1
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Carol HA, Mayer AS, Zhang MS, Dang V, Varghese J, Martinez Z, Schneider C, Baker JE, Tsoukas P, Behrens EM, Cron RQ, Diorio C, Henderson LA, Schulert G, Lee P, Kernan KF, Canna SW. Hyperferritinemia Screening to Aid Identification and Differentiation of Patients with Hyperinflammatory Disorders. J Clin Immunol 2024; 45:4. [PMID: 39264477 DOI: 10.1007/s10875-024-01797-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2024] [Accepted: 08/29/2024] [Indexed: 09/13/2024]
Abstract
High ferritin is an important and sensitive biomarker for the various forms of hemophagocytic lymphohistiocytosis (HLH), a diverse and deadly group of cytokine storm syndromes. Early action to prevent immunopathology in HLH often includes empiric immunomodulation, which can complicate etiologic work-up and prevent collection of early/pre-treatment research samples. To address this, we instituted an alert system at UPMC Children's Hospital where serum ferritin > 1000 ng/mL triggered real-time chart review, assessment of whether the value reflected "inflammatory hyperferritnemia (IHF)", and biobanking of remnant samples from consenting IHF patients. We extracted relevant clinical data; periodically measured serum total IL-18, IL-18 binding protein (IL-18BP), and CXCL9; retrospectively classified patients by etiology into infectious, rheumatic, or immune dysregulation; and subjected a subgroup of samples to a 96-analyte biomarker screen. 180 patients were identified, 30.5% of which had IHF. Maximum ferritin levels were significantly higher in patients with IHF than with either hemoglobinopathy or transplant, and highly elevated total IL-18 levels were distinctive to patients with Stills Disease and/or Macrophage Activation Syndrome (MAS). Multi-analyte analysis showed elevation in proteins associated with cytotoxic lymphocytes in all IHF samples when compared to healthy controls and depression of proteins such as ANGPT1 and VEGFR2 in samples from hyperferritinemic sepsis patients relative to non-sepsis controls. This real-time IFH screen proved feasible and efficient, validated prior observations about the specificity of IL-18, enabled early sample collection from a complex population, suggested a unique vascular biomarker signature in hyperferritinemic sepsis, and expanded our understanding of IHF heterogeneity.
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Affiliation(s)
- Hallie A Carol
- Division of Pediatric Rheumatology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Adam S Mayer
- Division of Pediatric Rheumatology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Division of Rheumatology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Michael S Zhang
- Division of Pediatric Allergy/Immunology, University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Vinh Dang
- Division of Pediatric Rheumatology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- RK Mellon Institute for Pediatric Research & Pediatric Rheumatology, University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Jemy Varghese
- Division of Pediatric Rheumatology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Zachary Martinez
- Division of Pediatric Oncology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Corinne Schneider
- RK Mellon Institute for Pediatric Research & Pediatric Rheumatology, University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Joy Elizabeth Baker
- Division of Pediatric Rheumatology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Paul Tsoukas
- Division of Pediatric Rheumatology, Hospital for Sick Children, Toronto, ON, Canada
| | - Edward M Behrens
- Division of Pediatric Rheumatology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Randy Q Cron
- Division of Pediatric Rheumatology, The University of Alabama at Birmingham, Birmingham, AL, USA
| | - Caroline Diorio
- Division of Pediatric Oncology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | | | - Grant Schulert
- Division of Pediatric Rheumatology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Pui Lee
- Division of Immunology, Boston Children's Hospital, Boston, MA, USA
| | - Kate F Kernan
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Scott W Canna
- Division of Pediatric Rheumatology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.
- RK Mellon Institute for Pediatric Research & Pediatric Rheumatology, University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA.
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2
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Carol HA, Mayer AS, Zhang MS, Dang V, Varghese J, Martinez Z, Schneider C, Baker JE, Tsoukas P, Behrens EM, Cron RQ, Diorio C, Henderson LA, Schulert G, Lee P, Kernan KF, Canna SW. Hyperferritinemia screening to aid identification and differentiation of patients with hyperinflammatory disorders. RESEARCH SQUARE 2024:rs.3.rs-4523502. [PMID: 38978562 PMCID: PMC11230465 DOI: 10.21203/rs.3.rs-4523502/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/10/2024]
Abstract
High ferritin is an important and sensitive biomarker for hemophagocytic lymphohistiocytosis (HLH), a diverse and deadly group of cytokine storm syndromes. Early action to prevent immunopathology in HLH often includes empiric immunomodulation, which can complicate etiologic work-up and prevent collection of early/pre-treatment research samples. To address this, we instituted an alert system where serum ferritin > 1000ng/mL triggered real-time chart review, assessment of whether the value reflected "inflammatory hyperferritnemia (IHF)", and biobanking of remnant samples from consenting IHF patients. We extracted relevant clinical data; periodically measured serum total IL-18, IL-18 binding protein (IL-18BP), and CXCL9; retrospectively classified patients by etiology into infectious, rheumatic, or immune dysregulation; and subjected a subgroup of samples to a 96-analyte biomarker screen. 180 patients were identified, 30.5% of which had IHF. Maximum ferritin levels were significantly higher in patients with IHF than with either hemoglobinopathy or transplant, and highly elevated total IL-18 levels were distinctive to patients with Stills Disease and/or Macrophage Activation Syndrome (MAS). Multi-analyte analysis showed elevation in proteins associated with cytotoxic lymphocytes in all IHF samples when compared to healthy controls and depression of proteins such as ANGPT1 and VEGFR2 in samples from hyperferritinemic sepsis patients relative to non-sepsis controls. This single-center, real-time IFH screen proved feasible and efficient, validated prior observations about the specificity of IL-18, enabled early sample collection from a complex population, suggested a unique vascular biomarker signature in hyperferritinemic sepsis, and expanded our understanding of IHF heterogeneity.
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Affiliation(s)
- Hallie A Carol
- Division of Pediatric Rheumatology, The Children's Hospital of Philadelphia
| | - Adam S Mayer
- Division of Pediatric Rheumatology, The Children's Hospital of Philadelphia
| | - Michael S Zhang
- Division of Pediatric Allergy/Immunology, University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh
| | - Vinh Dang
- Division of Pediatric Rheumatology, The Children's Hospital of Philadelphia
| | - Jemy Varghese
- Division of Pediatric Rheumatology, The Children's Hospital of Philadelphia
| | - Zachary Martinez
- Division of Pediatric Oncology, The Children's Hospital of Philadelphia
| | - Corinne Schneider
- RK Mellon Institute for Pediatric Research & Pediatric Rheumatology, University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh
| | - Joy Elizabeth Baker
- Division of Pediatric Rheumatology, Cincinnati Children's Hospital Medical Center
| | - Paul Tsoukas
- Division of Pediatric Rheumatology, Hospital for Sick Children,Toronto, ON
| | - Edward M Behrens
- Division of Pediatric Rheumatology, The Children's Hospital of Philadelphia
| | - Randy Q Cron
- Division of Pediatric Rheumatology, The University of Alabama at Birmingham
| | - Caroline Diorio
- Division of Pediatric Oncology, The Children's Hospital of Philadelphia
| | | | - Grant Schulert
- Division of Pediatric Rheumatology, Cincinnati Children's Hospital Medical Center
| | - Pui Lee
- Division of Immunology, Boston Children's Hospital
| | - Kate F Kernan
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh
| | - Scott W Canna
- Division of Pediatric Rheumatology, The Children's Hospital of Philadelphia
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3
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Gioia C, Paroli M, Izzo R, Di Sanzo L, Rossi E, Pignatelli P, Accapezzato D. Pathogenesis of Hemophagocytic Lymphohistiocytosis/Macrophage Activation Syndrome: A Case Report and Review of the Literature. Int J Mol Sci 2024; 25:5921. [PMID: 38892108 PMCID: PMC11173133 DOI: 10.3390/ijms25115921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2024] [Revised: 05/27/2024] [Accepted: 05/28/2024] [Indexed: 06/21/2024] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening condition characterized by the uncontrolled activation of cytotoxic T lymphocytes, NK cells, and macrophages, resulting in an overproduction of pro-inflammatory cytokines. A primary and a secondary form are distinguished depending on whether or not it is associated with hematologic, infectious, or immune-mediated disease. Clinical manifestations include fever, splenomegaly, neurological changes, coagulopathy, hepatic dysfunction, cytopenia, hypertriglyceridemia, hyperferritinemia, and hemophagocytosis. In adults, therapy, although aggressive, is often unsuccessful. We report the case of a 41-year-old man with no apparent history of previous disease and an acute onset characterized by fever, fatigue, and weight loss. The man was from Burkina Faso and had made trips to his home country in the previous five months. On admission, leukopenia, thrombocytopenia, increased creatinine and transaminases, LDH, and CRP with a normal ESR were found. The patient also presented with hypertriglyceridemia and hyperferritinemia. An infectious or autoimmune etiology was ruled out. A total body CT scan showed bilateral pleural effusion and hilar mesenterial, abdominal, and paratracheal lymphadenopathy. Lymphoproliferative disease with HLH complication was therefore suspected. High doses of glucocorticoids were then administered. A cytologic analysis of the pleural effusion showed anaplastic lymphoma cells and bone marrow aspirate showed hemophagocytosis. An Epstein-Barr Virus (EBV) DNA load of more than 90000 copies/mL was found. Bone marrow biopsy showed a marrow localization of peripheral T lymphoma. The course was rapidly progressive until the patient died. HLH is a rare but usually fatal complication in adults of hematologic, autoimmune, and malignant diseases. Very early diagnosis and treatment are critical but not always sufficient to save patients.
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Affiliation(s)
| | | | | | | | | | | | - Daniele Accapezzato
- Division of Clinical Immunology, Department of Clinical, Anesthesiologic and Cardiovascular Sciences, Sapienza University of Rome, 00185 Rome, Italy; (C.G.); (M.P.); (R.I.); (L.D.S.); (E.R.); (P.P.)
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Gagro A. Usefulness of interleukin-1 blockade in autoinflammatory diseases. Reumatologia 2024; 62:71-73. [PMID: 38799781 PMCID: PMC11114131 DOI: 10.5114/reum/188546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2024] [Accepted: 04/22/2024] [Indexed: 05/29/2024] Open
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Uchida T, Oda T. Concept and Diagnostic Challenges of Renal-Limited Hemophagocytic Syndrome/Macrophage Activation Syndrome. J Clin Med 2024; 13:2161. [PMID: 38673434 PMCID: PMC11050812 DOI: 10.3390/jcm13082161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Revised: 04/02/2024] [Accepted: 04/07/2024] [Indexed: 04/28/2024] Open
Abstract
Hemophagocytic syndrome/macrophage activation syndrome (HPS/MAS) is a serious clinical condition that frequently leads to multiple organ failure, including acute kidney injury (AKI). Although the pathogenesis of AKI is not yet fully understood, it is believed to result from uncontrolled activation of the immune system involving macrophages and cytotoxic lymphocytes. Renal histology in HPS/MAS often presents with characteristic foamy glomerular lesions (glomerular lipidosis) with massive macrophage infiltration, known as histiocytic glomerulopathy. In this review, we introduce the recently proposed concept of renal-limited HPS/MAS as a novel etiology of histiocytic glomerular lipidosis. Patients with renal-limited HPS/MAS often develop AKI but do not fulfill the diagnostic criteria for HPS/MAS because their systemic manifestations are less severe. Therefore, the diagnosis largely depends on characteristic histological findings, that is, diffuse and global glomerular accumulation of foamy macrophages and cytotoxic lymphocytes accompanied by the interaction of these cells as well as the exclusion of various differential diseases. Although there are no established therapeutic regimens, these patients receive various types of therapies, including high-dose glucocorticoids, immunosuppressants, or anti-interleukin-1 drug, and generally achieve favorable outcomes. We summarized the concept, diagnostic challenges, and recent topics of this disease entity and discussed treatment options based on our own experiences.
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Affiliation(s)
- Takahiro Uchida
- Department of Nephrology and Blood Purification, Kidney Disease Center, Tokyo Medical University Hachioji Medical Center, Tokyo 193-0998, Japan;
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Haruta K, Suzuki T, Yamaguchi M, Fukuda Y, Torii Y, Takahashi Y, Ito Y, Kawada JI. Comparison of plasma proteomic profiles of patients with Epstein-Barr virus-associated hemophagocytic lymphohistiocytosis and infectious mononucleosis. J Med Virol 2024; 96:e29450. [PMID: 38304956 DOI: 10.1002/jmv.29450] [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: 08/23/2023] [Revised: 12/18/2023] [Accepted: 01/23/2024] [Indexed: 02/03/2024]
Abstract
Primary Epstein-Barr virus (EBV) infection occasionally causes EBV-infectious mononucleosis (EBV-IM) and EBV-hemophagocytic lymphohistiocytosis (EBV-HLH). Although EBV-IM is mostly mild and self-limiting, EBV-HLH is a life-threatening disease characterized by excessive immune activation. However, the pathogenesis of EBV-HLH is yet to be fully elucidated. A diagnostic biomarker for EBV-HLH is desirable because early diagnosis and treatment are critical for the effective management of patients. In this study, the proteomic profiling of plasma was performed using liquid chromatography-mass spectrometry to identify proteins specific to EBV-IM and EBV-HLH. Furthermore, pathway analysis was performed for the proteins upregulated in patients with EBV-IM and EBV-HLH. Compared to healthy controls, 63 and 18 proteins were upregulated in patients with EBV-IM and EBV-HLH, respectively. Pathway and process enrichment analyses revealed that the complement system was the most enriched category of upregulated proteins in EBV-IM, whereas proteins related to immune effector processes were the most enriched in EBV-HLH. Among the 18 proteins upregulated in EBV-HLH, seven were exclusive to EBV-HLH. These specific proteins were associated with three pathways, and apolipoprotein E was commonly found in all the pathways. Proteomic analysis may provide new insights into the host response to EBV infection and the pathogenesis of EBV-related diseases.
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Affiliation(s)
- Kazunori Haruta
- Department of Pediatrics, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Takako Suzuki
- Department of Pediatrics, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Makoto Yamaguchi
- Department of Pediatrics, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yuto Fukuda
- Department of Pediatrics, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yuka Torii
- Department of Pediatrics, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yoshiyuki Takahashi
- Department of Pediatrics, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yoshinori Ito
- Department of Pediatrics, Aichi Medical University, Nagakute, Japan
| | - Jun-Ichi Kawada
- Department of Pediatrics, Nagoya University Graduate School of Medicine, Nagoya, Japan
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Walton ZE, Frigault MJ, Maus MV. Current and emerging pharmacotherapies for cytokine release syndrome, neurotoxicity, and hemophagocytic lymphohistiocytosis-like syndrome due to CAR T cell therapy. Expert Opin Pharmacother 2024; 25:263-279. [PMID: 38588525 DOI: 10.1080/14656566.2024.2340738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Accepted: 03/01/2024] [Indexed: 04/10/2024]
Abstract
INTRODUCTION Chimeric antigen receptor (CAR) T cells have revolutionized the treatment of multiple hematologic malignancies. Engineered cellular therapies now offer similar hope to transform the management of solid tumors and autoimmune diseases. However, toxicities can be serious and often require hospitalization. AREAS COVERED We review the two chief toxicities of CAR T therapy, cytokine release syndrome (CRS) and immune effector cell-associated neurotoxicity syndrome (ICANS), and the rarer immune effector cell-associated hemophagocytic lymphohistiocytosis-like syndrome. We discuss treatment paradigms and promising future pharmacologic strategies. Literature and therapies reviewed were identified by PubMed search, cited references therein, and review of registered trials. EXPERT OPINION Management of CRS and ICANS has improved, aided by consensus definitions and guidelines that facilitate recognition and timely intervention. Further data will define optimal timing of tocilizumab and corticosteroids, current foundations of management. Pathophysiologic understanding has inspired off-label use of IL-1 receptor antagonism, IFNγ and IL-6 neutralizing antibodies, and janus kinase inhibitors, with data emerging from ongoing clinical trials. Further strategies to reduce toxicities include novel pharmacologic targets and safety features engineered into CAR T cells themselves. As these potentially curative therapies are used earlier in oncologic therapy and even in non-oncologic indications, effective accessible strategies to manage toxicities are critical.
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Affiliation(s)
- Zandra E Walton
- Cellular Immunotherapy Program, Massachusetts General Hospital Cancer Center, Boston, MA, USA
- Division of Rheumatology, Massachusetts General Hospital, Boston, MA, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Matthew J Frigault
- Cellular Immunotherapy Program, Massachusetts General Hospital Cancer Center, Boston, MA, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Marcela V Maus
- Cellular Immunotherapy Program, Massachusetts General Hospital Cancer Center, Boston, MA, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
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Sola D, Smirne C, Bruggi F, Bottino Sbaratta C, Tamen Njata AC, Valente G, Pavanelli MC, Vitetta R, Bellan M, De Paoli L, Pirisi M. Unveiling the Mystery of Adult-Onset Still's Disease: A Compelling Case Report. Life (Basel) 2024; 14:195. [PMID: 38398704 PMCID: PMC10890189 DOI: 10.3390/life14020195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Revised: 01/24/2024] [Accepted: 01/26/2024] [Indexed: 02/25/2024] Open
Abstract
Adult-onset Still's disease (AOSD) is a rare systemic inflammatory disorder. Diagnosis can take a long time, especially in the presence of confounding factors, and it is, to some extent, a process of exclusion. AOSD has life-threating complications ranging from asymptomatic to severe, such as macrophage activation syndrome (MAS), which is also referred to as hemophagocytic lymphohistocytosis (HLH). This condition is correlated with cytokine storm production and monocyte/macrophage overactivation and typically occurs with rash, pyrexia, pancytopenia, hepatosplenomegaly and systemic involvement. Exitus occurs in approximately 10% of cases. For the treatment of MAS-HLH, the Histiocyte Society currently suggests high-dose corticosteroids, with the possible addition of cyclosporine A, anti-interleukin (IL)-1, or IL-6 biological drugs; the inclusion of etoposide is recommended for the most severe conditions. In all cases, a multidisciplinary collaboration involving the resources and expertise of several specialists (e.g., rheumatologist, infectiologist, critical care medicine specialist) is advised. Herein, we provide a detailed description of the clinical case of a previously healthy young woman in which MAS developed as a dramatic onset manifestation of AOSD and whose diagnosis posed a real clinical challenge; the condition was finally resolved by applying the HLH-94 protocol (i.e., etoposide in combination with dexamethasone).
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Affiliation(s)
- Daniele Sola
- Department of Translational Medicine, Università del Piemonte Orientale, 28100 Novara, Italy
- Internal Medicine Unit, Maggiore della Carità Hospital, 28100 Novara, Italy
- CAAD (Center for Autoimmune and Allergic Diseases), Università del Piemonte Orientale, 28100 Novara, Italy
- IRCAD (Interdisciplinary Research Center of Autoimmune Diseases), Università del Piemonte Orientale, 28100 Novara, Italy
| | - Carlo Smirne
- Department of Translational Medicine, Università del Piemonte Orientale, 28100 Novara, Italy
- Internal Medicine Unit, Maggiore della Carità Hospital, 28100 Novara, Italy
| | - Francesco Bruggi
- Department of Translational Medicine, Università del Piemonte Orientale, 28100 Novara, Italy
- Internal Medicine Unit, Maggiore della Carità Hospital, 28100 Novara, Italy
| | - Chiara Bottino Sbaratta
- Department of Translational Medicine, Università del Piemonte Orientale, 28100 Novara, Italy
- Internal Medicine Unit, Maggiore della Carità Hospital, 28100 Novara, Italy
| | - Aubin Cardin Tamen Njata
- Department of Translational Medicine, Università del Piemonte Orientale, 28100 Novara, Italy
- Internal Medicine Unit, Maggiore della Carità Hospital, 28100 Novara, Italy
| | - Guido Valente
- Department of Translational Medicine, Università del Piemonte Orientale, 28100 Novara, Italy
- Pathology Unit, Sant'Andrea Hospital, 13100 Vercelli, Italy
| | | | - Rosetta Vitetta
- Rheumatology Unit, Sant'Andrea Hospital, 13100 Vercelli, Italy
| | - Mattia Bellan
- Department of Translational Medicine, Università del Piemonte Orientale, 28100 Novara, Italy
- Internal Medicine Unit, Maggiore della Carità Hospital, 28100 Novara, Italy
- CAAD (Center for Autoimmune and Allergic Diseases), Università del Piemonte Orientale, 28100 Novara, Italy
- IRCAD (Interdisciplinary Research Center of Autoimmune Diseases), Università del Piemonte Orientale, 28100 Novara, Italy
| | | | - Mario Pirisi
- Department of Translational Medicine, Università del Piemonte Orientale, 28100 Novara, Italy
- Internal Medicine Unit, Maggiore della Carità Hospital, 28100 Novara, Italy
- CAAD (Center for Autoimmune and Allergic Diseases), Università del Piemonte Orientale, 28100 Novara, Italy
- IRCAD (Interdisciplinary Research Center of Autoimmune Diseases), Università del Piemonte Orientale, 28100 Novara, Italy
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9
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Flower L, Manson JJ. Secondary haemophagocytic lymphohistiocytosis: time for a united approach to diagnosis and cytokine blockade. Anaesth Rep 2024; 12:e12291. [PMID: 38655565 PMCID: PMC11035011 DOI: 10.1002/anr3.12291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/03/2024] [Indexed: 04/26/2024] Open
Affiliation(s)
- L. Flower
- Barts Health NHS TrustLondonUK
- Queen Mary University of LondonLondonUK
| | - J. J. Manson
- University College London Hospital NHS Foundation TrustLondonUK
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