir, Turkey
| | - Melis Köse
- Department of Pediatrics, Health Sciences University, Tepecik Training and Research Hospital, İzmir, Turkey.,Department of Pediatric Metabolism, İzmir Katip Çelebi University, İzmir, Turkey
| | - Burcu Öztürk Hişmi
- Department of Pediatric Metabolism, Marmara University, İstanbul, Turkey
| | - Maşallah Baran
- Department of Pediatrics, Health Sciences University, Tepecik Training and Research Hospital, İzmir, Turkey.,Department of Pediatrics, Division of Pediatric Gastroenterology, İzmir Katip Çelebi University, İzmir, Turkey
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23
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Rossano M, Rogani G, D’Errico MM, Cucchetti M, Baldo F, Torreggiani S, Beretta G, Lanni S, Petaccia A, Agostoni C, Filocamo G, Minoia F. Infection-Triggered Hyperinflammatory Syndromes in Children. CHILDREN 2022; 9:children9040564. [PMID: 35455608 PMCID: PMC9025340 DOI: 10.3390/children9040564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 04/08/2022] [Accepted: 04/12/2022] [Indexed: 12/02/2022]
Abstract
An association between infectious diseases and macrophage activation syndrome (MAS) has been reported, yet the exact role of infection in MAS development is still unclear. Here, a retrospective analysis of the clinical records of patients with rheumatic diseases complicated with MAS who were treated in a pediatric tertiary care center between 2011 and 2020 was performed. Any infection documented within the 30 days preceding the onset of MAS was reported. Out of 125 children in follow-up for systemic rheumatic diseases, 12 developed MAS, with a total of 14 episodes. One patient experienced three episodes of MAS. Clinical and/or laboratory evidence of infection preceded the onset of MAS in 12 events. Clinical features, therapeutic strategies, and patient outcomes were described. The aim of this study was to evaluate the possible role of infection as a relevant trigger for MAS development in children with rheumatic conditions. The pathogenetic pathways involved in the cross-talk between uncontrolled inflammatory activity and the immune response to infection deserve further investigation.
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Affiliation(s)
- Martina Rossano
- Pediatric Rheumatology, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milano IT and University of Milan, 20122 Milan, Italy; (M.R.); (G.R.); (M.C.); (F.B.); (S.T.); (G.B.); (S.L.); (A.P.); (C.A.); (F.M.)
| | - Greta Rogani
- Pediatric Rheumatology, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milano IT and University of Milan, 20122 Milan, Italy; (M.R.); (G.R.); (M.C.); (F.B.); (S.T.); (G.B.); (S.L.); (A.P.); (C.A.); (F.M.)
| | - Maria Maddalena D’Errico
- Department of Medical Sciences, IRCCS Casa Sollievo della Sofferenza, 71013 San Giovanni Rotondo, Italy;
| | - Martina Cucchetti
- Pediatric Rheumatology, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milano IT and University of Milan, 20122 Milan, Italy; (M.R.); (G.R.); (M.C.); (F.B.); (S.T.); (G.B.); (S.L.); (A.P.); (C.A.); (F.M.)
| | - Francesco Baldo
- Pediatric Rheumatology, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milano IT and University of Milan, 20122 Milan, Italy; (M.R.); (G.R.); (M.C.); (F.B.); (S.T.); (G.B.); (S.L.); (A.P.); (C.A.); (F.M.)
| | - Sofia Torreggiani
- Pediatric Rheumatology, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milano IT and University of Milan, 20122 Milan, Italy; (M.R.); (G.R.); (M.C.); (F.B.); (S.T.); (G.B.); (S.L.); (A.P.); (C.A.); (F.M.)
| | - Gisella Beretta
- Pediatric Rheumatology, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milano IT and University of Milan, 20122 Milan, Italy; (M.R.); (G.R.); (M.C.); (F.B.); (S.T.); (G.B.); (S.L.); (A.P.); (C.A.); (F.M.)
| | - Stefano Lanni
- Pediatric Rheumatology, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milano IT and University of Milan, 20122 Milan, Italy; (M.R.); (G.R.); (M.C.); (F.B.); (S.T.); (G.B.); (S.L.); (A.P.); (C.A.); (F.M.)
| | - Antonella Petaccia
- Pediatric Rheumatology, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milano IT and University of Milan, 20122 Milan, Italy; (M.R.); (G.R.); (M.C.); (F.B.); (S.T.); (G.B.); (S.L.); (A.P.); (C.A.); (F.M.)
| | - Carlo Agostoni
- Pediatric Rheumatology, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milano IT and University of Milan, 20122 Milan, Italy; (M.R.); (G.R.); (M.C.); (F.B.); (S.T.); (G.B.); (S.L.); (A.P.); (C.A.); (F.M.)
| | - Giovanni Filocamo
- Pediatric Rheumatology, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milano IT and University of Milan, 20122 Milan, Italy; (M.R.); (G.R.); (M.C.); (F.B.); (S.T.); (G.B.); (S.L.); (A.P.); (C.A.); (F.M.)
- Correspondence:
| | - Francesca Minoia
- Pediatric Rheumatology, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milano IT and University of Milan, 20122 Milan, Italy; (M.R.); (G.R.); (M.C.); (F.B.); (S.T.); (G.B.); (S.L.); (A.P.); (C.A.); (F.M.)
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24
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Clinical spectrum and therapeutic management of systemic lupus erythematosus-associated macrophage activation syndrome: a study of 20 Moroccan adult patients. Clin Rheumatol 2022; 41:2021-2033. [PMID: 35179662 DOI: 10.1007/s10067-022-06055-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 01/02/2022] [Accepted: 01/04/2022] [Indexed: 12/12/2022]
Abstract
OBJECTIVE The objective of this study was to describe the clinical and laboratory manifestations, triggers factors, treatment, and outcome of MAS complicating SLE. METHODS We retrospectively analyzed the medical records of adult patients with SLE for a period of 8 years (2009-2016) and identified patients who had developed MAS. We conducted statistical analysis to identify factors associated with MAS. RESULTS Among 208 consecutive lupus patients, 20 patients (19 women) were identified having MAS. The mean age of patients was 35.4 ± 10 years. MAS revealed lupus in 7 patients. In the others, the delay between diagnosis of SLE and MAS was 33,3 months. All cases required hospital admission, and 2 patients were admitted to the intensive care unit. An anemia (hemoglobin < 10 g/dL) was found in all patients. A thrombopenia was observed in 19 (95%) cases. Hypertriglyceridemia and hyperferritinemia were present in all patients. All patients had anti-nuclear antibodies and anti-double-stranded DNA antibodies. Bone marrow aspiration showed hemophagocytosis in 15 (94%) cases. The mean SLEDAI was 20.95 corresponding to an SLE of a very high activity. The mean H-Score was 233.85. MAS was associated with a lupus flare in 13 patients. Documented bacterial infections, viral infections, and a breast cancer were respectively diagnosed in 4, 3, and 1 cases respectively. The corticosteroids were administered in all patients. Intravenous cyclophosphamide was used together with corticosteroids in 6 patients, mycophenolate mofetil in 2 cases and azathioprine in 2 cases. Intravenous immunoglobulin was given in 4 cases, etoposide in one case and rituximab was used as the third line treatment in one patient. All infectious episodes were also treated by broad spectrum antibiotics. All patients had a good outcome without any mortality at the management, with a mean follow-up of 24 months. The clinical parameters significantly associated with MAS were fever (p = 0,001), splenomegaly (p < 0.0001), lymphadenopathy (p < 0.0001), oral and/or nasopharyngeal ulceration (p = 0.04), arthritis (p = 0.017), and pulmonary signs (p = 0.003). Laboratory parameters associated with MAS were anemia (p < 0.0001), thrombopenia (p < 0.0001), hyperferritinemia (p < 0.0001), hypertriglyceridemia (p < 0.0001), SLEDAI (p < 0.0001), and H-Score (p < 0.0001). Receiver operating characteristic (ROC) analysis identified optimal cutoff values of ferritin (> 695 ng/mL) and SLEDAI (> 13.5) to predict the occurrence of MAS in SLE. CONCLUSION MAS was observed in 9.62% Moroccan adult patients with SLE. SLE flare and infection were the common triggers of MAS in our study. Our study indicates that the occurrence of unexplained fever, splenomegaly, lymphadenopathy, profound cytopenia, hyperferritinemia, hypertriglyceridemia, high SLEDAI, and H-Score should raises the possibility of the diagnosis of MAS in SLE patients. Early diagnosis and urgent therapeutic management improves the overall prognosis. Key Points • Macrophage activation syndrome (MAS) is an underdiagnosed complication of systemic lupus erythematosus (SLE). The prevalence of this complication in this study is nearly 10%. • The diagnosis of MAS represents a major challenge for clinicians, as it could mimic a SLE flare up or be confused with infections. Validated diagnostic criteria for MAS in adults secondary to SLE are urgently needed. • In this study, the H-score calculate the individual risk of adult patients having reactive MAS. The cut-off value for the H-score was 190.5 (sensitivity 96.7%, specificity 97.6%). • The prognosis of MAS with SLE is good in our study. However, in the literature MAS may be a fatal condition in SLE patients. Prospective studies are necessary to confirm these results.
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25
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Harnchoowong S, Soponkanaporn S, Vilaiyuk S, Lerkvaleekul B, Pakakasama S. Central nervous system involvement and thrombocytopenia as predictors of mortality in children with hemophagocytic lymphohistiocytosis. Front Pediatr 2022; 10:941318. [PMID: 36147804 PMCID: PMC9485874 DOI: 10.3389/fped.2022.941318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Accepted: 08/18/2022] [Indexed: 12/05/2022] Open
Abstract
INTRODUCTION Hemophagocytic lymphohistiocytosis (HLH) is a potentially life-threatening condition. This study aimed to evaluate treatment outcomes and identify prognostic-related factors in Thai children with HLH. MATERIALS AND METHODS We retrospectively reviewed the medical records of 76 pediatric patients with HLH who were treated at Ramathibodi Hospital between January 2004 and December 2019. Treatment outcomes were defined as early mortality (death within 30 days after diagnosis) and early treatment response (resolution of all clinical features and normalization of at least one HLH-related laboratory parameter within 4 weeks). RESULTS The overall mortality rate was 38% (29/76), with an early mortality rate of 45% (13/29). Malignancy-associated HLH had the highest mortality rate (88%), followed by primary HLH (56%). The predictors of early mortality were central nervous system (CNS) involvement [OR 13 (95%CI 2-83), p = 0.007] and platelet counts <44 × 106/mm3 [OR 8 (95%CI 1.3-49), p = 0.024]. The predictors of early treatment response were no CNS involvement [OR 6.6 (95%CI 1.5-28.8), p = 0.011], platelet counts more than 44 × 106/mm3 [OR 8 (95%CI 2.1-30.9), p = 0.003], and total bilirubin levels <1.8 mg/dL [OR 4 (95%CI 1.1-14.8), p = 0.036]. In the mixed-model analysis, platelet counts in non-survivors increased significantly less than those in survivors, with a mean difference in platelet changes between the two groups of 94.6 × 106/mm3 (p = 0.003). CONCLUSION The independent predictors of early mortality in children with HLH were CNS involvement and low baseline platelet counts. A slow rate of platelet increases during the first week after diagnosis was also associated with mortality.
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Affiliation(s)
- Saralee Harnchoowong
- Division of Rheumatology, Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Sirisucha Soponkanaporn
- Division of Rheumatology, Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Soamarat Vilaiyuk
- Division of Rheumatology, Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Butsabong Lerkvaleekul
- Division of Rheumatology, Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Samart Pakakasama
- Division of Hematology and Oncology, Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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26
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Khan A, Anwer Khan S, Shamim R, Batool S, Aslam M. Experience with macrophage activation syndrome associated with systemic lupus erythematosus: A single-center study from Pakistan. INDIAN JOURNAL OF RHEUMATOLOGY 2022. [DOI: 10.4103/injr.injr_230_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Maffei S, De Guzman M, Rochat R, Tran J, Risen S, Dean A, Coleman N. From Telemedicine to the ICU-Fever and Rash in a 9-Year-Old Girl. Pediatrics 2022; 149:183833. [PMID: 34972223 DOI: 10.1542/peds.2021-051501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/01/2021] [Indexed: 11/24/2022] Open
Abstract
A 9-year-old girl presented to her primary care pediatrician via telemedicine during the initial months of the coronavirus disease 2019 pandemic because of 4 days of warmth perceived by her mother, decreased energy, and a new rash on her upper extremities. After 10 additional days of documented fever >38°C, worsening fatigue, and 1 day of nausea, vomiting, and diarrhea, she was allowed to schedule an in-person visit with her pediatrician after testing negative for severe acute respiratory syndrome coronavirus 2. She appeared ill on arrival to clinic, and her pediatrician recommended evaluation in an emergency department. Her initial laboratory testing revealed nonspecific elevation in several inflammatory markers and leukopenia, and she responded well to intravenous hydration. Over the next 2 weeks, her fever persisted, constitutional symptoms worsened, and she developed progressively painful cervical lymphadenopathy and pancytopenia. She was evaluated in clinic by several specialists and eventually was urged to present to the emergency department again, at which time she was admitted to the PICU. After consulting additional specialists and waiting for laboratory results, the team reached a definitive diagnosis and initiated therapy; however, she experienced rapid clinical decline shortly thereafter. The specialists who assisted with identification of the underlying etiology of her symptoms were able to work together to manage the subsequent complications.
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28
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Keshtkarjahromi M, Chhetri S, Balagani A, Tayyab UUBB, Haas CJ. Macrophage activation syndrome in MDA5 antibody-positive dermatomyositis and COVID-19 infection. BMC Rheumatol 2021; 5:59. [PMID: 34895325 PMCID: PMC8666190 DOI: 10.1186/s41927-021-00225-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Accepted: 08/19/2021] [Indexed: 01/02/2023] Open
Abstract
Background Macrophage activation syndrome (MAS) is a rare multiorgan system disorder that may present as a fatal complication of underlying rheumatological disease, including dermatomyositis. Case presentation Here, we report the case of a 65-year-old Caucasian female with a history of psoriasis and a recent diagnosis of Coronavirus disease 2019 (COVID-19) who presented with progressive generalized weakness, joint pains, an erythematous rash, shortness of breath, and weight loss. She was ultimately diagnosed with biopsy-confirmed melanoma differentiation-associated protein 5 (MDA5)-positive dermatomyositis complicated by MAS, requiring intravenous immunoglobulin and high-dose methylprednisolone. Conclusions This report serves as a clinical reminder of the rare, yet clinically relevant association between MDA5-positive dermatomyositis and MAS, as well as highlights the potential contribution of other immune system activating diseases, such as COVID-19, associated with a cytokine storm and hyperinflammatory state.
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Affiliation(s)
| | - Sumit Chhetri
- MedStar Health Internal Medicine Residency Program, Baltimore, MD, USA
| | - Amulya Balagani
- MedStar Health Internal Medicine Residency Program, Baltimore, MD, USA
| | | | - Christopher J Haas
- MedStar Health Internal Medicine Residency Program, Baltimore, MD, USA.,Georgetown University School of Medicine, Washington, DC, USA
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Consensus-Based Guidelines for the Recognition, Diagnosis, and Management of Hemophagocytic Lymphohistiocytosis in Critically Ill Children and Adults. Crit Care Med 2021; 50:860-872. [PMID: 34605776 DOI: 10.1097/ccm.0000000000005361] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE Hemophagocytic lymphohistiocytosis is a hyperinflammatory syndrome that often requires critical care support and remains difficult to diagnose. These guidelines are meant to aid in the early recognition, diagnosis, supportive care, and treatment of patients with hemophagocytic lymphohistiocytosis in ICUs. DATA SOURCES The literature searches were performed with PubMed (MEDLINE). STUDY SELECTION Keywords and medical subject headings terms for literature search included "macrophage activation syndrome," hemophagocytic lymphohistiocytosis," and "hemophagocytic syndrome." DATA EXTRACTION The Histiocyte Society developed these consensus recommendations on the basis of published reports and expert opinions with level of evidence provided for each recommendation. They were endorsed by the Society of Critical Care Medicine. DATA SYNTHESIS Testing for hemophagocytic lymphohistiocytosis should be initiated promptly in all patients admitted to ICUs with an unexplained or disproportionate inflammatory response, especially those with rapid clinical deterioration. Meeting five or more of eight hemophagocytic lymphohistiocytosis 2004 diagnostic criteria serves as a valuable diagnostic tool for hemophagocytic lymphohistiocytosis. Early aggressive critical care interventions are often required to manage the multisystem organ failure associated with hemophagocytic lymphohistiocytosis. Thorough investigation of the underlying triggers of hemophagocytic lymphohistiocytosis, including infections, malignancies, and autoimmune/autoinflammatory diseases, is essential. Early steroid treatment is indicated for patients with familial hemophagocytic lymphohistiocytosis and is often valuable in patients with acquired hemophagocytic lymphohistiocytosis (i.e., secondary hemophagocytic lymphohistiocytosis) without previous therapy, including macrophage activation syndrome (hemophagocytic lymphohistiocytosis secondary to autoimmune/autoinflammatory disease) without persistent or relapsing disease. Steroid treatment should not be delayed, particularly if organ dysfunction is present. In patients with macrophage activation syndrome, whose disease does not sufficiently respond, interleukin-1 inhibition and/or cyclosporine A is recommended. In familial hemophagocytic lymphohistiocytosis and severe, persistent, or relapsing secondary macrophage activation syndrome, the addition of prompt individualized, age-adjusted etoposide treatment is recommended. CONCLUSIONS Further studies are needed to determine optimal treatment for patients with hemophagocytic lymphohistiocytosis in ICUs, including the use of novel and adjunct therapies.
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30
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Kang CM, Choi J, Lee J. Macrophage Activation Syndrome Presented in a Case of Neonatal Lupus. NEONATAL MEDICINE 2021. [DOI: 10.5385/nm.2021.28.3.139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
Macrophage activation syndrome (MAS) is a potentially life-threatening complication in many autoimmune diseases. Early recognition and intervention are essential for a favorable outcome. Neonatal lupus, an acquired autoimmune disease in neonates caused by the transplacental passage of maternal autoantibodies, is rare and usually self-limited. Herein, we report a case of MAS in a patient with neonatal lupus, which improved with intravenous immunoglobulin.
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31
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Posas-Mendoza TF, McLeod C, Davis W, Zakem J, Quinet R. Etiologies and management of haemophagocytic lymphohistiocytosis: is it time for an updated protocol and targeted treatments? Rheumatology (Oxford) 2021; 60:2927-2933. [PMID: 33313881 DOI: 10.1093/rheumatology/keaa741] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 10/07/2020] [Indexed: 01/14/2023] Open
Abstract
OBJECTIVE The objective of this study was to analyse the features, therapeutic approaches, and outcomes for adult patients with haemophagocytic lymphohistiocytosis (HLH) at a single centre. METHODS This study was a retrospective chart review of all patients >18 years of age diagnosed with HLH according to HLH-2004 or H-score criteria at Ochsner Medical Center-New Orleans between 2013 and 2019. RESULTS A total of 29 patients with HLH met inclusion criteria. A total of 7 patients had an underlying malignancy, 12 had an autoimmune disease, 2 were transplant patients, and 2 had a combination of malignancy, autoimmune disease, or immunodeficiency. A total of 6 patients developed HLH precipitated by infection alone. All 29 patients presented with fever. A total of 28 (97%) patients met H-score criteria, and only 20 (67%) met HLH-2004 criteria. Fifteen patients were treated with the HLH-2004 protocol. Of those treated with the HLH-2004 protocol, 73% (11/15) died, 8% (1/15) had recurrence of HLH, and 20% (3/15) had resolution of HLH. A total of 14 patients were treated with targeted therapy. Of those treated with targeted therapy, 93% (13/14) had resolution of HLH and 1 died. Targeted therapy included pulse steroids, tocilizumab, anakinra, IVIG, CSA, rituximab, and/or CYC in addition to antiviral or antibiotic therapy. CONCLUSION Our findings suggested that the rheumatologic patient population responded well to a targeted therapeutic approach and poorly to the HLH-2004 protocol. Whether the poor outcomes found with the use of the HLH-2004 protocol are secondary to the protocol itself or the aggressive nature of malignancy-associated HLH is unclear. Further studies are needed to develop tailored therapeutic regimens.
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Affiliation(s)
| | - Cara McLeod
- Department of Rheumatology, Ochsner Clinic Foundation, New Orleans, LA, USA
| | - William Davis
- Department of Rheumatology, Ochsner Clinic Foundation, New Orleans, LA, USA.,The University of Queensland, Faculty of Medicine, Ochsner Clinical School, New Orleans, LA, USA
| | - Jerald Zakem
- Department of Rheumatology, Ochsner Clinic Foundation, New Orleans, LA, USA.,The University of Queensland, Faculty of Medicine, Ochsner Clinical School, New Orleans, LA, USA
| | - Robert Quinet
- Department of Rheumatology, Ochsner Clinic Foundation, New Orleans, LA, USA.,The University of Queensland, Faculty of Medicine, Ochsner Clinical School, New Orleans, LA, USA
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32
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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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33
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Minoia F, Tibaldi J, Muratore V, Gallizzi R, Bracaglia C, Arduini A, Comak E, Vougiouka O, Trauzeddel R, Filocamo G, Mastrangelo A, Micalizzi C, Kasapcopur O, Unsal E, Kitoh T, Tsitsami E, Kostik M, Schmid JP, Prader S, Laube G, Maritsi D, Jelusic M, Shenoi S, Vastert S, Ardissino G, Cron RQ, Ravelli A. Thrombotic Microangiopathy Associated with Macrophage Activation Syndrome: A Multinational Study of 23 Patients. J Pediatr 2021; 235:196-202. [PMID: 33836183 DOI: 10.1016/j.jpeds.2021.04.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Revised: 03/07/2021] [Accepted: 04/02/2021] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To describe the clinical characteristics, treatment, and outcomes of a multinational cohort of patients with macrophage activation syndrome (MAS) and thrombotic microangiopathy (TMA). STUDY DESIGN International pediatric rheumatologists were asked to collect retrospectively the data of patients with the co-occurrence of MAS and TMA. Clinical and laboratory features of patients with systemic juvenile idiopathic arthritis (sJIA)-associated MAS and TMA were compared with those of an historical cohort of patients with sJIA and MAS. RESULTS Twenty-three patients with MAS and TMA were enrolled: 17 had sJIA, 2 systemic lupus erythematosus, 1 juvenile dermatomyositis, 1 mixed connective tissue disease, and 2 undifferentiated connective tissue disease. Compared with the historical cohort of MAS, patients with sJIA with coexistent MAS and TMA had higher frequencies of renal failure and neurologic involvement, hemorrhage, jaundice, and respiratory symptoms, as well as more severe anemia and thrombocytopenia, higher levels of alanine aminotransferase, lactate dehydrogenase, bilirubin and D-dimer, and lower levels of albumin and fibrinogen. They also required admission to the intensive care unit more frequently. Among patients tested, complement abnormalities and reduced ADAMTS13 activity were observed in 64.3% and 44.4% of cases, respectively. All patients received glucocorticoids. Treatment for TMA included plasma-exchange, eculizumab, and rituximab. CONCLUSIONS The possible coexistence of MAS and TMA in rheumatic diseases may be underrecognized. This association should be considered in patients with MAS who develop disproportionate anemia, thrombocytopenia, and lactate dehydrogenase increase, or have multiorgan failure.
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Affiliation(s)
- Francesca Minoia
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.
| | - Jessica Tibaldi
- IRCCS Istituto Giannina Gaslini, Genoa, Italy; Università degli Studi di Genova, Genoa, Italy
| | | | | | | | | | | | | | | | - Giovanni Filocamo
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | | | | | - Ozgur Kasapcopur
- Istanbul University-Cerrahpasa, Department of Pediatric Rheumatology, Istanbul, Turkey
| | - Erbil Unsal
- Department of Pediatric Rheumatology, Dokuz Eylul University Childrens' Hospital, Izmir, Turkey
| | - Toshiyuki Kitoh
- Laboratory of Pediatrics, Aichi Gakuin University School of Pharmacy, Nagoya, Japan
| | - Elena Tsitsami
- 1st Department of Pediatrics, University of Athens, Children's Hospital Aghia Sophia, Athens, Greece
| | - Mikhail Kostik
- Saint-Petersburg State Pediatric Medical University, Saint-Petersburg, Russia
| | - Jana Pachlopnik Schmid
- Universitäts-Kinderspital, Zürich, Switzerland; University of Zurich, Zurich, Switzerland
| | | | - Guido Laube
- Universitäts-Kinderspital, Zürich, Switzerland
| | | | - Marija Jelusic
- University of Zagreb School of Medicine, Zagreb, Croatia
| | | | | | | | - Randy Q Cron
- Children's Hospital of Alabama, Birmingham, AL, USA
| | - Angelo Ravelli
- IRCCS Istituto Giannina Gaslini, Genoa, Italy; Università degli Studi di Genova, Genoa, Italy; Sechenov First Moscow State Medical University, Moscow, Russian Federation
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Smitherman EA, Cron RQ. Hyperferritinemia Wins Again: Defining Macrophage Activation Syndrome in Pediatric Systemic Lupus Erythematosus. J Rheumatol 2021; 48:1355-1357. [PMID: 34329185 DOI: 10.3899/jrheum.210024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Emily A Smitherman
- E.A. Smitherman, MD, MS, Assistant Professor, R.Q. Cron, MD, PhD, Professor, Division of Pediatric Rheumatology, University of Alabama at Birmingham, Birmingham, Alabama, USA.
| | - Randy Q Cron
- E.A. Smitherman, MD, MS, Assistant Professor, R.Q. Cron, MD, PhD, Professor, Division of Pediatric Rheumatology, University of Alabama at Birmingham, Birmingham, Alabama, USA
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Abdirakhmanova A, Sazonov V, Mukusheva Z, Assylbekova M, Abdukhakimova D, Poddighe D. Macrophage Activation Syndrome in Pediatric Systemic Lupus Erythematosus: A Systematic Review of the Diagnostic Aspects. Front Med (Lausanne) 2021; 8:681875. [PMID: 34150813 PMCID: PMC8211727 DOI: 10.3389/fmed.2021.681875] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 04/20/2021] [Indexed: 01/12/2023] Open
Abstract
Macrophage Activation Syndrome (MAS) is a very severe complication of different rheumatic diseases, including pediatric Systemic Lupus Erythematosus (pSLE). MAS is not considered as a frequent complication of pSLE; however, its occurrence could be under-estimated and the diagnosis can be challenging. In order to address this issue, we performed a systematic review of the available medical literature, aiming to retrieve all those papers providing diagnostic (clinical/laboratory) data on patients with pSLE-related MAS, in individual or aggregated form. The selected case reports and series provided a pool of 46 patients, accounting for 48 episodes of MAS in total. We re-analyzed these patients in light of the diagnostic criteria for MAS validated in systemic Juvenile Idiopathic Arthritis (sJIA) patients and the preliminary diagnostic criteria for MAS in pSLE, respectively. Five clinical studies were also selected and used to support this analysis. This systematic review confirms that MAS diagnosis in pSLE patients is characterized by several diagnostic challenges, which could lead to delayed diagnosis and/or under-estimation of this complication. Specific criteria should be considered to diagnose MAS in different rheumatic diseases; as regards pSLE, the aforementioned preliminary criteria for MAS in pSLE seem to perform better than the sJIA-related MAS criteria, because of a lower ferritin cut-off.
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Affiliation(s)
- Altynay Abdirakhmanova
- Department of Medicine, Nazarbayev University School of Medicine (NUSOM), Nur-Sultan, Kazakhstan
| | - Vitaliy Sazonov
- Department of Biomedical Sciences, Nazarbayev University School of Medicine (NUSOM), Nur-Sultan, Kazakhstan
| | - Zaure Mukusheva
- Program of Pediatric Rheumatology, Department of Pediatrics, National Research Center for Maternal and Child Health, University Medical Center, Nur-Sultan, Kazakhstan
| | - Maykesh Assylbekova
- Program of Pediatric Rheumatology, Department of Pediatrics, National Research Center for Maternal and Child Health, University Medical Center, Nur-Sultan, Kazakhstan
| | - Diyora Abdukhakimova
- Department of Medicine, Nazarbayev University School of Medicine (NUSOM), Nur-Sultan, Kazakhstan
| | - Dimitri Poddighe
- Department of Medicine, Nazarbayev University School of Medicine (NUSOM), Nur-Sultan, Kazakhstan.,Department of Pediatrics, National Research Center for Maternal and Child Health, University Medical Center, Nur-Sultan, Kazakhstan
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Palmblad K, Schierbeck H, Sundberg E, Horne AC, Erlandsson Harris H, Henter JI, Andersson U. Therapeutic administration of etoposide coincides with reduced systemic HMGB1 levels in macrophage activation syndrome. MOLECULAR MEDICINE (CAMBRIDGE, MASS.) 2021; 27:48. [PMID: 33975537 PMCID: PMC8111379 DOI: 10.1186/s10020-021-00308-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 04/28/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND Macrophage activation syndrome (MAS) is a potentially fatal complication of systemic inflammation. HMGB1 is a nuclear protein released extracellularly during proinflammatory lytic cell death or secreted by activated macrophages, NK cells, and additional cell types during infection or sterile injury. Extracellular HMGB1 orchestrates central events in inflammation as a prototype alarmin. TLR4 and the receptor for advanced glycation end products operate as key HMGB1 receptors to mediate inflammation. METHODS Standard ELISA and cytometric bead array-based methods were used to examine the kinetic pattern for systemic release of HMGB1, ferritin, IL-18, IFN-γ, and MCP-1 before and during treatment of four children with critical MAS. Three of the patients with severe underlying systemic rheumatic diseases were treated with biologics including tocilizumab or anakinra when MAS developed. All patients required intensive care therapy due to life-threatening illness. Add-on etoposide therapy was administered due to insufficient clinical response with standard treatment. Etoposide promotes apoptotic rather than proinflammatory lytic cell death, conceivably ameliorating subsequent systemic inflammation. RESULTS This therapeutic intervention brought disease control coinciding with a decline of the increased systemic HMGB1, IFN-γ, IL-18, and ferritin levels whereas MCP-1 levels evolved independently. CONCLUSION Systemic HMGB1 levels in MAS have not been reported before. Our results suggest that the molecule is not merely a biomarker of inflammation, but most likely also contributes to the pathogenesis of MAS. These observations encourage further studies of HMGB1 antagonists. They also advocate therapeutic etoposide administration in severe MAS and provide a possible biological explanation for its mode of action.
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Affiliation(s)
- Karin Palmblad
- Department of Women's and Children's Health, Karolinska Institute at Karolinska University Hospital, 17176, Stockholm, Sweden
| | - Hanna Schierbeck
- Department of Women's and Children's Health, Karolinska Institute at Karolinska University Hospital, 17176, Stockholm, Sweden
| | - Erik Sundberg
- Department of Women's and Children's Health, Karolinska Institute at Karolinska University Hospital, 17176, Stockholm, Sweden
| | - Anna-Carin Horne
- Department of Women's and Children's Health, Karolinska Institute at Karolinska University Hospital, 17176, Stockholm, Sweden
| | - Helena Erlandsson Harris
- Rheumatology Unit, Department of Medicine, Karolinska Institute at Karolinska University Hospital, 17176, Stockholm, Sweden
| | - Jan-Inge Henter
- Childhood Cancer Research Unit, Department of Women׳s and Children׳s Health, Karolinska Institute, 17177, Stockholm, Sweden.,Theme of Children, Karolinska University Hospital, 17176, Solna, Stockholm, Sweden
| | - Ulf Andersson
- Department of Women's and Children's Health, Karolinska Institute at Karolinska University Hospital, 17176, Stockholm, Sweden.
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Khare N, Jinkala SR, Kanungo S. Performance of HScore in Reactive Hemophagocytic Lymphohistiocytosis. Indian J Hematol Blood Transfus 2021; 37:256-263. [PMID: 33867732 PMCID: PMC8012436 DOI: 10.1007/s12288-020-01342-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Accepted: 08/26/2020] [Indexed: 01/07/2023] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a life threatening systemic hyperinflammatory disorder that leads to multiple organ damage. The most widely used diagnostic guidelines are the HLH 2004 guidelines proposed by the Histiocyte society. Recently, Fardet et al. has proposed a Scoring system, "HScore" for diagnosis of reactive HLH. To test the performance of "HScore" in diagnosis of reactive HLH and compare the credibility of the same with the existing gold standard 2004 guidelines in a cohort of Indian patients. This was a descriptive study of cases referred to the department of Pathology for bone marrow examination with suspicion or diagnosis of HLH from Jan 2015 to June 2017. The clinical records of these patients were analysed and diagnosed as positive and negative for HLH using the HLH 2004 guidelines and HScore, the scoring system developed by Fardet et al. Fifty cases fulfilled the inclusion criteria. The variables fever, hepato and /or splenomegaly, high triglyceride levels and marrow hemophagocytosis are highly significant to predict an individuals risk of HLH. We propose a cut-off of ≥ 166 for the diagnosis of HLH by using HScore. If 4 of the 7 criteria are fulfilled by HLH 2004 guidelines, there is an 80% probability of having HLH by HScore. The HScore is less restrictive in confirming a diagnosis of HLH compared to the HLH 2004 guidelines. HScore is a simple, and cost effective tool for diagnosis of reactive HLH. The higher the HScore, more is the probability of HLH.
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Affiliation(s)
- Neerav Khare
- VI Semester MBBS, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, 605006 India
| | - Sree Rekha Jinkala
- Department of Pathology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, 605006 India
| | - Srikanta Kanungo
- Department of Preventive and Social Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, 605006 India
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Abstract
Macrophage activation syndrome is a severe yet under-recognized complication encountered in pediatric rheumatology. It manifests as secondary hemophagocytic lymphohistiocytosis leading to a hyper-inflammatory state resulting from an underlying cytokine storm. If unchecked, it may lead to multiorgan failure and mortality. Early diagnosis and timely initiation of specific therapy is pivotal for a successful outcome. This review outlines the key clinical and laboratory features and management of macrophage activation syndrome.
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Affiliation(s)
- Narendra Kumar Bagri
- Division of Pediatric Rheumatology, Department of Pediatrics, AIIMS, New Delhi; India. Correspondence to: Dr Narendra Kumar Bagri, Associate Professor, Division of Pediatric Rheumatology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi 110 027, India.
| | - Latika Gupta
- Department of Clinical Immunology and Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Ethan S Sen
- Department of Pediatric Rheumatology, Great North Children's Hospital, and Faculty of Medical Sciences, Newcastle University, Newcastle Upon Tyne, UK
| | - A V Ramanan
- Department of Pediatric Rheumatology, University Hospitals Bristol NHS Foundation Trust and Translational Health Sciences, University of Bristol, Bristol, UK
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McGonagle D, Ramanan AV, Bridgewood C. Immune cartography of macrophage activation syndrome in the COVID-19 era. Nat Rev Rheumatol 2021; 17:145-157. [PMID: 33547426 PMCID: PMC7863615 DOI: 10.1038/s41584-020-00571-1] [Citation(s) in RCA: 66] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/23/2020] [Indexed: 02/06/2023]
Abstract
A hyperinflammatory 'cytokine storm' state termed macrophage activation syndrome (MAS), culminating from a complex interplay of genetics, immunodeficiency, infectious triggers and dominant innate immune effector responses, can develop across disparate entities including systemic juvenile idiopathic arthritis (sJIA) and its counterpart adult-onset Still disease (AOSD), connective tissue diseases, sepsis, infection, cancers and cancer immunotherapy. Classifying MAS using the immunological disease continuum model, with strict boundaries that define the limits of innate and adaptive immunity, at one boundary is MAS with loss of immune function, as occurs in the 'perforinopathies' and some cases of sJIA-AOSD. Conversely, at the other boundary, immune hypersensitivity with gain of immune function in MHC class II-associated sJIA-AOSD and with chimeric antigen receptor (CAR) T cell therapy also triggers MAS. This provides a benchmark for evaluating severe inflammation in some patients with COVID-19 pneumonia, which cripples primary type I interferon immunity and usually culminates in a lung-centric 'second wave' cytokine-driven alveolitis with associated immunothrombosis; this phenomenon is generally distinct from MAS but can share features with the proposed 'loss of immune function' MAS variant. This loss and gain of function MAS model offers immune cartography for a novel mechanistic classification of MAS with therapeutic implications.
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Affiliation(s)
- Dennis McGonagle
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK.
- National Institute for Health Research (NIHR), Leeds Biomedical Research Centre (BRC), Leeds Teaching Hospitals, Leeds, UK.
| | - Athimalaipet V Ramanan
- University Hospitals Bristol NHS Foundation Trust & Translational Health Sciences, University of Bristol, Bristol, UK
| | - Charlie Bridgewood
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
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Horne A, von Bahr Greenwood T, Chiang SC, Meeths M, Björklund C, Ekelund M, Erensjö P, Berg S, Hagelberg S, Bryceson YT, Andersson U, Henter JI. Efficacy of Moderately Dosed Etoposide in Macrophage Activation Syndrome–Hemophagocytic Lymphohistiocytosis. J Rheumatol 2021; 48:1596-1602. [DOI: 10.3899/jrheum.200941] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/02/2021] [Indexed: 11/22/2022]
Abstract
Objective Macrophage activation syndrome (MAS) constitutes 1 subtype of the hyperinflammatory syndrome hemophagocytic lymphohistiocytosis (HLH), and the term MAS-HLH was recently proposed for HLH with underlying autoimmune/autoinflammatory conditions. The mortality of MAS-HLH has been estimated at 5–10%. Here we report our experiences with moderately dosed etoposide in severe MAS-HLH; the objective was to effectively reduce severe hyperinflammatory activity with limited side effects. Methods In addition to conventional antiinflammatory treatment, moderately dosed etoposide was administered to 7 children affected by rapidly progressing MAS-HLH with central nervous system (n = 5) and/ or pulmonary (n = 5) involvement. Three had underlying systemic juvenile idiopathic arthritis (sJIA), 2 had atypical sJIA (no arthritis at diagnosis), and 2 had systemic lupus erythematosus. We performed lymphocyte cytotoxicity analyses in all 7 and genetic analyses in 6. Results All children promptly responded to moderately dosed etoposide (50–100 mg/m2 once weekly), added to conventional MAS-HLH treatment that was considered insufficient. The mean accumulated etoposide dose was 671 mg/m2 (range 300–1050 mg/m2) as compared to 1500 mg/m2 recommended in the first 8 weeks of the HLH-94/HLH-2004 protocols. One child developed neutropenic fever and another neutropenic sepsis (neutrophils 0.3 × 109/L at therapy onset). Five of 7 children had low percentages (< 5%) of circulating natural killer (NK) cells prior to or in association with diagnosis; NK cell activity was pathologically low in 2 of 5 children studied. Disease-causing variants in HLH-associated genes were not found. All children were alive at latest follow-up (2–9 yrs after onset); neurological symptoms had normalized in 4 of 5 affected children. Conclusion Moderately dosed etoposide may be beneficial in severe and/or refractory MAS-HLH.
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Macrophage activation syndrome in systemic lupus erythematosus and systemic-onset juvenile idiopathic arthritis: a retrospective study of similarities and dissimilarities. Rheumatol Int 2021; 41:625-631. [PMID: 33388903 DOI: 10.1007/s00296-020-04763-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Accepted: 11/25/2020] [Indexed: 01/14/2023]
Abstract
Macrophage activation syndrome (MAS) is a serious complication of rheumatic diseases. Fever and hyperferritinemia are common in active systemic-onset juvenile idiopathic arthritis (sJIA) and cytopenia in active systemic lupus erythematosus (SLE), thus recognizing MAS in them is a challenge. We compared clinical and laboratory parameters, various classification criteria, and outcomes of MAS in SLE and sJIA. Clinical and laboratory data were extracted from case records of patients with clinician diagnosed cases of SLE-MAS (adult and pediatric) and sJIA-MAS, admitted (2004-2018) at a tertiary care hospital. Ravelli, International consensus, HLH-2004, and criteria proposed by Parodi et al. were applied and compared. Among 33 patients (18 females) with MAS, 19 had SLE (7, childhood-onset SLE) and 14 had sJIA. MAS was more likely to be the presenting manifestation of disease in SLE (p < 0.05). There were no differences in the clinical features among them. Patients with SLE-MAS had lower baseline total leucocyte and platelet counts (p < 0.01), whereas patients with sJIA-MAS had significantly higher median CRP (p = 0.002), fall in TLC (p = 0.012), delta ESR/CRP ratio (p = 0.02), and lower fibrinogen level (p = 0.006). Neutrophil-to-lymphocyte ratio, ferritin/CRP ratio, and the number of patients with ferritin/ESR > 80 were similar. Only 6/33(18%) fulfilled the HLH criteria. Criteria meant for sJIA-MAS or SLE-MAS performed well for both diseases and the majority of patients could be diagnosed using them. Two patients died in each group. MAS in SLE and sJIA is more similar than dissimilar in clinical features and outcome. Criteria meant for MAS in sJIA or SLE-MAS performed equally well in both diseases.
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Shi N, Wang X, Zou L, Yang X, Ma Q, Lu M. Case Report: Macrophage Activation Syndrome and Widespread Neuroimaging Abnormality in Childhood-Onset Systemic Lupus Erythematosus. Front Pediatr 2021; 9:767115. [PMID: 34970517 PMCID: PMC8713754 DOI: 10.3389/fped.2021.767115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 11/17/2021] [Indexed: 11/13/2022] Open
Abstract
Macrophage activation syndrome (MAS) and widespread brain lesions are rare and severe complications of childhood-onset systemic lupus erythematosus (SLE). We report an 11-year-old girl who presented with recurrent rashes for half a year and fever for 2 weeks. Clinical and laboratory features at admission pointed to the diagnosis of SLE and SLE-associated MAS. Cerebral magnetic resonance imaging taken on day 4 after admission showed abnormal signals. Glucocorticoid therapy was started on day 5. Two days later, the patient appeared weak and ill, then the next day she exhibited dizziness, drowsiness, apathia, and dysarthria. High-dose methylprednisolone, cyclophosphamide, and intravenous immunoglobulin were used to treat the patient, and intrathecal dexamethasone was given. The patient was discharged on day 30 after admission and showed complete clinical resolution and improved magnetic resonance imaging resolution.
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Affiliation(s)
- Nana Shi
- Department of Hematology-Oncology, Children' Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | | | - Lixia Zou
- Department of Rheumatology Immunology and Allergy, Children' Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Xinghui Yang
- Department of Radiology, Children' Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Qian Ma
- Department of Rheumatology Immunology and Allergy, Children' Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Meiping Lu
- Department of Rheumatology Immunology and Allergy, Children' Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
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Warmoth T, Ramesh M, Iwuji K, Pixley JS. Macrophage Activation Syndrome in Adults: A Retrospective Case Series. J Investig Med High Impact Case Rep 2021; 9:23247096211026406. [PMID: 34180255 PMCID: PMC8243089 DOI: 10.1177/23247096211026406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 04/20/2021] [Accepted: 05/20/2021] [Indexed: 11/19/2022] Open
Abstract
Macrophage activation syndrome (MAS) is a form of hemophagocytic lymphohistocytosis that occurs in patients with a variety of inflammatory rheumatologic conditions. Traditionally, it is noted in pediatric patients with systemic juvenile idiopathic arthritis and systemic lupus erythematous. It is a rapidly progressive and life-threatening syndrome of excess immune activation with an estimated mortality rate of 40% in children. It has become clear recently that MAS occurs in adult patients with underlying rheumatic inflammatory diseases. In this article, we describe 6 adult patients with likely underlying MAS. This case series will outline factors related to diagnosis, pathophysiology, and review present therapeutic strategies.
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Affiliation(s)
- Taylor Warmoth
- Texas Tech University Health Sciences
Center, Lubbock, TX, USA
| | - Malvika Ramesh
- Texas Tech University Health Sciences
Center, Lubbock, TX, USA
| | - Kenneth Iwuji
- Texas Tech University Health Sciences
Center, Lubbock, TX, USA
| | - John S. Pixley
- Texas Tech University Health Sciences
Center, Lubbock, TX, USA
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44
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Gerstein M, Borgia RE, Dominguez D, Feldman BM, Liao F, Levy DM, Ng L, Abdelhaleem M, Silverman ED, Hiraki LT. Predicting Macrophage Activation Syndrome in Childhood-onset Systemic Lupus Erythematosus Patients at Diagnosis. J Rheumatol 2020; 48:1450-1457. [PMID: 33262295 DOI: 10.3899/jrheum.200292] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/20/2020] [Indexed: 12/17/2022]
Abstract
OBJECTIVE Macrophage activation syndrome (MAS), a life-threatening inflammatory complication, is increasingly recognized in childhood-onset systemic lupus erythematosus (cSLE). It can be a challenge to differentiate active cSLE from MAS. We generated decision rules for discriminating MAS from active cSLE in newly diagnosed patients. METHODS We conducted a retrospective cohort study of consecutive, newly diagnosed, active cSLE patients with fever, requiring hospital admission to The Hospital for Sick Children from January 2003 to December 2007 (cohort 1) and January 2008 to December 2013 (cohort 2). All patients met ≥ 4 American College of Rheumatology or Systemic Lupus International Collaborating Clinics criteria, and were steroid-naïve and infection-free. MAS was diagnosed based on expert opinion. Recursive partitioning was applied to each cohort to derive a decision rule based on clinical and laboratory features, distinguishing MAS from non-MAS cSLE. Each decision rule was applied to the alternate, independent cohort. Sensitivity and specificity of these decision rules were compared to existing criteria. RESULTS Cohort 1 (n = 34) and cohort 2 (n = 41) each had 10 patients with MAS. Recursive partitioning in cohort 1 identified ferritin ≥ 699 μg/L as the sole best discriminator between MAS and non-MAS patients (R2 = 0.48), and in cohort 2, ferritin ≥ 1107 μg/L was the best discriminator for MAS, followed by lymphocytes < 0.72 × 103/mm3 (R2 = 0.52). Cross-validation of our decision rules maintained 90-100% sensitivity and 65-85% specificity. CONCLUSION Our decision rule demonstrated improved performance compared to preliminary guidelines for MAS in cSLE from the Lupus Working Group of the Paediatric Rheumatology European Society and familial hemophagocytic lymphohistiocytosis diagnostic criteria. Validation in independent cohorts is required.
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Affiliation(s)
- Maya Gerstein
- M. Gerstein, MD, Division of Rheumatology, The Hospital for Sick Children, Toronto, Ontario, Canada, and Pediatric Rheumatology Unit, Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel
| | - R Ezequiel Borgia
- R.E. Borgia, MD, Division of Rheumatology, The Hospital for Sick Children, Toronto, and Department of Pediatrics, College of Medicine, University of Florida, Gainesville, Florida, USA
| | - Daniela Dominguez
- D. Dominguez, MD, MSc, B.M. Feldman, MD, MSc, FRCPC, F. Liao, MSc, D.M. Levy, MD, MS, FRCPC, L. Ng, BSc, E.D. Silverman, MD, FRCPC, L.T. Hiraki, MD, FRCPC, ScD, Division of Rheumatology, The Hospital for Sick Children, Toronto, Ontario Canada
| | - Brian M Feldman
- D. Dominguez, MD, MSc, B.M. Feldman, MD, MSc, FRCPC, F. Liao, MSc, D.M. Levy, MD, MS, FRCPC, L. Ng, BSc, E.D. Silverman, MD, FRCPC, L.T. Hiraki, MD, FRCPC, ScD, Division of Rheumatology, The Hospital for Sick Children, Toronto, Ontario Canada
| | - Fangming Liao
- D. Dominguez, MD, MSc, B.M. Feldman, MD, MSc, FRCPC, F. Liao, MSc, D.M. Levy, MD, MS, FRCPC, L. Ng, BSc, E.D. Silverman, MD, FRCPC, L.T. Hiraki, MD, FRCPC, ScD, Division of Rheumatology, The Hospital for Sick Children, Toronto, Ontario Canada
| | - Deborah M Levy
- D. Dominguez, MD, MSc, B.M. Feldman, MD, MSc, FRCPC, F. Liao, MSc, D.M. Levy, MD, MS, FRCPC, L. Ng, BSc, E.D. Silverman, MD, FRCPC, L.T. Hiraki, MD, FRCPC, ScD, Division of Rheumatology, The Hospital for Sick Children, Toronto, Ontario Canada
| | - Lawrence Ng
- D. Dominguez, MD, MSc, B.M. Feldman, MD, MSc, FRCPC, F. Liao, MSc, D.M. Levy, MD, MS, FRCPC, L. Ng, BSc, E.D. Silverman, MD, FRCPC, L.T. Hiraki, MD, FRCPC, ScD, Division of Rheumatology, The Hospital for Sick Children, Toronto, Ontario Canada
| | - Mohamed Abdelhaleem
- M. Abdelhaleem, MBBCh, PhD, FRCPC, Division of Haematopathology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Earl D Silverman
- D. Dominguez, MD, MSc, B.M. Feldman, MD, MSc, FRCPC, F. Liao, MSc, D.M. Levy, MD, MS, FRCPC, L. Ng, BSc, E.D. Silverman, MD, FRCPC, L.T. Hiraki, MD, FRCPC, ScD, Division of Rheumatology, The Hospital for Sick Children, Toronto, Ontario Canada
| | - Linda T Hiraki
- D. Dominguez, MD, MSc, B.M. Feldman, MD, MSc, FRCPC, F. Liao, MSc, D.M. Levy, MD, MS, FRCPC, L. Ng, BSc, E.D. Silverman, MD, FRCPC, L.T. Hiraki, MD, FRCPC, ScD, Division of Rheumatology, The Hospital for Sick Children, Toronto, Ontario Canada;
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Yang CA, Chiang BL. Inflammasomes and Childhood Autoimmune Diseases: A Review of Current Knowledge. Clin Rev Allergy Immunol 2020; 61:156-170. [PMID: 33236284 PMCID: PMC7685913 DOI: 10.1007/s12016-020-08825-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/09/2020] [Indexed: 02/08/2023]
Abstract
Inflammasomes are multiprotein complexes capable of sensing pathogen-associated molecular patterns (PAMPs), danger-associated molecular patterns (DAMPs), and cellular perturbations. Upon stimulation, the inflammasomes activate the production of the pro-inflammatory cytokines IL-1β and IL-18 and induce gasdermin D-mediated pyroptosis. Dysregulated inflammasome signaling could lead to hyperinflammation in response to environmental triggers, thus contributing to the pathogenesis of childhood autoimmune/autoinflammatory diseases. In this review, we group childhood rheumatic diseases into the autoinflammation to autoimmunity spectrum and discuss about the involvement of inflammasomes in disease mechanisms. Genetic mutations in inflammasome components cause monogenic autoinflammatory diseases, while inflammasome-related genetic variants have been implicated in polygenic childhood rheumatic diseases. We highlight the reported associations of inflammasome signaling-related genetic polymorphisms/protein levels with pediatric autoimmune disease susceptibility and disease course. Furthermore, we discuss about the use of IL-1 receptor antagonist as an adjunctive therapy in several childhood autoimmune diseases, including macrophage activation syndrome (MAS) and multisystem inflammatory syndrome in children (MIS-C) related to COVID-19. A comprehensive multi-cohort comparison on inflammasome gene expression profile in different pediatric rheumatic diseases is needed to identify patient subsets that might benefit from the adjunctive therapy of IL-1β inhibitors.
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Affiliation(s)
- Chin-An Yang
- Division of Laboratory Medicine and Division of Pediatrics, China Medical University Hsinchu Hospital, Jubei, Hsinchu, Taiwan
- College of Medicine, China Medical University, Taichung, Taiwan
| | - Bor-Luen Chiang
- Department of Pediatrics, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan.
- Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan.
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Webb BJ, Peltan ID, Jensen P, Hoda D, Hunter B, Silver A, Starr N, Buckel W, Grisel N, Hummel E, Snow G, Morris D, Stenehjem E, Srivastava R, Brown SM. Clinical criteria for COVID-19-associated hyperinflammatory syndrome: a cohort study. LANCET RHEUMATOLOGY 2020; 2:e754-e763. [PMID: 33015645 PMCID: PMC7524533 DOI: 10.1016/s2665-9913(20)30343-x] [Citation(s) in RCA: 201] [Impact Index Per Article: 50.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Background A subset of patients with COVID-19 develops a hyperinflammatory syndrome that has similarities with other hyperinflammatory disorders. However, clinical criteria specifically to define COVID-19-associated hyperinflammatory syndrome (cHIS) have not been established. We aimed to develop and validate diagnostic criteria for cHIS in a cohort of inpatients with COVID-19. Methods We searched for clinical research articles published between Jan 1, 1990, and Aug 20, 2020, on features and diagnostic criteria for secondary haemophagocytic lymphohistiocytosis, macrophage activation syndrome, macrophage activation-like syndrome of sepsis, cytokine release syndrome, and COVID-19. We compared published clinical data for COVID-19 with clinical features of other hyperinflammatory or cytokine storm syndromes. Based on a framework of conserved clinical characteristics, we developed a six-criterion additive scale for cHIS: fever, macrophage activation (hyperferritinaemia), haematological dysfunction (neutrophil to lymphocyte ratio), hepatic injury (lactate dehydrogenase or asparate aminotransferase), coagulopathy (D-dimer), and cytokinaemia (C-reactive protein, interleukin-6, or triglycerides). We then validated the association of the cHIS scale with in-hospital mortality and need for mechanical ventilation in consecutive patients in the Intermountain Prospective Observational COVID-19 (IPOC) registry who were admitted to hospital with PCR-confirmed COVID-19. We used a multistate model to estimate the temporal implications of cHIS. Findings We included 299 patients admitted to hospital with COVID-19 between March 13 and May 5, 2020, in analyses. Unadjusted discrimination of the maximum daily cHIS score was 0·81 (95% CI 0·74-0·88) for in-hospital mortality and 0·92 (0·88-0·96) for mechanical ventilation; these results remained significant in multivariable analysis (odds ratio 1·6 [95% CI 1·2-2·1], p=0·0020, for mortality and 4·3 [3·0-6·0], p<0·0001, for mechanical ventilation). 161 (54%) of 299 patients met two or more cHIS criteria during their hospital admission; these patients had higher risk of mortality than patients with a score of less than 2 (24 [15%] of 138 vs one [1%] of 161) and for mechanical ventilation (73 [45%] vs three [2%]). In the multistate model, using daily cHIS score as a time-dependent variable, the cHIS hazard ratio for worsening from low to moderate oxygen requirement was 1·4 (95% CI 1·2-1·6), from moderate oxygen to high-flow oxygen 2·2 (1·1-4·4), and to mechanical ventilation 4·0 (1·9-8·2). Interpretation We proposed and validated criteria for hyperinflammation in COVID-19. This hyperinflammatory state, cHIS, is commonly associated with progression to mechanical ventilation and death. External validation is needed. The cHIS scale might be helpful in defining target populations for trials and immunomodulatory therapies. Funding Intermountain Research and Medical Foundation.
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Affiliation(s)
- Brandon J Webb
- Division of Infectious Diseases and Clinical Epidemiology, Intermountain Healthcare, Intermountain Medical Center, Salt Lake City, UT, USA.,Division of Infectious Diseases and Geographic Medicine, Stanford Medicine, Palo Alto, CA, USA
| | - Ithan D Peltan
- Pulmonary and Critical Care Medicine, Intermountain Medical Center, Salt Lake City, UT, USA.,Department of Pulmonary and Critical Care Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Paul Jensen
- Division of Rheumatology, Intermountain Healthcare, Dixie Regional Medical Center, St George, UT, USA
| | - Daanish Hoda
- Intermountain Acute Leukemia, Blood and Marrow Transplant Program, LDS Hospital, Salt Lake City, UT, USA
| | - Bradley Hunter
- Intermountain Acute Leukemia, Blood and Marrow Transplant Program, LDS Hospital, Salt Lake City, UT, USA
| | - Aaron Silver
- Division of Hospital Medicine, Intermountain Healthcare, Intermountain Medical Center, Salt Lake City, UT, USA
| | - Nathan Starr
- Division of Hospital Medicine, Intermountain Healthcare, Intermountain Medical Center, Salt Lake City, UT, USA
| | - Whitney Buckel
- Pharmacy Services, Antimicrobial Stewardship, Intermountain Healthcare, Salt Lake City, UT, USA
| | - Nancy Grisel
- Division of Infectious Diseases and Clinical Epidemiology, Intermountain Healthcare, Intermountain Medical Center, Salt Lake City, UT, USA
| | - Erika Hummel
- Intermountain Healthcare Office of Research, Salt Lake City, UT, USA
| | - Gregory Snow
- Healthcare Delivery Institute, Intermountain Healthcare, Murray, UT, USA
| | - Dave Morris
- Division of Trauma and Critical Care, Intermountain Medical Center, Murray, UT, USA
| | - Eddie Stenehjem
- Division of Infectious Diseases and Clinical Epidemiology, Intermountain Healthcare, Intermountain Medical Center, Salt Lake City, UT, USA.,Division of Infectious Diseases and Geographic Medicine, Stanford Medicine, Palo Alto, CA, USA.,Office of Patient Experience, Intermountain Healthcare, Salt Lake City, UT, USA
| | - Rajendu Srivastava
- Healthcare Delivery Institute, Intermountain Healthcare, Murray, UT, USA.,Division of Inpatient Medicine, Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Samuel M Brown
- Pulmonary and Critical Care Medicine, Intermountain Medical Center, Salt Lake City, UT, USA.,Department of Pulmonary and Critical Care Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
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Ke Y, Lv C, Xuan W, Wu J, Da Z, Wei H, Zhang M, Tan W. Clinical analysis of macrophage activation syndrome in adult rheumatic disease: A multicenter retrospective study. Int J Rheum Dis 2020; 23:1488-1496. [PMID: 32885598 DOI: 10.1111/1756-185x.13955] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 08/05/2020] [Accepted: 08/05/2020] [Indexed: 01/08/2023]
Abstract
AIM To evaluate the clinical and laboratory characteristics, prognostic factors, and outcome of adult rheumatic disease-associated macrophage activation syndrome (MAS). METHOD A multicenter retrospective study was performed across 4 tertiary hospitals in China between January 1, 2017 to December 31, 2019. RESULTS There were 61 rheumatic disease patients with MAS enrolled into this retrospective clinical study. Fever and hyperferritinemia are the most frequent clinical feature and laboratory abnormality in MAS patients. Serum ferritin > 6000 ng/mL (odds ratio [OR] = 9.46, 95% CI = 2.53-47.13, P = .005) and hemophagocytosis in bone marrow smear (OR = 11.12, 95%, CI = 3.29-50.65, P = .001) were the 2 most prominent predictive factors indicating MAS occurrence. The 90-day all-cause mortality rate of all rheumatic disease patients with MAS was 22.9% (hazards ratio [HR] = 2.15, 95% CI = 0.81-6.78, P = .05). Platelets < 100 × 109 /L (HR = 3.23, 95% CI = 2.51-4.81, P = .01) and ferritin > 6000ng/mL (HR = 6.12, 95% CI = 2.93-16.27, P = .005) were independent predictors of poor outcome in rheumatic disease-associated MAS. CONCLUSION Macrophage activation syndrome could be a fatal complication in rheumatic disease. Patients presenting with unexplained fever, serum ferritin > 6000 ng/mL, hepatosplenomegaly and cytopenia at baseline should raise the suspicion of MAS. The presence of serum ferritin > 6000 ng/mL, hepatosplenomegaly and low number of platelets was associated with poor outcome.
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Affiliation(s)
- Yao Ke
- Department of Rheumatology, the First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Chengyin Lv
- Department of Rheumatology, the First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Wenhua Xuan
- Department of Rheumatology, the Second People's Hospital of Wuxi, Wuxi, China
| | - Jian Wu
- Department of Rheumatology, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Zhanyun Da
- Department of Rheumatology, Affiliated Hospital of Nantong University, Nantong, China
| | - Hua Wei
- Division of Rheumatology, Clinical Medical College, Yangzhou University, China
| | - Miaojia Zhang
- Department of Rheumatology, the First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Wenfeng Tan
- Department of Rheumatology, the First Affiliated Hospital of Nanjing Medical University, Nanjing, China
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Macrophage Activation Syndrome in Childhood Inflammatory Disorders: Diagnosis, Genetics, Pathophysiology, and Treatment. CURRENT TREATMENT OPTIONS IN RHEUMATOLOGY 2020. [DOI: 10.1007/s40674-020-00153-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Mizuta M, Shimizu M, Irabu H, Usami M, Inoue N, Nakagishi Y, Wada T, Yachie A. Comparison of serum cytokine profiles in macrophage activation syndrome complicating different background rheumatic diseases in children. Rheumatology (Oxford) 2020; 60:231-238. [DOI: 10.1093/rheumatology/keaa299] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Revised: 05/02/2020] [Indexed: 12/18/2022] Open
Abstract
Abstract
Objectives
To compare the cytokines involved in the development of macrophage activation syndrome (MAS) in different background rheumatic diseases and to identify serum biomarkers for MAS diagnosis.
Methods
Serum neopterin, IL-6, IL-18 and soluble TNF receptor (sTNFR) type I (sTNFR-I) and type II (sTNFR-II) levels were determined using ELISA in 12 patients with SLE, including five with MAS; 12 patients with JDM, including four with MAS; 75 patients with Kawasaki disease (KD), including six with MAS; and 179 patients with systemic JIA (s-JIA), including 43 with MAS. These results were compared with the clinical features of MAS.
Results
Serum neopterin, IL-18 and sTNFR-II levels were significantly higher during the MAS phase than during the active phase in patients with all diseases. Furthermore, serum sTNFR-I levels were significantly higher during the MAS phase than during the active phase in patients with SLE, KD and s-JIA. Receiver operating characteristic (ROC) curve analysis revealed that serum sTNFR-I levels for SLE, serum IL-18 levels for JDM, and serum sTNFR-II levels for KD and s-JIA had the highest areas under the ROC curve. Serum levels of these cytokines were significantly and positively correlated with serum ferritin levels.
Conclusions
Overproduction of IFN-γ, IL-18 and TNF-α might be closely related to the development of MAS. Serum levels of sTNFR-I for SLE, IL-18 for JDM, and sTNFR-II for KD and s-JIA might be useful diagnostic markers for the transition from active phase to MAS.
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Affiliation(s)
- Mao Mizuta
- Department of Pediatrics, School of Medicine, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University, Kanazawa
| | - Masaki Shimizu
- Department of Pediatrics, School of Medicine, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University, Kanazawa
| | - Hitoshi Irabu
- Department of Pediatrics, School of Medicine, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University, Kanazawa
| | - Masaaki Usami
- Department of Pediatrics, School of Medicine, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University, Kanazawa
| | - Natsumi Inoue
- Department of Pediatrics, School of Medicine, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University, Kanazawa
| | - Yasuo Nakagishi
- Department of Pediatric Rheumatology, Hyogo Prefectural Kobe Children’s Hospital, Kobe, Japan
| | - Taizo Wada
- Department of Pediatrics, School of Medicine, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University, Kanazawa
| | - Akihiro Yachie
- Department of Pediatrics, School of Medicine, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University, Kanazawa
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Pal P, Bathia J, Giri PP, Roy M, Nandi A. Macrophage activation syndrome in pediatrics: 10 years data from an Indian center. Int J Rheum Dis 2020; 23:1412-1416. [PMID: 32666639 DOI: 10.1111/1756-185x.13915] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Revised: 06/21/2020] [Accepted: 06/21/2020] [Indexed: 11/29/2022]
Abstract
AIMS Macrophage activation syndrome (MAS) is a dreaded complication of systemic inflammatory diseases and is most commonly seen in systemic juvenile idiopathic arthritis (sJIA). We evaluate the clinical features, laboratory findings and outcomes in pediatric MAS, assess the response to different pharmacological therapies, and finally identify possible factors associated with an unfavorable outcome. METHODS This is a retrospective analysis of data from patients diagnosed as having MAS, admitted between July 2008 and April 2018 into the Department of Pediatric Rheumatology, Institute Of Child Health Kolkata. The data noted were the clinical and laboratory features, treatment details, responses to therapy and outcomes. RESULTS Thirty-one patients were diagnosed as having MAS. Primary illness was sJIA in 26 (84%), systemic lupus erythematosus in 4 (13%) and Kawasaki disease (KD) in 1 (3%). All had fever with varying degrees of multisystemic involvement. Hyperferritinemia was universally present. Pulse methylprednisolone with cyclosporine was used for treating the majority. Ten patients (32%) expired. CONCLUSION Macrophage activation syndrome is a near fatal complication with protean manifestations and multiorgan dysfunction. Hyperferritinemia is characteristic, higher values being associated with increased mortality. Cases resistant to steroids and cyclosporine had a poor prognosis. Late presentations with multiorgan dysfunction were associated with the poorest outcomes.
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Affiliation(s)
- Priyankar Pal
- Pediatric Rheumatology, Institute of Child Health, Kolkata, India
| | - Jigna Bathia
- Deptartment of Pediatrics, Institute of Child Health, Kolkata, India
| | | | - Mandira Roy
- Deptartment of Pediatrics, Institute of Child Health, Kolkata, India
| | - Alolika Nandi
- Deptartment of Pediatrics, Institute of Child Health, Kolkata, India
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