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Zoref-Lorenz A, Lehmberg K, Jordan M. Hemophagocytic Lymphohistiocytosis in the Context of Hematological Malignancies and Solid Tumors. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2024; 1448:429-440. [PMID: 39117831 DOI: 10.1007/978-3-031-59815-9_29] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/10/2024]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) has been described for decades in association with malignancies (M-HLH). While its mechanism is unknown, M-HLH has a poor prognosis, ranging from 10% to 30% overall survival. Mature T-cell lymphomas, diffuse large B-cell lymphoma, and Hodgkin lymphoma, with or without viral co-triggers such as Epstein-Barr virus, are among the most frequent underlying entities. Most M-HLH cases occur at the presentation of malignancy, but they may also occur during therapy as a result of immune compromise from chemotherapy (HLH in the context of immune compromise, IC-HLH) and (typically) disordered response to infection or after immune-activating therapies (Rx-HLH, also known as cytokine release syndrome, CRS). IC-HLH typically occurs months after diagnosis in the context of fungal, bacterial, or viral infection, though it may occur without an apparent trigger. Rx-HLH can be associated with checkpoint blockade, chimeric antigen receptor T-cell therapy, or bispecific T-cell engaging therapy. Until recently, M-HLH diagnosis and treatment strategies were extrapolated from familial HLH (F-HLH), though optimized diagnostic and therapeutic treatment strategies are emerging.
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Affiliation(s)
- Adi Zoref-Lorenz
- Hematology Institute, Meir Medical Center, Faculty of Medical & Health Sciences, Tel Aviv University, Tel Aviv, Israel
| | - Kai Lehmberg
- Division of Pediatric Stem Cell Transplantation and Immunology, Clinic of Pediatric Hematology and Oncology, University Medical Center Hamburg Eppendorf, Hamburg, Germany
| | - Michael Jordan
- Divisions of Immunobiology and Bone Marrow Transplantation/Immune Deficiency, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA.
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Bami S, Vagrecha A, Soberman D, Badawi M, Cannone D, Lipton JM, Cron RQ, Levy CF. The use of anakinra in the treatment of secondary hemophagocytic lymphohistiocytosis. Pediatr Blood Cancer 2020; 67:e28581. [PMID: 32725881 DOI: 10.1002/pbc.28581] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 06/22/2020] [Accepted: 06/23/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Hemophagocytic lymphohistiocytosis (HLH) can be familial or secondary, which is often triggered by infection or malignancy. HLH therapy includes dexamethasone and etoposide. However, therapy is associated with significant morbidity and mortality. Anakinra, a recombinant interleukin-1 receptor antagonist, has been reported to treat macrophage activation syndrome (MAS), rheumatic sHLH. We report our experience with anakinra to treat patients with nonrheumatic secondary HLH (sHLH). PROCEDURE Six children were diagnosed with HLH from December 2014 to August 2016 and were treated with subcutaneous anakinra (6-10 mg/kg/day divided over four doses) with or without dexamethasone (10 mg/m2 /day). Therapy was either escalated or weaned based on clinical and laboratory response. RESULTS Five of six patients were treated with anakinra and dexamethasone, and one with anakinra alone due to active cytomegalovirus (CMV) pneumonitis. The median age of diagnosis was 1.8 years (range 0.8-14.9 years). No pathogenic mutations associated with HLH were identified, but three of six possessed genetic variants of unknown significance. Infectious triggers were identified for four patients and two patients had malignancies. The average treatment duration was 8 weeks with 3.5-5.5 years of follow up. No patient needed escalation of therapy to include etoposide. All patients achieved remission. Anakinra was well tolerated without significant adverse effects. CONCLUSION Initial treatment with anakinra (with or without dexamethasone) is a feasible treatment alternative for patients with secondary HLH and may allow for avoidance of etoposide. We recommend early initiation of anakinra when HLH is suspected. A broader investigation of the use of anakinra as a first-line agent for HLH is ongoing.
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Affiliation(s)
- Sakshi Bami
- Hospitalist Medicine Program, St Jude Children's Research Hospital, Memphis, Tennessee
| | - Anshul Vagrecha
- Department of Pediatrics, Division of Hematology/Oncology and Cellular Therapy, Cohen Children's Medical Center, New Hyde Park, New York.,Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York
| | | | - Mohamad Badawi
- Division of Pediatric Hematology/Oncology, West Virginia University, Charleston, West Virginia
| | - Daniel Cannone
- Division of Pediatric Hematology/Oncology and Stem Cell Transplantation, Children's Hospital of Richmond, Virginia Commonwealth University, Richmond, Virginia
| | - Jeffrey M Lipton
- Department of Pediatrics, Division of Hematology/Oncology and Cellular Therapy, Cohen Children's Medical Center, New Hyde Park, New York.,Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York
| | - Randy Q Cron
- Division of Pediatric Rheumatology, Children's Hospital of Alabama, University of Alabama, Birmingham, Alabama
| | - Carolyn Fein Levy
- Department of Pediatrics, Division of Hematology/Oncology and Cellular Therapy, Cohen Children's Medical Center, New Hyde Park, New York.,Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York
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Alsaid HM, Wahdan AAM, Tahboub IN, Almakadma NM. Hemophagocytic Lymphohistiocytosis and Relapsing Polychondritis with Acute Myelogenous Leukemia: Case Report and Review of the Literature. AMERICAN JOURNAL OF CASE REPORTS 2020; 21:e925287. [PMID: 32812531 PMCID: PMC7458697 DOI: 10.12659/ajcr.925287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Patient: Female, 16-year-old Final Diagnosis: Hemophagocytic lymphohistiocytosis • relapsing polychondritis Symptoms: Fever • joint pain • leukopenia Medication: — Clinical Procedure: — Specialty: Cardiology • Critical Care Medicine • Hematology • General and Internal Medicine • Pediatrics and Neonatology • Rheumatology
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Affiliation(s)
- Hamza M Alsaid
- Department of Medicine, Hadassah University Hospital, Al-Quds School of Medicine, Jerusalem, Israel
| | - Adnan A M Wahdan
- Department of Internal Medicine, Palestine Medical Complex, Ramallah, West Bank, Palestinian Territory, Occupied
| | - Ihab N Tahboub
- Department of Medicine, College of Medicine and Health Sciences, An-Najah National University, Nablus, West Bank, Palestinian Territory, Occupied
| | - Nour M Almakadma
- Department of Internal Medicine, Palestine Medical Complex, Ramallah, West Bank, Palestinian Territory, Occupied
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Haloot J, Kaheri M, Hamby T, Ray A. Hemophagocytic Lymphohistiocytosis Secondary to Malignancy and Chemotherapy in Pediatric Patients: A Single-Institution Experience. Indian J Med Paediatr Oncol 2019. [DOI: 10.4103/ijmpo.ijmpo_197_17] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
AbstractHemophagocytic lymphohistiocytosis (HLH) is an uncommon yet potentially devastating systemic disease, arising from uncontrolled activation of the immune system. While the primary form of this disease can be caused by genetic mutation(s), the secondary form may be triggered by infection and hematologic, malignant, and metabolic conditions. The diagnosis of HLH remains a clinical challenge due to nonspecific symptoms. Proper diagnosis is significantly more difficult among patients with acute leukemia who have received chemotherapy. The objective of this study is to describe three unique cases of secondary HLH, describe the specific treatment, and improve the awareness of this condition. Two patients with acute myeloid leukemia (AML) and one with acute lymphoblastic leukemia were diagnosed with HLH, having fulfilled the criteria as outlined in the HLH-2004 protocol. They then received HLH-specific treatment. Two patients passed – one from refractory HLH and one from primary disease (i.e., AML) – and one patient remains alive 22 months after her allogeneic bone marrow transplant. The diagnosis of HLH requires the presence of any five of the eight criteria. Due to its heterogeneous presentation, it remains imperative that treating clinicians remain cognizant about HLH so that prompt diagnosis may allow appropriate treatment.
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Affiliation(s)
- Justin Haloot
- Texas College of Osteopathic Medicine, University of North Texas Health Science Center, Fort Worth, Texas, USA
| | - Mahdi Kaheri
- Texas College of Osteopathic Medicine, University of North Texas Health Science Center, Fort Worth, Texas, USA
| | - Tyler Hamby
- Departments of Research Operations, Cook Children’s Health Care System, Fort Worth, Texas, USA
| | - Anish Ray
- Departments of Pediatric Hematology/Oncology, Cook Children’s Health Care System, Fort Worth, Texas, USA
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Sepulveda FE, de Saint Basile G. Hemophagocytic syndrome: primary forms and predisposing conditions. Curr Opin Immunol 2017; 49:20-26. [PMID: 28866302 DOI: 10.1016/j.coi.2017.08.004] [Citation(s) in RCA: 74] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Accepted: 08/12/2017] [Indexed: 12/18/2022]
Abstract
Hemophagocytic lymphohistiocytosis (HLH, also referred to a hemophagocytic syndrome) is a life-threatening condition in which uncontrolled activation of lymphocytes and macrophages, and thus the secretion of large amounts of inflammatory cytokines, leads to a severe hyperinflammatory state. Over the last few decades, researchers have characterized primary forms of HLH caused by genetic defects that impair lymphocytes' cytotoxic machinery. Other genetic causes of HLH not related to impaired cytotoxicity have also recently been identified. Furthermore, the so-called 'acquired' forms of HLH are encountered in the context of severe infections, autoimmune and autoinflammatory diseases, malignancy, and metabolic disorders, and may also be associated with primary immunodeficiencies. This implies that a variety of disease mechanisms can lead to HLH. Today's research seeks to gain a better understanding of the various pathogenetic and environmental factors that converge to induce HLH.
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Affiliation(s)
- Fernando E Sepulveda
- INSERM UMR1163, Laboratory of Normal and Pathological Homeostasis of the Immune System, Paris F-75015, France; Paris Descartes University-Sorbonne Paris Cité, Imagine Institute, Paris F-75015, France
| | - Geneviève de Saint Basile
- INSERM UMR1163, Laboratory of Normal and Pathological Homeostasis of the Immune System, Paris F-75015, France; Paris Descartes University-Sorbonne Paris Cité, Imagine Institute, Paris F-75015, France; Centre d'Etudes des Déficites Immunitaires, Assistance Publique-Hôpitaux de Paris, F-75015, France.
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Wang H, Xiong L, Tang W, Zhou Y, Li F. A systematic review of malignancy-associated hemophagocytic lymphohistiocytosis that needs more attentions. Oncotarget 2017; 8:59977-59985. [PMID: 28938698 PMCID: PMC5601794 DOI: 10.18632/oncotarget.19230] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Accepted: 06/29/2017] [Indexed: 12/11/2022] Open
Abstract
As an infrequent but potentially life-threatening hyperinflammatory syndrome, hemophagocytic lymphohistiocytosis (HLH) is clinically characterized with prolonged fever, hepatosplenomegaly, cytopenia, hypertriglyceridemia, hyperferritinemia and hemophagocytosis in bone marrow, liver, spleen or lymph nodes. Malignancy-associated HLH (M-HLH), one type of acquired HLH, usually presents variable overlaps of symptoms with other types of HLH, thus resulting in higher incidence of misdiagnosis and mortality. In recent years, with the increasing awareness to this disease, the diagnosis and management of HLH have gained more and more attention, and improvements have been made accordingly. As a result, the survival of patients is greatly prolonged. However, there is still no consensus on the diagnostic criteria and treatment strategies due to lack of large samples or prospective clinical trials. In order to improve recognition and diagnosis, and provide guidance regarding the treatment of M-HLH, the Study Group in HLH Subtypes of the Histiocyte Society has developed consensus recommendations for the diagnosis and management of M-HLH in 2015. In the present article, we summarized and discussed some updated understandings in M-HLH.
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Affiliation(s)
- Hongluan Wang
- Department of Hematology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi 330006, China.,Medical College, Nanchang University, Nanchang, Jiangxi 330006, China.,Department of Respiratory, Jiangxi Provincial People's Hospital, Nanchang, Jiangxi 330006, China
| | - Lixia Xiong
- Department of Hematology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi 330006, China.,Medical College, Nanchang University, Nanchang, Jiangxi 330006, China
| | - Weiping Tang
- Department of Hematology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi 330006, China.,Medical College, Nanchang University, Nanchang, Jiangxi 330006, China
| | - Ying Zhou
- Medical College, Nanchang University, Nanchang, Jiangxi 330006, China
| | - Fei Li
- Department of Hematology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi 330006, China
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Lehmberg K, Nichols KE, Henter JI, Girschikofsky M, Greenwood T, Jordan M, Kumar A, Minkov M, La Rosée P, Weitzman S. Consensus recommendations for the diagnosis and management of hemophagocytic lymphohistiocytosis associated with malignancies. Haematologica 2016; 100:997-1004. [PMID: 26314082 DOI: 10.3324/haematol.2015.123562] [Citation(s) in RCA: 69] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
The hyperinflammatory syndrome hemophagocytic lymphohistiocytosis can occur in the context of malignancies. Malignancy-triggered hemophagocytic lymphohistiocytosis should be regarded separately from hemophagocytic lymphohistiocytosis during chemotherapeutic treatment, which is frequently associated with an infectious trigger. The substantial overlap between the features of hemophagocytic lymphohistiocytosis with features of neoplasms makes its identification difficult when it occurs in malignant conditions. To facilitate recognition and diagnostic workup, and provide guidance regarding the treatment of malignancy-associated hemophagocytic lymphohistiocytosis, consensus recommendations were developed by the Study Group on Hemophagocytic Lymphohistiocytosis Subtypes of the Histiocyte Society, an interdisciplinary group consisting of pediatric and adult hemato-oncologists and immunologists.
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Affiliation(s)
- Kai Lehmberg
- Department of Pediatric Hematology and Oncology, University Medical Center Eppendorf, Hamburg, Germany
| | - Kim E Nichols
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Jan-Inge Henter
- Childhood Cancer Research Unit, Department of Women's and Children's Health, Karolinska Institutet, Karolinska University Hospital Solna, Stockholm, Sweden
| | - Michael Girschikofsky
- Department of Medicine I, Hematology and Stem Cell Transplantation, Hemostasis and Medical Oncology, Elisabethinen Hospital, Linz, Austria
| | - Tatiana Greenwood
- Childhood Cancer Research Unit, Department of Women's and Children's Health, Karolinska Institutet, Karolinska University Hospital Solna, Stockholm, Sweden
| | - Michael Jordan
- Department of Immunology, Cincinnati Children's Hospital, OH, USA
| | - Ashish Kumar
- Department of Immunology, Cincinnati Children's Hospital, OH, USA
| | - Milen Minkov
- Department of Pediatric Hematology and Oncology, St. Anna Children's Hospital, Vienna, Austria
| | - Paul La Rosée
- Klinik für Innere Medizin II, Abt. Hämatologie und internistische Onkologie, Universitätsklinikum Jena, Germany
| | - Sheila Weitzman
- Department of Hematology and Oncology, Sick Kids Hospital, Toronto, Canada
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Loghavi S, Kutok JL, Jorgensen JL. B-acute lymphoblastic leukemia/lymphoblastic lymphoma. Am J Clin Pathol 2015; 144:393-410. [PMID: 26276770 DOI: 10.1309/ajcpan7bh5dnywzb] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVES This session of the 2013 Society of Hematopathology/European Association for Haematopathology Workshop was dedicated to B-acute lymphoblastic leukemia (B-ALL)/lymphoblastic lymphoma (LBL) with recurrent translocations and not otherwise specified. METHODS In this review, we summarize the cases discussed during the workshop, review the pertinent and most recent literature on the respective topics, and provide a few key points that may aid in the workup of patients with B-ALL/LBL. RESULTS Many of the submitted cases showed interesting diagnostic, immunophenotypic, or clinical aspects of B-ALL with BCR/ABL1, MLL-associated, and other recurrent chromosomal abnormalities. Several cases showed rare aberrancies such as coexistent IGH/BCL2 and MYC rearrangements and raised issues in classification. Other cases had unusual clinical presentations, including B-ALL with hypereosinophilia and therapy-related B-ALL. Several cases highlighted the role of flow cytometry immunophenotyping in distinguishing benign B-cell precursors from aberrant lymphoblasts, and other cases raised questions regarding the clinical importance of myeloperoxidase positivity in acute lymphoblastic leukemia. CONCLUSIONS The complexity and spectrum of cases presented in this review highlight the importance of clinicopathologic correlation and the value of ancillary studies in the classification and workup of patients with B-ALL/LBL.
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Affiliation(s)
- Sanam Loghavi
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston; and
| | | | - Jeffrey L. Jorgensen
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston; and
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Malinowska I, Machaczka M, Popko K, Siwicka A, Salamonowicz M, Nasiłowska-Adamska B. Hemophagocytic syndrome in children and adults. Arch Immunol Ther Exp (Warsz) 2014; 62:385-94. [PMID: 24509696 PMCID: PMC4164855 DOI: 10.1007/s00005-014-0274-1] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2013] [Accepted: 01/07/2014] [Indexed: 11/22/2022]
Abstract
Hemophagocytic syndrome, also known as hemophagocytic lymphohistiocytosis (HLH), is a heterogenic syndrome, which leads to an acute, life-threatening inflammatory reaction. HLH occurs both in children and adults, and can be triggered by various inherited as well as acquired factors. Depending on the etiology, HLH can be divided into genetic (i.e., primary) and acquired (i.e., secondary) forms. Among genetic HLH forms, one can distinguish between familial HLH and other genetically conditioned forms of HLH. Acquired HLH can be typically triggered by infections, autoimmune diseases, and malignancies. The most common symptoms of HLH are unremitting fever, splenomegaly, and peripheral blood cytopenia. Some severely ill patients present with central nervous system involvement. Laboratory tests reveal hyperferritinemia (often >10,000 μg/L), increased serum concentration of soluble receptor α for interleukin-2 (>2,400 U/L), hypertriglyceridemia, hypofibrinogenemia, coagulopathy, hyponatremia, hypoproteinemia, and elevated liver transaminases and bilirubin. Prognosis in HLH is very serious. Genetic HLH is always lethal if adequate therapy is not administered. Similarly, severe acquired cases often lead to death without appropriate treatment. Since HLH can be encountered by various specialists in the medical field, basic knowledge of this entity such as diagnostic criteria and treatment should be familiar to all physicians.
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Affiliation(s)
- Iwona Malinowska
- Department of Pediatrics, Hematology and Oncology, Medical University of Warsaw, 00-576 Warsaw, Poland
| | - Maciej Machaczka
- Division of Hematology, Department of Medicine at Huddinge, Karolinska Institutet, M54, SE-141 86 Stockholm, Sweden
- Medical Faculty, University of Rzeszow, Rzeszow, Poland
| | - Katarzyna Popko
- Department of Laboratory Medicine and Pediatric Immunology, Medical University of Warsaw, Warsaw, Poland
| | - Alicja Siwicka
- Department of Pediatrics, Hematology and Oncology, Medical University of Warsaw, 00-576 Warsaw, Poland
| | - Małgorzata Salamonowicz
- Department of Pediatrics, Hematology and Oncology, Medical University of Warsaw, 00-576 Warsaw, Poland
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Bennett TD, Fluchel M, Hersh AO, Hayward KN, Hersh AL, Brogan TV, Srivastava R, Stone BL, Korgenski EK, Mundorff MB, Casper TC, Bratton SL. Macrophage activation syndrome in children with systemic lupus erythematosus and children with juvenile idiopathic arthritis. ACTA ACUST UNITED AC 2013; 64:4135-42. [PMID: 22886474 DOI: 10.1002/art.34661] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2012] [Accepted: 07/31/2012] [Indexed: 01/02/2023]
Abstract
OBJECTIVE To describe patient demographics, interventions, and outcomes in hospitalized children with macrophage activation syndrome (MAS) complicating systemic lupus erythematosus (SLE) or juvenile idiopathic arthritis (JIA). METHODS We performed a retrospective cohort study using data recorded in the Pediatric Health Information System (PHIS) database from October 1, 2006 to September 30, 2010. Participants had International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes for MAS and either SLE or JIA. The primary outcome was hospital mortality (for the index admission). Secondary outcomes included intensive care unit (ICU) admission, critical care interventions, and medication use. RESULTS A total of 121 children at 28 children's hospitals met the inclusion criteria, including 19 children with SLE and 102 children with JIA. The index admission mortality rate was 7% (8 of 121 patients). ICU admission (33%), mechanical ventilation (26%), and inotrope/vasopressor therapy (26%) were common. Compared to children with JIA, those with SLE had a similar mortality rate (6% versus 11%, respectively; exact P = 0.6). More patients with SLE than those with JIA received ICU care (63% versus 27%; P = 0.002), received mechanical ventilation (53% versus 21%; P = 0.003), and had cardiovascular dysfunction (47% versus 23% received inotrope/vasopressor therapy; P = 0.02). Children with SLE and those with JIA received cyclosporine at similar rates, but more children with SLE received cyclophosphamide and mycophenolate mofetil, and more children with JIA received interleukin-1 antagonists. CONCLUSION Organ system dysfunction is common in children with rheumatic diseases complicated by MAS, and more organ system support is required in children with underlying SLE than in children with JIA. Current treatment of pediatric MAS varies based on the underlying rheumatic disease.
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Affiliation(s)
- Tellen D Bennett
- Pediatric Critical Care, University of Utah, Salt Lake City, UT 84158-1289, USA.
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Lehmberg K, Ehl S. Diagnostic evaluation of patients with suspected haemophagocytic lymphohistiocytosis. Br J Haematol 2012. [PMID: 23206255 DOI: 10.1111/bjh.12138] [Citation(s) in RCA: 89] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Haemophagocytic lymphohistiocytosis (HLH) is a life-threatening hyperinflammatory syndrome characterized by severely disturbed immune homeostasis. It can affect all age groups. Diagnostic evaluation of the patient with suspected HLH has to address three main questions: (i) does the patient have HLH? There is no simple diagnostic test, but a number of clinical and laboratory criteria define this clinical syndrome. (ii) Can a trigger be identified? A variety of infections, malignant or autoimmune diseases can contribute to the disturbed immune homeostasis with important consequences for treatment. (iii) Does the patient suffer from a genetic disease predisposing to HLH? Recent advances in the understanding of the genetic and pathophysiological basis of HLH have enabled a better and more rapid answer to this question, which is relevant for prognosis and the decision to perform haematopoietic stem cell transplantation. This review summarizes the current diagnostic approach to the patient with HLH.
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Affiliation(s)
- Kai Lehmberg
- Department of Paediatric Haematology and Oncology, University Medical Centre, Hamburg, Germany
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12
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Current world literature. Curr Opin Pediatr 2012; 24:134-44. [PMID: 22245849 DOI: 10.1097/mop.0b013e328350498a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
AbstractHemophagocytic lymphohistiocytosis (HLH) is a potentially fatal hyperinflammatory condition. It may occur as a primary (genetic) condition due to mutations in genes important in the cytolytic secretory pathway that cause perforin and granzymes to induce apoptosis in target cells. Primary HLH is divided into familial HLH (FHLH1-5), in which HLH is the only manifestation of disease, and other genetic causes in which HLH is one of several clinical manifestations. The identical clinical findings may arise secondary to infectious, rheumatologic, malignant, or metabolic conditions. Whether primary or secondary, HLH therapy needs to be instituted promptly to prevent irreversible tissue damage. It is helpful to think of HLH as the severe end of the spectrum of hyperinflammatory disorders when the immune system starts to damage host tissues (immunopathology). Therefore, no single clinical feature alone is diagnostic for HLH, and it is important that the entire clinical presentation be considered in making the diagnosis. This article contains a discussion of the genetic background, clinical presentation, diagnostic dilemmas, and features that are helpful in making the diagnosis of HLH, along with a discussion of common problems in its management.
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Machaczka M, Nahi H, Karbach H, Klimkowska M, Hägglund H. Successful treatment of recurrent malignancy-associated hemophagocytic lymphohistiocytosis with a modified HLH-94 immunochemotherapy and allogeneic stem cell transplantation. Med Oncol 2011; 29:1231-6. [PMID: 21533602 DOI: 10.1007/s12032-011-9963-3] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2011] [Accepted: 04/18/2011] [Indexed: 11/27/2022]
Abstract
Acquired hemophagocytic lymphohistiocytosis (HLH) triggered by a known or still to be recognized malignancy is a life-threatening hyperinflammatory syndrome due to massive cytokine release from activated lymphocytes and macrophages. Malignancy-associated HLH (M-HLH) often impedes adequate treatment of malignancy and has the worst outcome compared with any other form of HLH. The incidence of M-HLH is unknown, and there are no published treatment recommendations addressed to this HLH form. Here, we report the case of a young woman with recurrent ALK1-positive anaplastic large T-cell lymphoma and M-HLH successfully treated with a modified HLH-94 protocol, allogeneic stem cell transplantation (alloSCT) and donor lymphocyte infusion (DLI). More than 3 years after DLI, the patient is alive, in complete remission from her malignancy and HLH-free, although suffering from extensive chronic graft-versus-host disease. AlloSCT and, if needed, DLI performed to consolidate remission of malignancy and HLH may have a curative impact on both entities. We propose that when discussing possible treatment options for patients with M-HLH, alloSCT should be considered in eligible individuals.
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MESH Headings
- Adult
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Combined Modality Therapy
- Cytarabine/administration & dosage
- Dexamethasone/administration & dosage
- Drug Therapy, Combination
- Etoposide/administration & dosage
- Female
- Graft vs Host Disease/prevention & control
- Humans
- Immunosuppressive Agents/therapeutic use
- Lymphocyte Transfusion
- Lymphohistiocytosis, Hemophagocytic/immunology
- Lymphohistiocytosis, Hemophagocytic/therapy
- Lymphoma, Large-Cell, Anaplastic/immunology
- Lymphoma, Large-Cell, Anaplastic/therapy
- Mitoxantrone/administration & dosage
- Neoplasm Recurrence, Local/immunology
- Neoplasm Recurrence, Local/therapy
- Prognosis
- Remission Induction
- Stem Cell Transplantation
- Transplantation, Homologous
- Young Adult
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Affiliation(s)
- Maciej Machaczka
- Hematology Center Karolinska, Karolinska University Hospital Huddinge, 141 86 Stockholm, Sweden.
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