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Abida F, Ben Salah R, Chaari M, Koubaa M, Ben Jemaa M, Elleuch H, Bahloul Z. Reactive hemophagocytic lymphohistiocytosis: Epidemiological, clinico-biological and etiological profile. Curr Res Transl Med 2024; 72:103459. [PMID: 39002408 DOI: 10.1016/j.retram.2024.103459] [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: 03/11/2024] [Revised: 06/18/2024] [Accepted: 06/26/2024] [Indexed: 07/15/2024]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is an hyperinflammatory state resulting from increased secretion of proinflammatory cytokines, which are responsible for clinical, biological and cytological manifestations. OBJECTIVE The aim of our study is to describe the epidemiological, clinical, biological, etiological and evolutionary profile of HLH in Tunisia. METHODS A retrospective study that involved patients, with images of hemophagocytosis in myelograms analyzed at the laboratory of biological hematology of the University Hospital "Hédi-Chaker" of Sfax-Tunisia, followed at these departments: hematology, internal medicine, department of infectious-diseases and department of gastroenterology, (June2017- May2021). First, we identified all patients with hemophagocytosis images. Secondly, we selected the patients who fulfilled the diagnostic criteria of the HLH-2004-score. RESULTS Nineteen patients were included in this study. Nine men and 10 women with a mean age of 37.95 years. Fever was present in all patients. Organomegaly was described in 74% of cases. The most frequent cytopenia was anemia (100%). Hypertriglyceridemia was noted in 79% of cases and hyperferritinemia (> 500 ng/mL) was ubiquitous. In myelogram, 68% of patients had slides showing numerous or very numerous images of hemophagocytosis. The infectious pathology was the most common cause of HLH (42%). No cause was found in 10% of cases. The corticosteroid therapy at a dose of 1 mg/kg/day was prescribed in 89% of our patients. The overall evolution was favorable in 58% of cases. The mortality was not associated with the causal pathology (p=0.218). CONCLUSION Secondary HLH is likely to be under-recognized, which contributes to its high morbidity and mortality. Early recognition is crucial for any reasonable attempt at curative therapy.
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Affiliation(s)
- Fatma Abida
- Laboratory of hematology, Hedi Chaker University Hospital, Sfax, Tunisia
| | - Raida Ben Salah
- Department of internal medicine, Hedi Chaker University Hospital, Sfax, Tunisia.
| | - Mourad Chaari
- Laboratory of hematology, Hedi Chaker University Hospital, Sfax, Tunisia
| | - Makram Koubaa
- Department of infectious diseases, Hedi Chaker University Hospital, Sfax, Tunisia
| | - Mounir Ben Jemaa
- Department of infectious diseases, Hedi Chaker University Hospital, Sfax, Tunisia
| | - Henda Elleuch
- Laboratory of hematology, Hedi Chaker University Hospital, Sfax, Tunisia
| | - Zouheir Bahloul
- Department of internal medicine, Hedi Chaker University Hospital, Sfax, Tunisia
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Dumas G, Arabi YM, Bartz R, Ranzani O, Scheibe F, Darmon M, Helms J. Diagnosis and management of autoimmune diseases in the ICU. Intensive Care Med 2024; 50:17-35. [PMID: 38112769 DOI: 10.1007/s00134-023-07266-7] [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: 06/23/2023] [Accepted: 11/01/2023] [Indexed: 12/21/2023]
Abstract
Autoimmune diseases encompass a broad spectrum of disorders characterized by disturbed immunoregulation leading to the development of specific autoantibodies, resulting in inflammation and multiple organ involvement. A distinction should be made between connective tissue diseases (mainly systemic lupus erythematosus, systemic scleroderma, inflammatory muscle diseases, and rheumatoid arthritis) and vasculitides (mainly small-vessel vasculitis such as antineutrophil cytoplasmic antibody-associated vasculitis and immune-complex mediated vasculitis). Admission of patients with autoimmune diseases to the intensive care unit (ICU) is often triggered by disease flare-ups, infections, and organ failure and is associated with high mortality rates. Management of these patients is complex, including prompt disease identification, immunosuppressive treatment initiation, and life-sustaining therapies, and requires multi-disciplinary involvement. Data about autoimmune diseases in the ICU are limited and there is a need for multicenter, international collaboration to improve patients' diagnosis, management, and outcomes. The objective of this narrative review is to summarize the epidemiology, clinical features, and selected management of severe systemic autoimmune diseases.
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Affiliation(s)
- Guillaume Dumas
- Medical Intensive Care Unit, Service de Médecine Intensive-Réanimation, CHU Grenoble-Alpes, Université Grenoble-Alpes, INSERM, U1042-HP2, Grenoble, France.
| | - Yaseen M Arabi
- Intensive Care Department, Ministry of the National Guard-Health Affairs, Riyadh, Kingdom of Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Kingdom of Saudi Arabia
- King Saud Bin Abdulaziz University for Health Sciences Riyadh, Riyadh, Kingdom of Saudi Arabia
| | - Raquel Bartz
- Department of Anesthesia, Perioperative, and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Otavio Ranzani
- Barcelona Institute for Global Health, ISGlobal, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
- Pulmonary Division, Faculdade de Medicina, Heart Institute, InCor, Hospital das Clinicas HCFMUSP, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Franziska Scheibe
- Department of Neurology and Experimental Neurology, Charité- Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany
- NeuroCure Clinical Research Center, Charité-Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Michaël Darmon
- Medical Intensive Care Unit, APHP, Hôpital Saint-Louis, Famirea Study Group, ECSTRA Team, and Clinical EpidemiologyUMR 1153, Center of Epidemiology and Biostatistics, Sorbonne Paris Cité, CRESS, INSERM, Université Paris Cité, Paris, France
| | - Julie Helms
- Faculté de Médecine, Service de Médecine Intensive-Réanimation, Université de Strasbourg (UNISTRA), Hôpitaux Universitaires de Strasbourg, Nouvel Hôpital Civil, 1 Place de L'Hôpital, Strasbourg, France
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Landy E, Varghese J, Dang V, Szymczak-Workman A, Kane LP, Canna SW. Complementary HLH susceptibility factors converge on CD8 T-cell hyperactivation. Blood Adv 2023; 7:6949-6963. [PMID: 37738167 PMCID: PMC10690564 DOI: 10.1182/bloodadvances.2023010502] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 09/11/2023] [Accepted: 09/12/2023] [Indexed: 09/24/2023] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) and macrophage activation syndrome (MAS) are life-threatening hyperinflammatory syndromes. Familial HLH is caused by genetic impairment of granule-mediated cytotoxicity (eg, perforin deficiency). MAS is linked to excess activity of the inflammasome-activated cytokine interleukin-18 (IL-18). Though individually tolerated, mice with dual susceptibility (Prf1⁻/⁻Il18tg; DS) succumb to spontaneous, lethal hyperinflammation. We hypothesized that understanding how these susceptibility factors synergize would uncover key pathomechanisms in the activation, function, and persistence of hyperactivated CD8 T cells. In IL-18 transgenic (Il18tg) mice, IL-18 effects on CD8 T cells drove MAS after a viral (lymphocytic choriomeningitis virus), but not innate (toll like receptor 9), trigger. In vitro, CD8 T cells also required T-cell receptor (TCR) stimulation to fully respond to IL-18. IL-18 induced but perforin deficiency impaired immunoregulatory restimulation-induced cell death (RICD). Paralleling hyperinflammation, DS mice displayed massive postthymic oligoclonal CD8 T-cell hyperactivation in their spleens, livers, and bone marrow as early as 3 weeks. These cells increased proliferation and interferon gamma production, which contrasted with increased expression of receptors and transcription factors associated with exhaustion. Broad-spectrum antibiotics and antiretrovirals failed to ameliorate the disease. Attempting to genetically "fix" TCR antigen-specificity instead demonstrated the persistence of spontaneous HLH and hyperactivation, chiefly on T cells that had evaded TCR fixation. Thus, drivers of HLH may preferentially act on CD8 T cells: IL-18 amplifies activation and demand for RICD, whereas perforin supplies critical immunoregulation. Together, these factors promote a terminal CD8 T-cell activation state, combining features of exhaustion and effector function. Therefore, susceptibility to hyperinflammation may converge on a unique, unrelenting, and antigen-dependent state of CD8 T-cell hyperactivation.
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Affiliation(s)
- Emily Landy
- Department of Immunology, University of Pittsburgh, Pittsburgh, PA
- Graduate Program in Microbiology and Immunology, University of Pittsburgh, Pittsburgh, PA
| | - Jemy Varghese
- Rheumatology & Immune Dysregulation, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Vinh Dang
- Rheumatology & Immune Dysregulation, Children’s Hospital of Philadelphia, Philadelphia, PA
| | | | - Lawrence P. Kane
- Department of Immunology, University of Pittsburgh, Pittsburgh, PA
| | - Scott W. Canna
- Rheumatology & Immune Dysregulation, Children’s Hospital of Philadelphia, Philadelphia, PA
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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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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Qiu Q, Li D, Chen Y, Song Y, Lou S, Zhou K, Deng J. Clinical features and prognostic risk prediction of adult hemophagocytic lymphohistiocytosis: a 9-year retrospective study. Ann Hematol 2023; 102:2671-2682. [PMID: 37464139 DOI: 10.1007/s00277-023-05368-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 07/11/2023] [Indexed: 07/20/2023]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) has a low incidence and high mortality. In order to improve our understanding of the clinical features and prognostic risk factors of adult HLH, we analyzed the clinical characteristics and prognostic risk factors of adult HLH and developed a prognostic model to predict the overall survival (OS) of adult HLH. The clinical characteristics and survival statistics of adult patients with HLH identified at The Second Affiliated Hospital of Chongqing Medical University between February 2012 and October 2020 were retrospectively analyzed to constitute the primary cohort, while patients between 25 October 2020 and 20 March 2023 were collected at the same institution as a validation cohort for the prospective study. A total of 142 patients met the inclusion criteria, with 72 and 70 in the primary cohort and validation cohort respectively. In the primary cohort, the median OS was 102 days, with 37.5%, 34.5%, and 28.7% 1-, 2-, and 3-year OS, respectively. Univariate analysis showed that age, interleukin-10 (IL-10), interleukin-2 receptor (IL-2R), prothrombin time (PT), and indirect bilirubin (IBiL) were correlated with prognosis. Multivariate analysis showed that IL-10 and PT were independent factors affecting OS in adult patients with HLH. A prognostic model consisting of IL-2R, PT, and IL-10 and a corresponding prognostic nomogram were developed adopting the principle of minimum value of Akaike information criterion(AIC). The model has a high prediction accuracy letter (C-index = 0.708). The AUC values of 1-year, 2-year, and 3-year were 0.826, 0.865, and 0.882, correspondingly. In the validation cohort, all patients were divided into high-risk and low-risk groups, and the risk of death was significantly higher in the high-risk group than in the low-risk group (p < 0.01). The calibration curve for the model shows that the Nomogram constructed in this study is very reliable to predict the OS of HLH patients. IL-10 and PT have significant prognostic value in adult HLH. The prognostic model and the nomogram built in this study can forecast the OS of adult HLH patients.
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Affiliation(s)
- Qunxiang Qiu
- Department of Hematology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010, China
| | - Dan Li
- Department of Hematology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010, China
| | - Ying Chen
- Department of Hematology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010, China
| | - Ying Song
- Department of Hematology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010, China
| | - Shifeng Lou
- Department of Hematology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010, China
| | - Kang Zhou
- Department of Hematology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010, China.
| | - Jianchuan Deng
- Department of Hematology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010, China.
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Gautam D, Dadheech M, Ingle V, Jayashankar E, Purwar S, Maurya AK. Disseminated tuberculosis in rare association with hemophagocytic lymphocytosis - A case report from central India. Heliyon 2023; 9:e15646. [PMID: 37151652 PMCID: PMC10161793 DOI: 10.1016/j.heliyon.2023.e15646] [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] [Received: 07/29/2022] [Revised: 03/18/2023] [Accepted: 04/17/2023] [Indexed: 05/09/2023] Open
Abstract
Hemophagocytic Lymphohistiocytosis (HLH) is an uncommon, diverse and rare genetic hyper-inflammatory syndrome. HLH associated with tuberculosis (TB-HLH) has been described as a clinical and diagnostic quandary. The co-existence leads to significantly higher morbidity and mortality. Our case highlights the presence of disseminated tuberculosis and worsening of the case due to underlying hemophagocytic syndrome leading to rapid deterioration of patient prognosis. Prompt diagnosis and treatment remains help to improve patient management.
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Affiliation(s)
- Disha Gautam
- Department of Microbiology, All India Institute of Medical Sciences, Bhopal, India
| | - Malti Dadheech
- Department of Microbiology, All India Institute of Medical Sciences, Bhopal, India
| | - Vaibhav Ingle
- Department of General Medicine, All India Institute of Medical Sciences, Bhopal, India
| | | | - Shashank Purwar
- Department of Microbiology, All India Institute of Medical Sciences, Bhopal, India
| | - Anand Kumar Maurya
- Department of Microbiology, All India Institute of Medical Sciences, Bhopal, India
- Corresponding author.
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7
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Benlamkaddem S, Doughmi D, Tlamçani I, Berdai MA, Harandou M. The Challenging Aspect of Macrophage Activation Syndrome in the Setting of Sepsis or Systemic Inflammatory Response Syndrome (SIRS). Cureus 2023; 15:e36228. [PMID: 37069877 PMCID: PMC10105518 DOI: 10.7759/cureus.36228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/16/2023] [Indexed: 03/18/2023] Open
Abstract
Macrophage activation syndrome (MAS) is a rare but potentially fatal disease. It is characterized by hyperinflammation, including the proliferation and activation of immune cells (CD8 T cells and NK cells) associated with hypercytokinemia. Patients present with fever, splenomegaly, and cytopenia, associated with a hemophagocytosis picture in the bone marrow. It can progress to a multiorgan failure syndrome (MODS), mimicking sepsis or a systemic inflammatory response syndrome (SIRS). We report the case of an 8-year-old girl admitted to the pediatric intensive care unit for the management of major trauma due to a domestic accident. She presented with a protracted fever in the context of a septic shock, despite appropriate treatment. The association with bicytopenia, hyperferritinemia, hypofibrinogenemia, and hypertriglyceridemia was suggestive of MAS which was confirmed by a bone marrow puncture showing hemophagocytosis. A Bolus of corticotherapy was then added to the supportive treatment and broad-spectrum antibiotherapy, with a good outcome.
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Bris PN, Gauchez P, Devillier R, Galicier L, Collignon A, Piana G, Poizat F, Faucher M, Hospital MA, Vey N, Gonzalez F, Servan L, Chow-Chine L, Sannini A, Mokart D, Saillard C, Bisbal M. Hepatic haemophagocytosis in haematology patients with hepatic dysfunction: prognostic impact and contribution of liver biopsy combined with the haemophagocytic syndrome diagnostic score (HScore). Br J Haematol 2022; 199:106-116. [PMID: 35968907 DOI: 10.1111/bjh.18382] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 07/05/2022] [Accepted: 07/12/2022] [Indexed: 01/07/2023]
Abstract
Hepatic dysfunction (HD) is common in patients with haematological malignancies. Hepatic haemophagocytosis (HH) was detected in >50% of liver biopsies taken when HD remained unresolved after standard examination. We aimed to explore the contribution of liver biopsy in patients with both haematological malignancies and HD, describe the population of patients with HH, assess the prognostic impact of HH, and investigate haemophagocytic syndrome diagnostic score (HScore) utility in patients with HH. Between 2016 and 2019, 116 consecutive liver biopsies (76 transjugular, 40 percutaneous) were taken in 110 patients with haematological malignancy and HD (hyperbilirubinaemia, elevated transaminases, and/or cholestasis) and without a clear diagnosis. Liver biopsies were safe and diagnostically efficient. Predominant diagnoses included: HH (56%), graft-versus-host disease (55%), associated infections (24%), sinusoidal obstruction syndrome (15%), and tumoral infiltration (8%). Of patients, 35% were critically ill and 74% were allogeneic haematopoietic stem cell transplantation recipients, while 1-year overall survival (OS) was 35% with HH versus 58% without HH (p = 0.026). The 1-year OS was 24% with a HScore of ≥169 versus 50% with a HScore of <169 (p = 0.019). Liver biopsies are feasible in and contribute significantly to haematology patients with HD. HH occurred frequently and was associated with a poor prognosis. Combined with liver biopsy, the HScore may be helpful in refining haemophagocytic syndrome diagnosis.
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Affiliation(s)
- Pierre-Nicolas Bris
- Anaesthesia and Critical Care Department, Intensive Care Unit, Institut Paoli Calmettes, Marseille, France
| | - Philippe Gauchez
- Pathology Department, Centre Hospitalier Universitaire de la Réunion, Saint Pierre, France
| | | | | | - Aude Collignon
- Hematology Department, Institut Paoli Calmettes, Marseille, France
| | - Gilles Piana
- Imagery Department, Institut Paoli Calmettes, Marseille, France
| | - Flora Poizat
- Pathology Department, Institut Paoli Calmettes, Marseille, France
| | - Marion Faucher
- Anaesthesia and Critical Care Department, Intensive Care Unit, Institut Paoli Calmettes, Marseille, France
| | | | - Norbert Vey
- Hematology Department, Institut Paoli Calmettes, Marseille, France.,Aix-Marseille University, Marseille, France
| | - Frederic Gonzalez
- Anaesthesia and Critical Care Department, Intensive Care Unit, Institut Paoli Calmettes, Marseille, France
| | - Luca Servan
- Anaesthesia and Critical Care Department, Intensive Care Unit, Institut Paoli Calmettes, Marseille, France
| | - Laurent Chow-Chine
- Anaesthesia and Critical Care Department, Intensive Care Unit, Institut Paoli Calmettes, Marseille, France
| | - Antoine Sannini
- Anaesthesia and Critical Care Department, Intensive Care Unit, Institut Paoli Calmettes, Marseille, France
| | - Djamel Mokart
- Anaesthesia and Critical Care Department, Intensive Care Unit, Institut Paoli Calmettes, Marseille, France
| | - Colombe Saillard
- Hematology Department, Institut Paoli Calmettes, Marseille, France
| | - Magali Bisbal
- Anaesthesia and Critical Care Department, Intensive Care Unit, Institut Paoli Calmettes, Marseille, France
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Xu L, Liu X, Wang Y, Wang Y, Chu X, Chen L. Successful treatment of hemophagocytic syndrome in a patient with T cell lymphoma, EBV infection, and bone marrow necrosis: A case report. Medicine (Baltimore) 2022; 101:e28943. [PMID: 35244052 PMCID: PMC8896522 DOI: 10.1097/md.0000000000028943] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Accepted: 02/09/2022] [Indexed: 01/04/2023] Open
Abstract
RATIONALE Hemophagocytic syndrome (HPS) is associated with a high mortality rate, and Epstein-Barr virus infection and hematological malignancies, especially T/natural killer cell lymphomas, are the most common causes; however, due to the complexity of clinical manifestations, the diagnosis is usually delayed. There are few reports of lymphoma-associated HPS (LAPS) in combination with bone marrow necrosis, and there is still no standard treatment for LAPS. PATIENT CONCERNS A 64-year-old man developed a fever, mild jaundice, fatigue, and bone pain. Positron emission tomography and bone marrow biopsy with immunohistochemistry were performed. DIAGNOSIS Imaging analysis and bone marrow examinations were compatible with HPS, T-cell lymphoma, and bone marrow necrosis. INTERVENTIONS The patient received combination therapy of rituximab and Cyclophosphamide, epirubicin, vincristine, glucocorticoid, etoposide. OUTCOMES The patient achieved complete remission and a disease-free survival of 52 months. LESSONS HPS and its potential diseases should be diagnosed and treated as soon as possible. Clinicians should be aware of the presence of lymphoma in patients with HPS. Rituximab plays an important role in the prognosis of HPS, particularly Epstein-Barr virus positivity. Cyclophosphamide, epirubicin, vincristine, glucocorticoid remains an effective regimen for the treatment of T-cell LAPS. This study provides a better understanding of the diagnosis and treatment of LAPS.
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Affiliation(s)
- Lingling Xu
- Department of Hematology, Yantai Yuhuangding Hospital Affilliated to Qingdao University, Yantai, China
| | - Xianqi Liu
- Department of Burn and Plastic Surgery, Yantai Yeda Hospital Affilliated to Binzhou Medical College, Yantai, China
| | - Yan Wang
- Department of Hematology, Yantai Yuhuangding Hospital Affilliated to Qingdao University, Yantai, China
| | - Yanming Wang
- Department of Hematology, Yantai Yuhuangding Hospital Affilliated to Qingdao University, Yantai, China
| | - Xiaoxia Chu
- Department of Hematology, Yantai Yuhuangding Hospital Affilliated to Qingdao University, Yantai, China
| | - Liming Chen
- Department of Hematology, Yantai Yuhuangding Hospital Affilliated to Qingdao University, Yantai, China
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Cui Y, Shi J, Lu G, Wang Y, Zhu X, Ren H, Zhu Y, Yan G, Wang C, Zhang Y. Prognostic death factors in secondary hemophagocytic lymphohistiocytosis children with multiple organ dysfunction syndrome receiving continuous renal replacement therapy: A multicenter prospective nested case-control study. Ther Apher Dial 2021; 26:1023-1029. [PMID: 34877787 PMCID: PMC9540864 DOI: 10.1111/1744-9987.13775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Revised: 12/01/2021] [Accepted: 12/05/2021] [Indexed: 11/30/2022]
Abstract
Introduction Multiple organ dysfunction syndrome (MODS) with secondary hemophagocytic lymphohistiocytosis (SHLH) causes significant mortality. We aimed to identify the predictor factors for death in pediatric patients with SHLH‐associated MODS receiving continuous renal replacement therapy (CRRT). Methods This multicentered nested case–control study was conducted from 2016 to 2020. The characteristics were compared between survivors and non‐survivors. Logistic regression was applied to identify the risk factors for death. The cutoff values were assessed by receiver operating characteristics curves. Results Fifty two patients were enrolled in this study. Interleukin‐6 level (p = 0.018) and the number of organ dysfunction (p = 0.047) were independent risk factors for death. The cutoff value of 13.12 pg/ml interleukin‐6 and three organs dysfunction at CRRT initiation presented a high sensitivity and specificity. Conclusion The number of organ dysfunction and interleukin‐6 at CRRT initiation are independent risk factors for death in pediatric patients with SHLH‐associated MODS.
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Affiliation(s)
- Yun Cui
- Department of Critical Care Medicine, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Jingyi Shi
- Department of Critical Care Medicine, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Guoping Lu
- Department of Critical Care Medicine, Children's Hospital of Fudan University, Shanghai, China
| | - Ying Wang
- Department of Critical Care Medicine, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xiaodong Zhu
- Department of Pediatric Critical Care Medicine, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Hong Ren
- Department of Critical Care Medicine, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yueniu Zhu
- Department of Pediatric Critical Care Medicine, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Gangfeng Yan
- Department of Critical Care Medicine, Children's Hospital of Fudan University, Shanghai, China
| | - Chunxia Wang
- Department of Critical Care Medicine, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai, China.,Institute of Pediatric Critical Care, Shanghai Jiao Tong University, Shanghai, China
| | - Yucai Zhang
- Department of Critical Care Medicine, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai, China.,Institute of Pediatric Critical Care, Shanghai Jiao Tong University, Shanghai, China
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11
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Harada T, Tsuboi I, Hino H, Yuda M, Hirabayashi Y, Hirai S, Aizawa S. Age-related exacerbation of hematopoietic organ damage induced by systemic hyper-inflammation in senescence-accelerated mice. Sci Rep 2021; 11:23250. [PMID: 34853370 PMCID: PMC8636590 DOI: 10.1038/s41598-021-02621-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Accepted: 11/16/2021] [Indexed: 12/11/2022] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening systemic hyper-inflammatory disorder. The mortality of HLH is higher in the elderly than in young adults. Senescence-accelerated mice (SAMP1/TA-1) exhibit characteristic accelerated aging after 30 weeks of age, and HLH-like features, including hematopoietic organ damage, are seen after lipopolysaccharide (LPS) treatment. Thus, SAMP1/TA-1 is a useful model of hematological pathophysiology in the elderly with HLH. In this study, dosing of SAMP1/TA-1 mice with LPS revealed that the suppression of myelopoiesis and B-lymphopoiesis was more severe in aged mice than in young mice. The bone marrow (BM) expression of genes encoding positive regulators of myelopoiesis (G-CSF, GM-CSF, and IL-6) and of those encoding negative regulators of B cell lymphopoiesis (TNF-α) increased in both groups, while the expression of genes encoding positive-regulators of B cell lymphopoiesis (IL-7, SDF-1, and SCF) decreased. The expression of the GM-CSF-encoding transcript was lower in aged mice than in young animals. The production of GM-CSF by cultured stromal cells after LPS treatment was also lower in aged mice than in young mice. The accumulation of the TNF-α-encoding transcript and the depletion of the IL-7-encoding transcript were prolonged in aged mice compared to young animals. LPS dosing led to a prolonged increase in the proportion of BM M1 macrophages in aged mice compared to young animals. The expression of the gene encoding p16INK4a and the proportion of β-galactosidase- and phosphorylated ribosomal protein S6-positive cells were increased in cultured stromal cells from aged mice compared to those from young animals, while the proportion of Ki67-positive cells was decreased in stromal cells from aged mice. Thus, age-related deterioration of stromal cells probably causes the suppression of hematopoiesis in aged mice. This age-related latent organ dysfunction may be exacerbated in elderly people with HLH, resulting in poor prognosis.
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Affiliation(s)
- Tomonori Harada
- Division of Anatomical Science, Department of Functional Morphology, Nihon University School of Medicine, 30-1 Oyaguchi-kamicho, Itabashi-ku, Tokyo, 173-8610, Japan.
| | - Isao Tsuboi
- Division of Anatomical Science, Department of Functional Morphology, Nihon University School of Medicine, 30-1 Oyaguchi-kamicho, Itabashi-ku, Tokyo, 173-8610, Japan
| | - Hirotsugu Hino
- Division of Anatomical Science, Department of Functional Morphology, Nihon University School of Medicine, 30-1 Oyaguchi-kamicho, Itabashi-ku, Tokyo, 173-8610, Japan
| | - Miyuki Yuda
- Division of Anatomical Science, Department of Functional Morphology, Nihon University School of Medicine, 30-1 Oyaguchi-kamicho, Itabashi-ku, Tokyo, 173-8610, Japan
| | - Yoko Hirabayashi
- Center for Biological Safety and Research, National Institute of Health Sciences, Kawasaki, 210-9501, Japan
| | - Shuichi Hirai
- Division of Anatomical Science, Department of Functional Morphology, Nihon University School of Medicine, 30-1 Oyaguchi-kamicho, Itabashi-ku, Tokyo, 173-8610, Japan
| | - Shin Aizawa
- Division of Anatomical Science, Department of Functional Morphology, Nihon University School of Medicine, 30-1 Oyaguchi-kamicho, Itabashi-ku, Tokyo, 173-8610, Japan
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12
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Gholizadeh M, Kianersi S, Noorazar L, Kaveh V, Roshandel E, Salari S. The rare Hematological disorder; A man with Hemophagocytic Lymphohistiocytosis (HLH). CASPIAN JOURNAL OF INTERNAL MEDICINE 2021; 12:S439-S442. [PMID: 34760101 PMCID: PMC8559648 DOI: 10.22088/cjim.12.0.439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Revised: 10/26/2020] [Accepted: 11/27/2020] [Indexed: 11/28/2022]
Abstract
Background: Hemophagocytic lymphohistiocytosis (HLH) is a rare disease with different causes. HLH has been categorized into two sub-groups; primary HLH which is associated with some gene mutations and secondary HLH that is developed by various causes, such as autoimmune disease, infections, and malignancies. However, the symptoms of both groups are identical and if left untreated, it will result in death. Case Presentation: In this study, we reported a 39 years old man had symptoms such as fever, weakness and chill for a month period of time. Firstly, due to pancytopenia in peripheral blood findings and clinical manifestations, he had been diagnosed with myelodysplastic syndrome (MDS) with an excess blast but the elevated liver enzymes and bilirubin were not consistent with this diagnosis. Hence, we recommended more investigation such as CT scan, bone marrow aspiration and bone marrow biopsy with immunohistochemistry tests. Finally, we found macrophages and histiocyte in bone marrow biopsy smear with Wright-Giemsa staining that engulfed the cells such as platelets and lymphocytes, so HLH syndrome was confirmed and treatment program with latest approved protocols started for the patient. Conclusion: HLH syndrome is a life-threatening disease that can be saved if timely diagnosed. Therefore, more consideration of all the laboratory findings and clinical signs of the patient can help to diagnose the disease more accurately. Also, we did a review of its pathophysiology, symptoms and therapeutic treatments.
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Affiliation(s)
- Majid Gholizadeh
- Hematopoietic Stem Cell Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran.,Department of Hematology and Blood Banking, School of Allied Medical Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Shirin Kianersi
- Hematopoietic Stem Cell Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran.,department of adult Hematology & Oncology ,School of Medicine, Ayatollah Taleghani Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Leila Noorazar
- Hematopoietic Stem Cell Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran.,Department of Hematology and Blood Banking, School of Allied Medical Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Vahid Kaveh
- Firouzgar Hospital, Iran University of Medical Sciences, Tehran, Iran.,Department of Hematology and Medical Oncology, Faculty of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Elham Roshandel
- Hematopoietic Stem Cell Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Sina Salari
- Hematopoietic Stem Cell Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran.,department of adult Hematology & Oncology ,School of Medicine, Ayatollah Taleghani Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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13
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Valade S, Joly BS, Veyradier A, Fadlallah J, Zafrani L, Lemiale V, Launois A, Stepanian A, Galicier L, Fieschi C, Mirouse A, Tudesq JJ, Lepretre AC, Azoulay E, Darmon M, Mariotte E. Coagulation disorders in patients with severe hemophagocytic lymphohistiocytosis. PLoS One 2021; 16:e0251216. [PMID: 34343182 PMCID: PMC8330932 DOI: 10.1371/journal.pone.0251216] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 06/14/2021] [Indexed: 01/13/2023] Open
Abstract
Background Coagulation disorders are common in patients with hemophagocytic lymphohistiocytosis (HLH), associated with an increased risk of bleeding and death. We aim to investigate coagulation disorders and their outcome implications in critically ill patients with HLH. Methods We prospectively evaluated 47 critically ill patients with HLH (median age of 54 years [42–67]) between April 2015 and December 2018. Coagulation assessments were performed at day 1. Abnormal standard coagulation was defined as prothrombin time (PT) <50% and/or fibrinogen <2g/L. HLH aetiology was mostly ascribed to haematological malignancies (74% of patients). Results Coagulation disorders and severe bleeding events were frequent, occurring in 30 (64%) and 11 (23%) patients respectively. At day 1, median fibrinogen level was 2∙65g/L [1.61–5.66]. Fibrinolytic activity was high as suggested by increased median levels of D-dimers, fibrin monomers, PAI-1 (plasminogen activator inhibitor) and tPA (tissue plasminogen activator). Forty-one (91%) patients had a decreased ADAMTS13 activity (A Disintegrin-like And Metalloproteinase with ThromboSpondin type 1 repeats, member 13). By multivariable analysis, the occurrence of a severe bleeding (OR 3.215 [1.194–8.653], p = 0∙021) and SOFA score (Sepsis-Related Organ Failure Assessment) at day 1 (OR 1.305 per point [1.146–1.485], p<0∙001) were independently associated with hospital mortality. No early biological marker was associated with severe bleeding. Conclusions Hyperfibrinolysis may be the primary mechanism responsible for hypofibrinogenemia and may also participate in ADAMTS13 degradation. Targeting the plasmin system appears as a promising approach in severe HLH-related coagulation disorders.
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Affiliation(s)
- Sandrine Valade
- AP-HP, Medical ICU, Hôpital Saint-Louis, Paris, France
- EA3518, Université de Paris, Paris, France
- * E-mail:
| | - Bérangère S. Joly
- EA3518, Université de Paris, Paris, France
- Hematology Biology Department, AP-HP, Hôpital Lariboisière, Paris, France
| | - Agnès Veyradier
- EA3518, Université de Paris, Paris, France
- Hematology Biology Department, AP-HP, Hôpital Lariboisière, Paris, France
| | - Jehane Fadlallah
- EA3518, Université de Paris, Paris, France
- Department of Clinical Immunology, AP-HP, Hôpital Saint-Louis, Paris, France
| | - Lara Zafrani
- AP-HP, Medical ICU, Hôpital Saint-Louis, Paris, France
- EA3518, Université de Paris, Paris, France
| | - Virginie Lemiale
- AP-HP, Medical ICU, Hôpital Saint-Louis, Paris, France
- EA3518, Université de Paris, Paris, France
| | - Amélie Launois
- EA3518, Université de Paris, Paris, France
- Hematology Biology Department, AP-HP, Hôpital Lariboisière, Paris, France
| | - Alain Stepanian
- EA3518, Université de Paris, Paris, France
- Hematology Biology Department, AP-HP, Hôpital Lariboisière, Paris, France
| | - Lionel Galicier
- EA3518, Université de Paris, Paris, France
- Department of Clinical Immunology, AP-HP, Hôpital Saint-Louis, Paris, France
| | - Claire Fieschi
- EA3518, Université de Paris, Paris, France
- Department of Clinical Immunology, AP-HP, Hôpital Saint-Louis, Paris, France
| | - Adrien Mirouse
- AP-HP, Medical ICU, Hôpital Saint-Louis, Paris, France
- EA3518, Université de Paris, Paris, France
| | - Jean Jacques Tudesq
- AP-HP, Medical ICU, Hôpital Saint-Louis, Paris, France
- EA3518, Université de Paris, Paris, France
| | - Anne-Claire Lepretre
- Transfusion Department, Etablissement Français Du Sang, Hôpital Saint-Louis, Paris, France
| | - Elie Azoulay
- AP-HP, Medical ICU, Hôpital Saint-Louis, Paris, France
- EA3518, Université de Paris, Paris, France
| | - Michael Darmon
- AP-HP, Medical ICU, Hôpital Saint-Louis, Paris, France
- EA3518, Université de Paris, Paris, France
| | - Eric Mariotte
- AP-HP, Medical ICU, Hôpital Saint-Louis, Paris, France
- EA3518, Université de Paris, Paris, France
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14
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Abstract
BACKGROUND Hemophagocytic lymphohistiocytosis (HLH), an uncontrolled overactivation of the immune system, is well characterized in pediatric patients, yet, much less is known about this life-threatening condition in adult patients. As HLH is often complicated by organ failure, patients will require admission to the intensive care unit for organ support therapy. However, recognition of HLH patients in the intensive care unit (ICU) is challenged by the clinical overlap with sepsis. Here, we analyze HLH patients to better understand its clinical presentation, diagnosis, and treatment. METHODS For the purpose of this retrospective observational study, we searched for suspected and diagnosed adult HLH of all patients admitted to at least one adult surgical, anesthesiological or medical ICU between January 2006 and August 2018 at the university hospital Charité - Universitätsmedizin Berlin. All cases were reviewed by two HLH experts, who confirmed or declined the diagnosis. RESULTS Of 6,340 ICU patients with ferritin measurement, 40 suffered from HLH (0.63%). Of these, in-hospital mortality was 60.0% over all cases, which was highest in malignancy-associated HLH (71.4%). Infections were identified as most common triggers (42.5%). A variety of 19 different treatment strategies were applied. Non-survivors showed higher ferritin at diagnosis compared with survivors (P = 0.021), which was also seen in multivariable analyses. A minimum ferritin of 4083 μg/L after diagnosis was most predictive for 30-day mortality (AUC 0.888, 95% CI 0.771-1.000; sensitivity 93.8%, specificity 78.9%). CONCLUSIONS Mortality in adult HLH patients in the ICU is high, particularly in malignancy-associated HLH. Infections are the most frequent HLH triggers in critically ill patients. At present, there is no standardized treatment for HLH in adult patients available. Assessment of ferritin is valuable for diagnosis, prognosis, and treatment monitoring. TRIAL REGISTRATION The study was registered with www.ClinicalTrials.gov (NCT02854943) on August 1, 2016.
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15
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Mechtoune M, Tissir R, Tazi I. Macrophage activation syndrome revealing Hodgkin's lymphoma: a case report. Pan Afr Med J 2021; 38:109. [PMID: 33912279 PMCID: PMC8051215 DOI: 10.11604/pamj.2021.38.109.27417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Accepted: 01/11/2021] [Indexed: 11/16/2022] Open
Abstract
Macrophage activation syndrome (MAS) is a rare immunologic syndrome, rapidly fatal in the absence of specific etiological treatment. It is defined by clinical, biological and cyto-histological criteria. Numerous etiologies have been described in MAS, the association with Hodgkin lymphoma (LH) is exceptional. We report the case of a young woman in whom a macrophage activation syndrome reveals a Hodgkin's lymphoma.
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Affiliation(s)
- Mustapha Mechtoune
- Service d'Hématologie Clinique et de Greffe de Moelle Osseuse, Faculté de Médecine et Pharmacie, Centre Hospitalier Universitaire (CHU) Mohammed VI, Université Cadi Ayyad, Marrakech, Maroc
| | - Rajae Tissir
- Service d'Hématologie Clinique et de Greffe de Moelle Osseuse, Faculté de Médecine et Pharmacie, Centre Hospitalier Universitaire (CHU) Mohammed VI, Université Cadi Ayyad, Marrakech, Maroc
| | - Ilias Tazi
- Service d'Hématologie Clinique et de Greffe de Moelle Osseuse, Faculté de Médecine et Pharmacie, Centre Hospitalier Universitaire (CHU) Mohammed VI, Université Cadi Ayyad, Marrakech, Maroc
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16
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Platelets parameters in septic shock: clinical usefulness and prognostic value. Blood Coagul Fibrinolysis 2021; 31:421-425. [PMID: 33065574 DOI: 10.1097/mbc.0000000000000937] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
: Septic shock is a common cause of admission in the ICUs. Despite tremendous improvement in the management modalities, mortality remains high. Early diagnosis and prompt resuscitation are required to improve prognosis. Therefore, identifying a biomarker that could reveal the sepsis at its earlier stage is of paramount importance. In this regards, platelet parameters, such as mean platelet volume, immature platelet fraction and platelet-derived microparticles have been investigated as possible sepsis biomarkers. In fact, haemostasis disturbances are one of the hallmark of septic shock where platelets play a pivotal role in orchestrating the inflammatory response of the host. Moreover, these parameters could have a prognostic value as the severity of the multiorgan dysfunction is correlated with the inflammatory reaction.
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17
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Nafees B, Lloyd A, Dewilde S. Estimating health state utilities in hemophagocytic lymphohistiocytosis. J Patient Rep Outcomes 2021; 5:12. [PMID: 33471193 PMCID: PMC7817728 DOI: 10.1186/s41687-020-00276-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Accepted: 12/15/2020] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Hemophagocyti.c lymphohistiocytosis (HLH) is a rare and severe disorder characterized by abnormal activation of the immune system. Primary HLH causes prolonged fever, spleen and liver enlargement, and organ dysfunction, usually in infancy and early childhood and is fatal if left untreated. As effective treatment options emerge, such as emapalumab-lzsg, Health Technology Assessment bodies around the world will assess them in terms of cost-effectiveness. This study was designed to estimate quality of life weights (utilities) for such analyses. METHODS Vignettes were developed describing HLH treatment related health states. Health states included active HLH, HLH plus neurological symptoms, receiving chemotherapy, undergoing stem cell transplant (SCT), graft versus host disease (GVHD), cure and end of life care. The vignettes were based on information from in depth interviews with clinical specialists; and qualitative research with four parents of children with primary HLH aged between 1 and 18 years old. The vignettes were then assessed in time trade off (TTO) interviews with members of the UK general public in one on one face to face interviews with trained, experienced interviewers. Preference data were analysed using the generalised estimating equations framework. RESULTS Detailed qualitative data captured the substantial burden of this disease for young children. One hundred participants completed the TTO interviews. The utility score for Active HLH was estimated as 0.32 (95% CI, 0.24 to 0.39). Values for other states were HLH plus neurological symptoms (0.27, 95%CI 0.18-0.35), receiving chemotherapy (0.26, 95%CI 0.17-0.34), undergoing SCT (0.18, 95%CI 0.07-0.28), GVHD (0.07, 95%CI -0.04-0.17), cure (0.72, 95%CI 0.67-0.77) and end of life care (- 0.17, 95%CI -0.27- -0.07). CONCLUSIONS This study has estimated utility weights for seven different HLH related states which are based on detailed input from carers and physicians and have good face validity. There are few other options for collecting these data in an ultra-rare setting.
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18
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Li X, Yan H, Xiao Z, Zhang X, Huang J, Xiang ST, Zheng M, Yao Z, Zang P, Zhu D, Li L, Lu X. Diagnostic Time Lag of Pediatric Haemophagocytic Lymphohistiocytosis and Patient Characteristics: A Retrospective Cohort Study. Front Pediatr 2021; 9:692849. [PMID: 34222154 PMCID: PMC8247774 DOI: 10.3389/fped.2021.692849] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 05/25/2021] [Indexed: 12/14/2022] Open
Abstract
The difficulties and challenges of applying the HLH-2004 diagnostic criteria to early identification and diagnosis of haemophagocytic lymphohistiocytosis have been fully addressed in previous studies. However, the distribution of the diagnostic time lag of haemophagocytic lymphohistiocytosis and related patient characteristics remain unclear. This study investigated the time lags between symptom onset and diagnosis and between hospital admission and diagnosis among pediatric patients with haemophagocytic lymphohistiocytosis, and identified factors that associated with a shorter or longer diagnostic time lag. The cohort of patients with haemophagocytic lymphohistiocytosis was drawn from a tertiary children's hospital and consisted of 122 pediatric patients. The distributions of symptom-to-diagnosis and admission-to-diagnosis time lags were assessed. Clinical characteristics within 48 h of admission and the fulfillment of HLH-2004 diagnostic criteria were compared among admission-to-diagnosis time lag categories. Logistic regression analyses were conducted to identify factors associated with an admission-to-diagnosis time lag >3 days. The median interval from first symptom onset to HLH diagnosis was 12 days (range 4-71 days) and the median interval from hospital admission to HLH diagnosis was 2 days (range 0-23 days). The following factors were negatively associated with admission-to-diagnosis > 3 days: Epstein-Barr virus infection; admission through pediatric intensive care unit; diagnosis established without NK-cell activity and soluble CD25 tests; the performance of all readily available diagnostic tests for HLH (within 48 and 72 h); concurrent fever, splenomegaly, and cytopenias within 48 h; hemophagocytosis, hypertriglyceridemia and/or hypofibrinogenemia within 48 h; and elevated ferritin, total bilirubin, alanine aminotransferase, and prothrombin time within 48 h. Our findings suggest that performance of adequate diagnostic tests for HLH is essential for early diagnosis of HLH. Once suspected, immediate and adequate diagnostic tests for HLH should be arranged for PICU patients. Improvements in diagnostic procedures and monitoring plans are needed to promote early diagnosis of HLH.
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Affiliation(s)
- Xun Li
- Pediatrics Research Institute of Hunan Province, Hunan Children's Hospital, Changsha, China
| | - Haipeng Yan
- Department of Pediatric Intensive Care Unit, Hunan Children's Hospital, Changsha, China
| | - Zhenghui Xiao
- Department of Pediatric Intensive Care Unit, Hunan Children's Hospital, Changsha, China
| | - Xinping Zhang
- Department of Pediatric Intensive Care Unit, Hunan Children's Hospital, Changsha, China
| | - Jiaotian Huang
- Department of Pediatric Intensive Care Unit, Hunan Children's Hospital, Changsha, China
| | - Shi-Ting Xiang
- Pediatrics Research Institute of Hunan Province, Hunan Children's Hospital, Changsha, China
| | - Mincui Zheng
- Department of Pediatric Hematology, Hunan Children's Hospital, Changsha, China
| | - Zhenya Yao
- Department of Pediatric Intensive Care Unit, Hunan Children's Hospital, Changsha, China
| | - Ping Zang
- Department of Pediatric Intensive Care Unit, Hunan Children's Hospital, Changsha, China
| | - Desheng Zhu
- Department of Pediatric Intensive Care Unit, Hunan Children's Hospital, Changsha, China
| | - Liping Li
- Pediatrics Research Institute of Hunan Province, Hunan Children's Hospital, Changsha, China
| | - Xiulan Lu
- Department of Pediatric Intensive Care Unit, Hunan Children's Hospital, Changsha, China
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19
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Li B, Guo J, Li T, Gu J, Zeng C, Xiao M, Zhang W, Li Q, Zhou J, Zhou X. Clinical Characteristics of Hemophagocytic Lymphohistiocytosis Associated with Non-Hodgkin B-Cell Lymphoma: A Multicenter Retrospective Study. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2020; 21:e198-e205. [PMID: 33303420 DOI: 10.1016/j.clml.2020.10.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/27/2020] [Revised: 10/17/2020] [Accepted: 10/19/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND Hemophagocytic lymphohistiocytosis (HLH) associated with B-cell lymphoma is a highly aggressive disease with unclear clinical features and has no standard treatment. PATIENTS AND METHODS We analyzed the clinical characteristics of 31 patients from two individual centers. RESULTS The median overall survival was only 1.5 months. Both univariate and multivariate analyses, based on lymphoma or HLH-related characteristics, revealed that patients with high Epstein-Barr virus (EBV) DNA load and ≥ 2 extranodal lesions, or hypofibrinogenemia, respectively, showed significantly poorer overall survival. Interestingly, some patients with high EBV DNA load had EBV-positive natural killer (NK) and/or T cells, which may be related to the coexistence of immunodeficiency and/or chronic active EBV infection. Molecular genetics examination confirmed that 47.4% (9/19) of patients had complex karyotypes, 37.5% (3/8) of patients had TP53 deletions, and 21.34% (3/14) of patients had TP53 mutation or alteration of malignancy-related pathways, including BCR/NF-κB, JAK-STAT, and epigenetic regulatory pathways, which may provide clues to choose targets for therapy. Treatment regimens containing etoposide, anti-CD20 monoclonal antibodies, or anthracyclines improved patient prognosis (P = .0183, .025, and .0436, respectively). Patients with infections had significantly shorter survival than those without infections (P = .00019). CONCLUSION The patients' performance status, number of extranodal lesions, high EBV DNA load, and hypofibrinogenemia are poor prognostic factors for HLH associated with B-cell lymphoma. Molecular genetic high-risk factors are of particular importance because these factors can provide information for prognosis prediction, treatment decisions, and disease surveillance.
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Affiliation(s)
- Baihua Li
- Department of Hematology, YiChang Central People's Hospital, The First College of Clinical Medical Science, China Three Gorges University, Yichang, China
| | - Jingming Guo
- Department of Hematology, YiChang Central People's Hospital, The First College of Clinical Medical Science, China Three Gorges University, Yichang, China
| | - Tongjuan Li
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jia Gu
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Chen Zeng
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Min Xiao
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Wei Zhang
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Qinlu Li
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jianfeng Zhou
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xiaoxi Zhou
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
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20
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Yin G, Man C, Huang J, Liao S, Gao X, Tian T, Duan L, Xu J, Qiu H. The prognostic role of plasma fibrinogen in adult secondary hemophagocytic lymphohistiocytosis. Orphanet J Rare Dis 2020; 15:332. [PMID: 33239052 PMCID: PMC7690012 DOI: 10.1186/s13023-020-01622-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Accepted: 11/16/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In adult patients with secondary hemophagocytic lymphohistiocytosis (sHLH), no valid immune biomarker has been available for predicting the prognosis of untreated sHLH patients. METHODS Circulating plasma levels of fibrinogen (FIB) were measured at diagnosis in 293 cases of adult sHLH. We categorized FIB levels into tertiles. Multivariable Cox proportional hazards models were used to evaluate the relationship between FIB and survival. Restricted cubic spline models and two-piecewise Cox proportional hazards models were used to address the nonlinear association between FIB and mortality. RESULTS During a median follow-up of 52 (interquartile ranges, 18-221) days, 208 deaths occurred, with 137 deaths in malignancy-associated hemophagocytic lymphohistiocytosis (MHLH) and 71 deaths in non-malignancy-associated hemophagocytic lymphohistiocytosis (non-MHLH). After multivariable adjustment, compared with the highest tertile of FIB, the hazard ratios (HRs) with 95% confidence intervals (CIs) of survival for tertile 2 and tertile 1 were 1.06 (0.90-1.24) and 0.84 (0.71-0.98), respectively. The restricted cubic spline curve displayed a nonlinear and inverse relationship between FIB and mortality. Furthermore, the threshold effect analysis demonstrated that the inflection point for the curve was at an FIB level of 1.76 g/L. The HRs (95% CIs) for survival were 0.68 (0.55-0.83) and 1.08 (0.96-1.21) on the left and right side of the inflection point, respectively. CONCLUSIONS These results suggest that plasma fibrinogen is nonlinearly and inversely associated with the risk of mortality in adult secondary hemophagocytic lymphohistiocytosis.
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Affiliation(s)
- Guangli Yin
- Department of Hematology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, 300 Guangzhou Road, Nanjing, 210029, China
| | - Changfeng Man
- Department of Hematology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, 300 Guangzhou Road, Nanjing, 210029, China
| | - Jiayu Huang
- Department of Hematology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, 300 Guangzhou Road, Nanjing, 210029, China
| | - Shengen Liao
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, 300 Guangzhou Road, Nanjing, 210029, China
| | - Xin Gao
- Department of Geriatric Hematology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, 300 Guangzhou Road, Nanjing, 210029, China
| | - Tian Tian
- Department of Geriatric Hematology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, 300 Guangzhou Road, Nanjing, 210029, China
| | - Limin Duan
- Department of Geriatric Hematology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, 300 Guangzhou Road, Nanjing, 210029, China
| | - Ji Xu
- Department of Geriatric Hematology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, 300 Guangzhou Road, Nanjing, 210029, China
| | - Hongxia Qiu
- Department of Hematology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, 300 Guangzhou Road, Nanjing, 210029, China. .,Department of Geriatric Hematology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, 300 Guangzhou Road, Nanjing, 210029, China.
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21
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Chidambaram AC, Maulik K, Ramamoorthy JG, Parameswaran N. A novel mutation of adenosine deaminase causing SCID presenting as hemophagocytic lymphohistiocytosis with acute kidney injury. Br J Haematol 2020; 191:509-512. [PMID: 33174709 DOI: 10.1111/bjh.17058] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Aakash C Chidambaram
- Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Kaushik Maulik
- Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Jaikumar G Ramamoorthy
- Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Narayanan Parameswaran
- Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
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22
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Wang S, Wu J, Jing X, Zhang Y, Tang H, Wu J. Etoposide combined with ruxolitinib for refractory hemophagocytic lymphohistiocytosis during pregnancy: a case report and literature review. ACTA ACUST UNITED AC 2020; 24:751-756. [PMID: 33138732 DOI: 10.1080/16078454.2020.1838708] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is an immune-mediated disorder caused by uncontrolled inflammatory responses and the activation of T lymphocytes. This life-threatening disease, characterized by fever, cytopenia and hepatosplenomegaly, is extremely rare during pregnancy with high mortality. Despite the improvement of treatment regimen in recent years, HLH is still a great challenge for clinicians. Here, we described a 26-year-old woman who admitted to our hospital at her first pregnancy with pyrexia. Her condition continued to deteriorate after receiving broad-spectrum antimicrobials, presenting with fever, pancytopenia, hepatosplenomegaly, ferritin ≥ 500 μg/L, hemophagocytosis and low NK-cell activity. HLH was eventually diagnosed by clinical manifestation and laboratory examination results. Then the patient recovered well after treatment with etoposide combined with ruxolitinib therapy and underwent successful induced-labor operation. Additionally, we summarized similar cases from the literature to improve the management of HLH during pregnancy. In conclusion, this study highlights the challenges and difficulties in the diagnosis and management of patients with HLH during pregnancy. Moreover, this is the first case report of etoposide combined with ruxolitinib in the treatment of patients with refractory secondary HLH during pregnancy.
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Affiliation(s)
- Shuoshan Wang
- Department of General Medicine, The First Affiliated Hospital, Sun Yat Sen University, Guangzhou, People's Republic of China
| | - Jingguo Wu
- Department of General Medicine, The First Affiliated Hospital, Sun Yat Sen University, Guangzhou, People's Republic of China
| | - Xiaoli Jing
- Department of General Medicine, The First Affiliated Hospital, Sun Yat Sen University, Guangzhou, People's Republic of China
| | - Yongwei Zhang
- Department of General Medicine, The First Affiliated Hospital, Sun Yat Sen University, Guangzhou, People's Republic of China
| | - Hao Tang
- Department of Emergency, The First Affiliated Hospital, Sun Yat Sen University, Guangzhou, People's Republic of China
| | - Junlin Wu
- Department of Emergency, The First Affiliated Hospital, Sun Yat Sen University, Guangzhou, People's Republic of China
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23
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Shoureshi P, Ruiz J, Abdulzahir A, Bisch AL, Naddaf N, Gisel J. Tuberculosis-associated HLH in a patient with chronic kidney disease on haemodialysis. Oxf Med Case Reports 2020; 2020:omaa082. [PMID: 33133616 PMCID: PMC7583401 DOI: 10.1093/omcr/omaa082] [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] [Received: 05/07/2020] [Revised: 06/16/2020] [Accepted: 07/30/2020] [Indexed: 11/13/2022] Open
Abstract
Abstract
Haemophagocytic lymphohistiocytosis (HLH) is a rare immunological disorder that is accompanied by a high mortality rate when the underlying aetiology is miliary tuberculosis. We report a case of tuberculosis (TB)-associated HLH in a haemodialysis patient, from a TB-endemic region, who missed two sessions of dialysis before developing the primary symptoms of HLH. The patient presented with non-specific findings including pancytopenia, coagulopathy and transaminitis. Computer-tomography imaging and microbiology from bronchoalveolar lavage evidenced miliary tuberculosis. Further testing revealed the TB-associated-HLH characteristic pattern of thrombocytosis, leukopenia, transaminitis, hyperferritinemia and elevated fibrinogen. The patient initially demonstrated improvement after initiation of anti-TB therapy. However, soon thereafter began to paradoxically deteriorate and then expire from apparent tuberculosis-immune reconstitution inflammatory syndrome. This case highlights the importance of early diagnosis and treatment, and consequently of the utility of diagnostic systems such as the HScore in cases of high clinical suspicion.
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Affiliation(s)
- Pouria Shoureshi
- Department of Internal Medicine, Orange Park Medical Center, Orange Park, FL, USA
| | - Johanna Ruiz
- Department of Internal Medicine, Orange Park Medical Center, Orange Park, FL, USA
| | - Ahmad Abdulzahir
- Department of Internal Medicine, Orange Park Medical Center, Orange Park, FL, USA
| | - Alexander L Bisch
- Medical student, Department of Internal Medicine, Edward Via College of Osteopathic Medicine- Carolinas, Spartanburg, SC, USA
| | - Naja Naddaf
- Core faculty, Department of Internal Medicine, Orange Park Medical Center, Orange Park, FL, USA
| | - Justin Gisel
- Core faculty, Department of Internal Medicine, Orange Park Medical Center, Orange Park, FL, USA
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24
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Li X, Yan H, Zhang X, Huang J, Xiang ST, Yao Z, Zang P, Zhu D, Xiao Z, Lu X. Clinical profiles and risk factors of 7-day and 30-day mortality among 160 pediatric patients with hemophagocytic lymphohistiocytosis. Orphanet J Rare Dis 2020; 15:229. [PMID: 32867836 PMCID: PMC7456759 DOI: 10.1186/s13023-020-01515-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2019] [Accepted: 08/19/2020] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Hemophagocytic lymphohistiocytosis (HLH) is a relatively rare and life-threatening disorder. Early mortality remains significantly high among patients with HLH. Our aim was to investigate clinical features and risk factors associated with 7-day and 30-day mortality among pediatric HLH patients. We retrospectively collected medical records of patients with discharge diagnosis of HLH between August 2014 and October 2018 from a tertiary children's hospital in China. The main outcome measures were the 7-day and 30-day outcome after hospital admission. The associations between symptoms, concomitant diagnoses, laboratory test results, and the risk of 7-day and 30-day mortality were examined. RESULTS Among 160 pediatric HLH patients, 18 (11.3%) patients were deceased within 7 days after admission, and 46 (28.8%) patients were deceased within 30 days. The identified strong risk factors (OR > 10 and p < 0.05) for 30-day mortality were myocardial damage, severe pneumonia, respiratory failure, coagulopathy, gastrointestinal disorder, and multiple organ dysfunction syndrome (MODS). Factors strongly associated with 7-day mortality were sepsis, myocardial damage, shock, and respiratory failure. All patients deceased within 7 days developed hepatic dysfunction, coagulopathy, and MODS. CONCLUSIONS The identified risk factors could help to stratify patients with high risk of early death, and need to be considered in the development of treatment protocols. As early mortality of HLH remains high, studies are needed to investigate how to initiate adequate HLH-directed treatment strategies for patients at higher risk of early death.
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Affiliation(s)
- Xun Li
- Pediatrics Research Institute of Hunan Province, Hunan Children's Hospital, University of South China, Changsha, China
| | - Haipeng Yan
- Department of Pediatric Intensive Care Unit, Hunan Children's Hospital, University of South China, Changsha, China
| | - Xinping Zhang
- Department of Pediatric Intensive Care Unit, Hunan Children's Hospital, University of South China, Changsha, China
| | - Jiaotian Huang
- Department of Pediatric Intensive Care Unit, Hunan Children's Hospital, University of South China, Changsha, China
| | - Shi-Ting Xiang
- Pediatrics Research Institute of Hunan Province, Hunan Children's Hospital, University of South China, Changsha, China
| | - Zhenya Yao
- Department of Pediatric Intensive Care Unit, Hunan Children's Hospital, University of South China, Changsha, China
| | - Ping Zang
- Department of Pediatric Intensive Care Unit, Hunan Children's Hospital, University of South China, Changsha, China
| | - Desheng Zhu
- Department of Pediatric Intensive Care Unit, Hunan Children's Hospital, University of South China, Changsha, China
| | - Zhenghui Xiao
- Department of Pediatric Intensive Care Unit, Hunan Children's Hospital, University of South China, Changsha, China.
| | - Xiulan Lu
- Department of Pediatric Intensive Care Unit, Hunan Children's Hospital, University of South China, Changsha, China.
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25
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Zhou J, Zhou J, Wu ZQ, Goyal H, Xu HG. A novel prognostic model for adult patients with Hemophagocytic Lymphohistiocytosis. Orphanet J Rare Dis 2020; 15:215. [PMID: 32819431 PMCID: PMC7439554 DOI: 10.1186/s13023-020-01496-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Accepted: 08/07/2020] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Hemophagocytic Lymphohistiocytosis (HLH) is a type of rare disease with low survival rate. We aimed to develop a model to evaluate the six-month prognosis in adult HLH patients. The data at discharge (will be called as post-treatment) for newly diagnosed adult HLH patients was collected and independent prognostic variables were selected for inclusion in the model. RESULTS Three laboratory markers were confirmed to be the independent risk factors (ferritin: hazard ratio (HR) 0.101, 95% confidence interval (CI) 0.036-0.282, P<0.001; platelets: HR 4.799, 95% CI 1.884-12.223, P = 0.001; alanine aminotransferase (ALT): HR 0.423, 95% CI 0.180-0.997, P = 0.049). These were included in the final clinical prediction model. Receiver operating characteristic (ROC) curves disclosed that this model had a better discrimination (area under the curve (AUC) = 0.842, 95% CI 0.773-0.910, P < 0.001) than each of them alone and the calibration curves aligned completely with the model predictions and actual observations. Kaplan-Meier curves revealed a significant difference in the overall survival (OS) in patients stratified by the model with higher values associated with a better OS. CONCLUSION These results point out that serum ferritin, platelets and ALT levels are independent elements of OS in adult patients with HLH, and that the proposed model have a better prognostic value than any of these markers alone.
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Affiliation(s)
- Jun Zhou
- Department of Laboratory Medicine, the First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Jing Zhou
- Department of Laboratory Medicine, the First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Zhi-Qi Wu
- Department of Laboratory Medicine, the First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Hemant Goyal
- The Wright Center of Graduate Medical Education, Scranton, USA
| | - Hua-Guo Xu
- Department of Laboratory Medicine, the First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China.
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26
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Pawińska-Wa Sikowska K, Cwiklinska M, Wyrobek E, Balwierz W, Bukowska-Strakova K, Dluzniewska A, Gozdzik J, Drabik G, Rygielska M, Stepien K, Skoczen S. Disseminated Juvenile Xanthogranuloma and Hemophagocytic Lymphohistiocytosis Developed During Treatment of Acute Lymphoblastic Leukemia: Case Report. Front Oncol 2020; 10:921. [PMID: 32719740 PMCID: PMC7350519 DOI: 10.3389/fonc.2020.00921] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Accepted: 05/11/2020] [Indexed: 12/02/2022] Open
Abstract
The association between acute lymphoblastic leukemia (ALL), non-Langerhans cell histiocytosis (non-LCH), and hemophagocytic lymphohistiocytosis (HLH), to the best of our knowledge, has not been published to date. Juvenile xanthogranuloma (JXG), as a type of non-LCH, is usually a benign disease limited to the skin. Systemic involvement is rarely reported. The present case report describes a 15-year-old boy diagnosed with disseminated JXG involving skin and bone marrow concurrent with severe symptoms of HLH during ALL therapy. Examination of immunoglobulin heavy chain genes in B-cell precursor leukemic blasts and histiocytes in the skin and bone marrow revealed identical rearrangements, confirming clonal relationship between both diseases. Implementation of corticosteroids, vinblastine, etoposide, cyclosporine, and tocilizumab resulted in partial skin lesion resolution with no improvement of bone marrow function; therefore, hematopoietic stem cell transplantation (HSCT) was eventually performed. The patient's hematological and general status has improved gradually; however, remarkable recovery of skin lesions was observed after empirical antitubercular therapy. Mycobacterium spp. infection should be considered as a possible secondary HLH trigger. Triple association of ALL, non-LCH, and HLH highlights heterogeneity of histiocytic disorders and possible common origin of dendritic and lymphoid cells.
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Affiliation(s)
- Katarzyna Pawińska-Wa Sikowska
- Department of Pediatric Oncology and Hematology, Faculty of Medicine, Jagiellonian University Medical College, Krakow, Poland.,Department of Oncology and Hematology, University Children's Hospital of Krakow, Krakow, Poland
| | - Magdalena Cwiklinska
- Department of Pediatric Oncology and Hematology, Faculty of Medicine, Jagiellonian University Medical College, Krakow, Poland.,Department of Oncology and Hematology, University Children's Hospital of Krakow, Krakow, Poland
| | - Elzbieta Wyrobek
- Department of Oncology and Hematology, University Children's Hospital of Krakow, Krakow, Poland
| | - Walentyna Balwierz
- Department of Pediatric Oncology and Hematology, Faculty of Medicine, Jagiellonian University Medical College, Krakow, Poland.,Department of Oncology and Hematology, University Children's Hospital of Krakow, Krakow, Poland
| | - Karolina Bukowska-Strakova
- Department of Clinical Immunology and Transplantation, Institute of Pediatrics, Jagiellonian University Medical College, Krakow, Poland
| | - Agnieszka Dluzniewska
- Department of Clinical Immunology and Transplantology, Stem Cell Transplant Center, University Children's Hospital of Krakow, Jagiellonian University Medical College, Krakow, Poland
| | - Jolanta Gozdzik
- Department of Clinical Immunology and Transplantology, Stem Cell Transplant Center, University Children's Hospital of Krakow, Jagiellonian University Medical College, Krakow, Poland
| | - Grazyna Drabik
- Department of Pathology, University Children's Hospital of Krakow, Krakow, Poland
| | - Monika Rygielska
- Department of Biochemistry, University Children's Hospital of Krakow, Krakow, Poland
| | - Konrad Stepien
- Student Scientific Group of Pediatric Oncology and Hematology, Jagiellonian University Medical College, Krakow, Poland
| | - Szymon Skoczen
- Department of Pediatric Oncology and Hematology, Faculty of Medicine, Jagiellonian University Medical College, Krakow, Poland.,Department of Oncology and Hematology, University Children's Hospital of Krakow, Krakow, Poland
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27
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Zhu DX, Qiao JJ, Fang H. Macrophage activation syndrome as a complication of dermatomyositis: A case report. World J Clin Cases 2020; 8:2339-2344. [PMID: 32548165 PMCID: PMC7281037 DOI: 10.12998/wjcc.v8.i11.2339] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 04/14/2020] [Accepted: 04/28/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Macrophage activation syndrome (MAS) can be a fatal complication of rheumatic disorders, which occurs most commonly in patients with systemic juvenile idiopathic arthritis or systemic lupus erythematosus. It has rarely been reported in patients with dermatomyositis. Here, we describe a fatal case of MAS that developed in an adult patient with dermatomyositis.
CASE SUMMARY A 44-year-old woman was admitted to our hospital with fever, generalized rash and muscle weakness. Fifteen days later, the fever persisted after the use of antibiotics, and repeat blood culture was negative. The patient then exhibited a typical Gottron sign and diffuse erythema on the face and neck, which were consistent with a diagnosis of dermatomyositis. The patient exhibited limb muscle strength of 2, and electromyography was suggestive of muscle-derived damage, which also supported a diagnosis of dermatomyositis. In addition, the patient exhibited high serum ferritin level, cytopenia, liver dysfunction, coagulopathy, enlarged spleen and hypertriglyceridemia, all of which are typical manifestations of MAS. The patient was diagnosed with dermatomyositis complicated by MAS. Although a high dose of methylprednisolone was administered for 15 d, the patient’s condition continued to deteriorate and central nervous system symptoms developed. Eventually, treatment was discontinued, and the patient died.
CONCLUSION MAS is an important, potentially fatal, complication of dermatomyositis. Although MAS is rare in dermatomyositis, it should be considered in the differential diagnosis of an unexplained change of hemoglobin, platelet, fibrinogen, ferritin and triglyceride, which may complicate dermatomyositis.
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Affiliation(s)
- Ding-Xian Zhu
- Department of Dermatology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou 310003, Zhejiang Province, China
| | - Jian-Jun Qiao
- Department of Dermatology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou 310003, Zhejiang Province, China
| | - Hong Fang
- Department of Dermatology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou 310003, Zhejiang Province, China
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28
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Tsuboi I, Harada T, Hirabayashi Y, Aizawa S. Dynamics of hematopoiesis is disrupted by impaired hematopoietic microenvironment in a mouse model of hemophagocytic lymphohistiocytosis. Ann Hematol 2020; 99:1515-1523. [PMID: 32506245 DOI: 10.1007/s00277-020-04095-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Accepted: 05/17/2020] [Indexed: 11/29/2022]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening systemic hyperinflammatory disorder. We found recently that repeated lipopolysaccharide (LPS) treatment induces HLH-like features in senescence-accelerated mice (SAMP1/TA-1) but not in senescence-resistant control mice (SAMR1). In this study, we analyzed the dynamics of hematopoiesis in this mouse model of HLH. When treated repeatedly with LPS, the numbers of myeloid progenitor cells (CFU-GM) and B-lymphoid progenitor cells (CFU-preB) in the bone marrow (BM) rapidly decreased after each treatment in both strains. The number of CFU-GM in SAMP1/TA-1 and SAMR1, and of CFU-preB in SAMR1, returned to pretreatment levels by 7 days after each treatment. However, the recovery in the number of CFU-preB in SAMP1/TA-1 was limited. In both strains, the BM expression of genes encoding positive regulators of myelopoiesis (granulocyte colony-stimulating factor (G-CSF), granulocyte macrophage colony-stimulating factor (GM-CSF), and interleukin (IL)-6), and negative regulators of B lymphopoiesis (tumor necrosis factor (TNF)-α) was increased. The expression of genes encoding positive regulators of B lymphopoiesis (stromal-cell derived factor (SDF)-1, IL-7, and stem cell factor (SCF)) was persistently decreased in SAMP1/TA-1 but not in SAMR1. Expression of the gene encoding p16INK4a and the proportion of β-galactosidase-positive cells were increased in cultured stromal cells obtained from LPS-treated SAMP1/TA-1 but not in those from LPS-treated SAMR1. LPS treatment induced qualitative changes in stromal cells, which comprise the microenvironment supporting appropriate hematopoiesis, in SAMP1/TA-1; these stromal cell changes are inferred to disrupt the dynamics of hematopoiesis. Thus, hematopoietic tissue is one of the organs that suffer life-threatening damage in HLH.
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Affiliation(s)
- Isao Tsuboi
- Division of Anatomical Science, Department of Functional Morphology, Nihon University School of Medicine, 30-1 Ohyaguchi-kami-machi, Itabashi-ku, Tokyo, 173-8610, Japan.
| | - Tomonori Harada
- Division of Anatomical Science, Department of Functional Morphology, Nihon University School of Medicine, 30-1 Ohyaguchi-kami-machi, Itabashi-ku, Tokyo, 173-8610, Japan
| | - Yoko Hirabayashi
- Center for Biological Safety and Research, National Institute of Health Sciences, Kawasaki, Japan
| | - Shin Aizawa
- Division of Anatomical Science, Department of Functional Morphology, Nihon University School of Medicine, 30-1 Ohyaguchi-kami-machi, Itabashi-ku, Tokyo, 173-8610, Japan
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29
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Li X, Yan H, Zhang X, Huang J, Xiang ST, Yao Z, Zang P, Zhu D, Xiao Z, Lu X. Elevated serum myoglobin levels at hospital admission and the risk of early death among patients with hemophagocytic lymphohistiocytosis: evidence from 155 pediatric patients. Ann Hematol 2020; 99:963-971. [PMID: 32221652 DOI: 10.1007/s00277-020-03980-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Accepted: 03/01/2020] [Indexed: 12/20/2022]
Abstract
Patients with hemophagocytic lymphohistiocytosis (HLH) have high risk of early mortality. The purpose of this study was to test the hypothesis that the elevated level of serum myoglobin among patients with HLH is associated with disease severity and increased risk of mortality. We retrospectively investigated the serum myoglobin levels from 155 pediatric patients diagnosed with HLH in the Hunan Children's Hospital, China. The levels of myoglobin and creatine kinase at hospital admission among non-survivors and survivors were compared. The myoglobin level was dichotomized for the estimation of hazard ratio (HR) for mortality. Patients who died within 7 and 30 days of hospitalization had significantly higher myoglobin levels than did survivors (p < 0.05). The myoglobin level was negatively associated with the days of survival among non-survivors (Spearman correlation coefficient = - 0.29, p = 0.04). An elevated myoglobin level (> 90 ng/mL) was significantly associated with increased mortality (unadjusted HR = 2.66, 95%CI: 1.41, 5.00, p = 0.0024) and persisted after adjusting for age, Epstein-Barr virus infection, admission department, acute kidney injury, myocardial damage, and shock. In conclusion, an elevated serum myoglobin level was associated with increased risk of early death among pediatric patients with HLH, suggesting the potential of myoglobin to be used as a reference indicator for monitoring and managing of HLH.
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Affiliation(s)
- Xun Li
- Pediatrics Research Institute of Hunan Province, Hunan Children's Hospital, University of South China, Changsha, China
| | - Haipeng Yan
- Department of Pediatric Intensive Care Unit, Hunan Children's Hospital, University of South China, Changsha, China
| | - Xinping Zhang
- Department of Pediatric Intensive Care Unit, Hunan Children's Hospital, University of South China, Changsha, China
| | - Jiaotian Huang
- Department of Pediatric Intensive Care Unit, Hunan Children's Hospital, University of South China, Changsha, China
| | - Shi-Ting Xiang
- Pediatrics Research Institute of Hunan Province, Hunan Children's Hospital, University of South China, Changsha, China
| | - Zhenya Yao
- Department of Pediatric Intensive Care Unit, Hunan Children's Hospital, University of South China, Changsha, China
| | - Ping Zang
- Department of Pediatric Intensive Care Unit, Hunan Children's Hospital, University of South China, Changsha, China
| | - Desheng Zhu
- Department of Pediatric Intensive Care Unit, Hunan Children's Hospital, University of South China, Changsha, China
| | - Zhenghui Xiao
- Department of Pediatric Intensive Care Unit, Hunan Children's Hospital, University of South China, Changsha, China.
| | - Xiulan Lu
- Department of Pediatric Intensive Care Unit, Hunan Children's Hospital, University of South China, Changsha, China.
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30
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Chen CL, Li MJ, Liu YN, Wang H, Guan ZB, Pan XY. [Expression and its implications of Th1/Th2 cytokines and lymphocyte subsets in adult patients with lymphoma-associated hemophagocytic lymphohistiocytosis]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2020; 40:777-779. [PMID: 31648484 PMCID: PMC7342452 DOI: 10.3760/cma.j.issn.0253-2727.2019.09.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- C L Chen
- Department of Hematology, The Frist Affiliated Hospital of Guangdong Pharmaceutical University, Guangzhou 510080, China
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31
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Valade S, Mariotte E, Azoulay E. Coagulation Disorders in Hemophagocytic Lymphohistiocytosis/Macrophage Activation Syndrome. Crit Care Clin 2020; 36:415-426. [PMID: 32172822 DOI: 10.1016/j.ccc.2019.12.004] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a rare and severe condition that can lead patients to the intensive care unit. HLH diagnosis may be challenging, as it relies on sets of aspecific criteria. Several organ dysfunctions have been described during HLH, including hemostasis impairment found in more than half of the patients. The most frequently reported anomaly is a decrease in the fibrinogen level, which has been associated with higher mortality rates. Coagulation impairment study in patients with HLH represents an interesting field of research, as little is known about the mechanism leading to hypofibrinogenemia.
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Affiliation(s)
- Sandrine Valade
- Medical ICU, Saint Louis University Hospital, Assistance Publique des Hôpitaux de Paris, 1 Avenue Claude Vellefaux, 75010 Paris, France.
| | - Eric Mariotte
- Medical ICU, Saint Louis University Hospital, Assistance Publique des Hôpitaux de Paris, 1 Avenue Claude Vellefaux, 75010 Paris, France
| | - Elie Azoulay
- Medical ICU, Saint Louis University Hospital, Assistance Publique des Hôpitaux de Paris, 1 Avenue Claude Vellefaux, 75010 Paris, France
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32
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Zhao Y, Lu D, Ma S, Li L, Zhu J, Zhou D, Zheng Y, Yang X, Zhu L, Zhu M, Xie M, Sun J, Ye X, Xie W. Risk factors of early death in adult patients with secondary hemophagocytic lymphohistiocytosis: a single-institution study of 171 Chinese patients. ACTA ACUST UNITED AC 2020; 24:606-612. [PMID: 31474196 DOI: 10.1080/16078454.2019.1660458] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Background: Adult secondary hemophagocytic lymphohistiocytosis (HLH) is a potentially life-threatening syndrome characterized by excessive activation of mononuclear-phagocytic system resulting in hyperinflammatory response. To date, the factors influencing early death of HLH are still not fully elucidated. Patients and Methods: We did a retrospective study of 171 adult patients with newly diagnosed HLH at our institution from January 2012 to April 2018. All patients' clinical features, laboratory findings, treatments and prognosis were reviewed. Results: The median age was 49 years (range, 18-88 years), and 110 (64.3%) were male. The major underlying trigger of HLH was malignancy (88/171, 51.5%), especially non-Hodgkin lymphoma. In a multivariate analysis, age ≥54 years (P = 0.002), platelet ≤39.5 × 109/L (P = 0.028), activated partial thromboplastin time (APTT) ≥54 sec (P = 0.048), triglyceride ≥3.23 mmol/L (P < 0.001), lactate dehydrogenase (LDH) ≥1300 U/L (P = 0.012) and malignancy (P = 0.001) were significantly associated with early death in HLH. Then, patients were classified into four groups according to the number of risk factors at the time of diagnosis: low risk (zero, one or two risk factors), low intermediate risk (three risk factors), high intermediate risk (four risk factors) and high risk (at least five risk factors), with the 30-day overall survival (OS) of 92.4%, 58.8%, 30.0% and 4.8%, respectively (P < 0.001). Conclusions: Patients with old age, thrombocytopenia, prolonged APTT, hypertriglyceridemia, elevated LDH and malignancy had inferior survival. It is important to identify those patients at risk of early death, which may guide treatment and reduce mortality.
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Affiliation(s)
- Yanchun Zhao
- Department of Hematology, the First Affiliated Hospital, College of Medicine, Zhejiang University , Hangzhou , People's Republic of China
| | - Danlei Lu
- Department of Hematology, the First Affiliated Hospital, College of Medicine, Zhejiang University , Hangzhou , People's Republic of China
| | - Shanshan Ma
- Department of Hematology, the First Affiliated Hospital, College of Medicine, Zhejiang University , Hangzhou , People's Republic of China
| | - Li Li
- Department of Hematology, the First Affiliated Hospital, College of Medicine, Zhejiang University , Hangzhou , People's Republic of China
| | - Jingjing Zhu
- Department of Hematology, the First Affiliated Hospital, College of Medicine, Zhejiang University , Hangzhou , People's Republic of China
| | - De Zhou
- Department of Hematology, the First Affiliated Hospital, College of Medicine, Zhejiang University , Hangzhou , People's Republic of China
| | - Yanlong Zheng
- Department of Hematology, the First Affiliated Hospital, College of Medicine, Zhejiang University , Hangzhou , People's Republic of China
| | - Xiudi Yang
- Department of Hematology, the First Affiliated Hospital, College of Medicine, Zhejiang University , Hangzhou , People's Republic of China
| | - Lixia Zhu
- Department of Hematology, the First Affiliated Hospital, College of Medicine, Zhejiang University , Hangzhou , People's Republic of China
| | - Mingyu Zhu
- Department of Hematology, the First Affiliated Hospital, College of Medicine, Zhejiang University , Hangzhou , People's Republic of China
| | - Mixue Xie
- Department of Hematology, the First Affiliated Hospital, College of Medicine, Zhejiang University , Hangzhou , People's Republic of China
| | - Jianai Sun
- Department of Hematology, the First Affiliated Hospital, College of Medicine, Zhejiang University , Hangzhou , People's Republic of China
| | - Xiujin Ye
- Department of Hematology, the First Affiliated Hospital, College of Medicine, Zhejiang University , Hangzhou , People's Republic of China
| | - Wanzhuo Xie
- Department of Hematology, the First Affiliated Hospital, College of Medicine, Zhejiang University , Hangzhou , People's Republic of China
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Sindzingre L, Elezi A, Peyrony O. Syndrome d’activation macrophagique chez un patient greffé rénal. ANNALES FRANCAISES DE MEDECINE D URGENCE 2020. [DOI: 10.3166/afmu-2019-0197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Abstract
BACKGROUND Hemophagocytic lymphohistiocytosis in adults (aHLH) is a rare life-threatening hyperinflammatory syndrome caused by excessive activation of macrophages and CD8+ T-cells. Due to the clinical overlap with severe sepsis, aHLH often remains undiagnosed resulting in poor outcome. Here, we present a retrospective study of incidence, clinical findings, and the outcome of aHLH in intensive care units (ICUs). METHODS This retrospective analysis was performed at the university hospital Charité - Universitätsmedizin Berlin. We gathered data from 556 out of 46,532 patients admitted to our anesthesiological ICUs between 2006 and 2013, who had at least one plasma ferritin measurement during ICU treatment, and were at least 18 years old. Of these, 244 patients with ferritin at least 500 μg/L and available datasets of at least 4 HLH-2004 criteria were included. HLH-2004 diagnostic criteria and the recently published HScore were used. An aHLH expert team retrospectively reviewed the potential aHLH cases. RESULTS Seventy-one of the included 244 patients died; 9 out of the 244 patients were retrospectively classified as aHLH of whom 4 patients had died (44.4%). Two of the 9 aHLH patients had been correctly diagnosed and had received specific aHLH treatment. Thus, 7 out of 9 patients (77.8%) remained undetected. ICU patients with at least 1 captured ferritin value and hyperferritinemia showed an aHLH rate of 3.7%, which rises up to 5.6% when only deceased patients are considered. Mortality in this selected cohort is 44.4%. CONCLUSIONS Overall, 7 out of 9 patients (77.8%) suffering from aHLH remained undiagnosed. Awareness of this life-threatening syndrome, especially in ICUs, should be raised. The inclusion of ferritin into the admission lab panel for ICU is warranted.Clinical trial registered with www.ClinicalTrials.gov (NCT02854943) on August 1, 2016. As this is a retrospective study, trial registration was after final data collection date.
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Abstract
OBJECTIVES Hematologic malignancies may result in multiple organ involvement including pulmonary and renal dysfunctions, and the less common acute circulatory failure. We herein addressed the outcome of patients with sepsis-like shock related to aggressive hematologic malignancies. DESIGN A 10-year (2007-2016) monocenter retrospective study. SETTINGS A medical ICU in a tertiary care center. PATIENTS Patients with circulatory shock requiring vasopressors and who subsequently received chemotherapy. Shock was presumably related to the underlying malignancy after ruling out an ongoing or new-onset infectious process. The extent and time course of organ failures was assessed by a modified Sequential Organ Failure Assessment score devoid of the platelet component. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Seventeen patients were included, including 13 with non-Hodgkin lymphoma, two with hyperleukocytic acute myeloid leukemia, and two with "Human Herpes virus 8"-associated multicentric Castleman's disease. The following associated conditions prompted urgent administration of chemotherapy: tumor lysis syndrome (n = 10), hemophagocytic lymphohistiocytosis (n = 3), compressive bulky tumor (n = 3), pulmonary involvement (n = 3), and disseminated intravascular coagulation (n = 1). Following the initiation of chemotherapy, a number of patients died rapidly from untractable multiple organ failure. In contrast, chemotherapy led to a fast and dramatic improvement in organ failures in early survivors, as shown by the decrease in the modified Sequential Organ Failure Assessment score. However, the overall outcome was poor since only four and three patients could be discharged alive from the ICU and the hospital, and three and two patients remained alive at 6 months and 1 year. CONCLUSIONS Multiple organ dysfunction syndrome related to hematologic malignancies is associated with a dismal outcome. A chemotherapy trial may provide a fast prognostic assessment of the reversibility of organ failure.
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Haemophagocytic lymphohistiocytosis (HLH) secondary to miliary tuberculosis. Indian J Tuberc 2019; 67:366-370. [PMID: 32825870 DOI: 10.1016/j.ijtb.2019.08.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Accepted: 08/10/2019] [Indexed: 10/26/2022]
Abstract
HLH is a rare, life-threatening, hematologic disorder resulting from prolonged and excessive activation of antigen presenting cells (macrophages, histiocytes) and CD8+ T cells. It is characterized by fever, pancytopenia,splenomegaly and haemophagocytosis in bone marrow,liver or lymph node. This hyperinflammatory condition is often triggered by a variety of agents or events, mostly genetic or infectious. HLH secondary to TB, have 100 % mortality in absence of anti-tubercular treatment .Since it mimics other disorders, its timely diagnosis remains a challenge. We report a case of hemophagocytic syndrome associated with disseminated tuberculosis in an immunocompetent man managed with anti-tubercular treatment and corticosteroid as immune modulator.
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Etiologies and Clinical Outcomes of Patients With Secondary Hemophagocytic Lymphohistiocytosis at a Tertiary PICU. Pediatr Crit Care Med 2019; 20:e311-e318. [PMID: 31149968 DOI: 10.1097/pcc.0000000000001980] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To assess the etiologies and outcomes of patients with secondary hemophagocytic lymphohistiocytosis in the PICU. DESIGN Prospective observational cohort study. SETTING A single PICU at a pediatric tertiary hospital in Hanoi, Vietnam. PATIENTS Pediatric patients meeting the criteria for secondary hemophagocytic lymphohistiocytosis. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Between June 2017 and May 2018, 25 consecutive patients with a mean (SD) age of 23.3 months (21.6 mo) were included. Collected variables included etiologies of hemophagocytic lymphohistiocytosis and clinical and laboratory findings at admission. The Pediatric Index of Mortality 2 score at admission was calculated. Outcomes were death and multiple organ dysfunction. The severity of multiple organ dysfunction was assessed by the Pediatric Logistic Organ Dysfunction 2 score. The mean (SD) Pediatric Index of Mortality 2 predicted mortality rate was 5.6% (7.6%). Cytomegalovirus and Epstein-Barr virus coinfections (60%) were the most common suspected etiology of hemophagocytic lymphohistiocytosis. Other etiologies included Epstein-Barr virus sole infections (20%), cytomegalovirus sole infections (16%), and one unknown cause (4%). Multiple organ dysfunction (excluding hematologic failure) was found in 22 patients (88%) with death occurring in 14 patients (56%). The mean (SD) Pediatric Logistic Organ Dysfunction 2 predicted mortality rate among patients with multiple organ dysfunction was 11.9% (11.2%). Despite having lower Pediatric Index of Mortality 2 predicted mortality rates at admission, Epstein-Barr virus-cytomegalovirus coinfection cases with multiple organ dysfunction had slightly greater Pediatric Logistic Organ Dysfunction 2 predicted mortality rates than Epstein-Barr virus sole infection cases with multiple organ dysfunction: 12.2% (10.5%) versus 11.3% (11.0%). However, these rates were lower than cytomegalovirus sole infection cases with multiple organ dysfunction (14.4% [16.3%]). Area under the curve values for Pediatric Index of Mortality 2 and Pediatric Logistic Organ Dysfunction 2 were 0.74 (95% CI, 0.52-0.95) and 0.78 (95% CI, 0.52-1.00), respectively, suggesting that both scales were fair to good at predicting mortality. CONCLUSIONS Viral infections, particularly Epstein-Barr virus-cytomegalovirus coinfections, were a common cause of secondary hemophagocytic lymphohistiocytosis. The implication of these coinfections on the clinical course of hemophagocytic lymphohistiocytosis needs to be delineated.
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Recommendations for the management of hemophagocytic lymphohistiocytosis in adults. Blood 2019; 133:2465-2477. [PMID: 30992265 DOI: 10.1182/blood.2018894618] [Citation(s) in RCA: 515] [Impact Index Per Article: 103.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Accepted: 04/12/2019] [Indexed: 12/11/2022] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a severe hyperinflammatory syndrome induced by aberrantly activated macrophages and cytotoxic T cells. The primary (genetic) form, caused by mutations affecting lymphocyte cytotoxicity and immune regulation, is most common in children, whereas the secondary (acquired) form is most frequent in adults. Secondary HLH is commonly triggered by infections or malignancies but may also be induced by autoinflammatory/autoimmune disorders, in which case it is called macrophage activation syndrome (MAS; or MAS-HLH). Most information on the diagnosis and treatment of HLH comes from the pediatric literature. Although helpful in some adult cases, this raises several challenges. For example, the HLH-2004 diagnostic criteria developed for children are commonly applied but are not validated for adults. Another challenge in HLH diagnosis is that patients may present with a phenotype indistinguishable from sepsis or multiple organ dysfunction syndrome. Treatment algorithms targeting hyperinflammation are frequently based on pediatric protocols, such as HLH-94 and HLH-2004, which may result in overtreatment and unnecessary toxicity in adults. Therefore, dose reductions, individualized tailoring of treatment duration, and an age-dependent modified diagnostic approach are to be considered. Here, we present expert opinions derived from an interdisciplinary working group on adult HLH, sponsored by the Histiocyte Society, to facilitate knowledge transfer between physicians caring for pediatric and adult patients with HLH, with the aim to improve the outcome for adult patients affected by HLH.
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Meena NK, Sinokrot O, Duggal A, Alpat D, Singh ZN, Coviello JM, Li M, Wang X, Mireles-Cabodevila E. The Performance of Diagnostic Criteria for Hemophagocytic Lymphohistiocytosis in Critically Ill Patients. J Intensive Care Med 2019; 35:1476-1482. [PMID: 30862243 DOI: 10.1177/0885066619837139] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE The diagnostic criteria for secondary hemophagocytic lymphohistiocytosis (HLH) have not been validated in the critically ill adult population. We set out to evaluate the performance of diagnostic criteria and determine the ferritin cutoff in critically ill adults. DESIGN A retrospective single-center study. SETTING AND PATIENTS Patients admitted to intensive care unit between 2008 and March 2010. Data were collected on consecutive patients who had ferritin measured. Charts were reviewed for the diagnostic criteria of HLH and components of Hscore. MEASUREMENTS AND MAIN RESULTS A total of 445 patients had a ferritin level measured during the study period. A diagnosis of HLH was made for 10 patients. Having 5 of 6 criteria had a specificity of 97% and a sensitivity of 70%. Hemophagocytosis was found in 41 (47.1%) of 87 bone marrow biopsies. Two hundred thirty-one patients had a ferritin level above 500 ng/dL. When determining the odds of HLH being clinically diagnosed, the optimal cut point for ferritin was 1197 ng/dL. When determining the odds of HLH based on the Hscore, the best cutoff was 143.5 (sensitivity of 90% and specificity of 90%) and patients who had HLH in our study population had an Hscore of 203.8 ± 64.9. CONCLUSION In this cohort of critically ill patients, the HLH criteria are specific for HLH but not sensitive. Critically ill patients can have a higher incidence of hemophagocytosis without HLH. A higher ferritin cutoff in combination with 5 other clinical criteria is comparable to the Hscore for the recognition of HLH in the critically ill population.
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Affiliation(s)
- Nikhil K Meena
- Department of Pulmonary and Critical Care Medicine, 155638University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Odai Sinokrot
- Department of Internal Medicine, 2569Cleveland Clinic Foundation, Cleveland, OH, USA.,New York University Medical Center, New York, NY, USA
| | - Abhijit Duggal
- Department of Pulmonary and Critical Care Medicine, 2569Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Daisy Alpat
- Department of Pathology, 155638University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Zeba N Singh
- Department of Pathology, 155638University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Jean M Coviello
- Department of Pathology, 155638University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Manshi Li
- Department of Quantitative Health Sciences, 2569Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Xiaofeng Wang
- Department of Quantitative Health Sciences, 2569Cleveland Clinic Foundation, Cleveland, OH, USA
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Tsuboi I, Harada T, Hirabayashi Y, Aizawa S. Senescence-accelerated mice (SAMP1/TA-1) treated repeatedly with lipopolysaccharide develop a condition that resembles hemophagocytic lymphohistiocytosis. Haematologica 2019; 104:1995-2005. [PMID: 30819910 PMCID: PMC6886438 DOI: 10.3324/haematol.2018.209551] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Accepted: 02/25/2019] [Indexed: 11/21/2022] Open
Abstract
Hemophagocytic lymphohistiocytosis is a life-threatening systemic hyperinflammatory disorder with primary and secondary forms. Primary hemophagocytic lymphohistiocytosis is associated with inherited defects in various genes that affect the immunological cytolytic pathway. Secondary hemophagocytic lymphohistiocytosis is not inherited, but complicates various medical conditions including infections, autoinflammatory/autoimmune diseases, and malignancies. When senescence-accelerated mice (SAMP1/TA-1) with latent deterioration of immunological function and senescence-resistant control mice (SAMR1) were treated repeatedly with lipopolysaccharide, SAMP1/TA-1 mice displayed the clinicopathological features of hemophagocytic lymphohistiocytosis such as hepatosplenomegaly, pancytopenia, hypofibrinogenemia, hyperferritinemia, and hemophagocytosis. SAMR1 mice showed no features of hemophagocytic lymphohistiocytosis. Lipopolysaccharide induced upregulation of proinflammatory cytokines such as interleukin-1β, interleukin-6, tumor necrosis factor-α, and interferon-γ, and interferon-γ-inducible chemokines such as c-x-c motif chemokine ligands 9 and 10 in the liver and spleen in both SAMP1/TA-1 and SAMR1 mice. However, upregulation of proinflammatory cytokines and interferon-γ-inducible chemokines in the liver persisted for longer in SAMP1/TA-1 mice than in SAMR1 mice. In addition, the magnitude of upregulation of interferon-γ in the liver and spleen after lipopolysaccharide treatment was greater in SAMP1/TA-1 mice than in SAMR1 mice. Furthermore, lipopolysaccharide treatment led to a prolonged increase in the proportion of peritoneal M1 macrophages and simultaneously to a decrease in the proportion of M2 macrophages in SAMP1/TA-1 mice compared with SAMR1 mice. Lipopolysaccharide appeared to induce a hyperinflammatory reaction and prolonged inflammation in SAMP1/TA-1 mice, resulting in features of secondary hemophagocytic lymphohistiocytosis. Thus, SAMP1/TA-1 mice represent a useful mouse model to investigate the pathogenesis of bacterial infection-associated secondary hemophagocytic lymphohistiocytosis.
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Affiliation(s)
- Isao Tsuboi
- Division of Anatomical Science, Department of Functional Morphology, Nihon University School of Medicine, Tokyo .,Cellular and Molecular Toxicology Division, National Center for Biological Safety and Research, National Institute of Health Science, Kawasaki, Japan
| | - Tomonori Harada
- Division of Anatomical Science, Department of Functional Morphology, Nihon University School of Medicine, Tokyo
| | - Yoko Hirabayashi
- Cellular and Molecular Toxicology Division, National Center for Biological Safety and Research, National Institute of Health Science, Kawasaki, Japan
| | - Shin Aizawa
- Division of Anatomical Science, Department of Functional Morphology, Nihon University School of Medicine, Tokyo
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Parrott J, Shilling A, Male HJ, Holland M, Clark-Ganheart CA. Hemophagocytic Lymphohistiocytosis in Pregnancy: A Case Series and Review of the Current Literature. Case Rep Obstet Gynecol 2019; 2019:9695367. [PMID: 30891322 PMCID: PMC6390238 DOI: 10.1155/2019/9695367] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Accepted: 01/29/2019] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Hemophagocytic lymphohistiocytosis (HLH) is a rare disease that can be fatal in pregnancy. We report two cases of severe HLH that highlight etoposide use in pregnancy. CASE 1 28-year-old G2P1 with lupus presented at 18 weeks with acute hypoxic respiratory failure, hepatic dysfunction, leukopenia, thrombocytopenia, and elevated ferritin. Bone marrow biopsy confirmed HLH. Etoposide and corticosteroid treatment was initiated per HLH protocol; however clinical status declined rapidly. Fetal demise occurred at 21 weeks and she subsequently suffered a massive cerebral vascular accident. She was transitioned to comfort measures and the patient deceased. CASE 2 37-year-old G4P3 presented at 25 weeks with fever, acute liver failure, thrombocytopenia, and elevated ferritin. HLH treatment was initiated, including etoposide, and diagnosis confirmed with liver biopsy. Fetal growth restriction was diagnosed at 27 weeks. Delivery occurred at 37 weeks. The neonate was found to be CMV positive despite negative maternal serology. CONCLUSION The addition of etoposide to corticosteroid use is a key component in HLH treatment of nonpregnant individuals. While this is usually avoided in pregnancy, the benefit to the mother may outweigh the potential harm to the fetus in severe cases and it should be strongly considered.
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Affiliation(s)
- Jessica Parrott
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Kansas Medical Center, 3901 Rainbow Boulevard, Kansas City, KS 66160, USA
| | - Alexander Shilling
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Kansas Medical Center, 3901 Rainbow Boulevard, Kansas City, KS 66160, USA
| | - Heather J. Male
- Division of Hematologic Malignancies and Cellular Therapeutics, Department of Internal Medicine, University of Kansas Medical Center, 3901 Rainbow Boulevard, Kansas City, KS 66160, USA
| | - Marium Holland
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Kansas Medical Center, 3901 Rainbow Boulevard, Kansas City, KS 66160, USA
| | - Cecily A. Clark-Ganheart
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Kansas Medical Center, 3901 Rainbow Boulevard, Kansas City, KS 66160, USA
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Diagnosis, Treatment, and Management of Hemophagocytic Lymphohistiocytosis in the Critical Care Unit. CRITICAL CARE OF THE PEDIATRIC IMMUNOCOMPROMISED HEMATOLOGY/ONCOLOGY PATIENT 2019. [PMCID: PMC7123852 DOI: 10.1007/978-3-030-01322-6_9] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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Rood JE, Burn TN, Neal V, Chu N, Behrens EM. Disruption of IL-33 Signaling Limits Early CD8+ T Cell Effector Function Leading to Exhaustion in Murine Hemophagocytic Lymphohistiocytosis. Front Immunol 2018; 9:2642. [PMID: 30515155 PMCID: PMC6256032 DOI: 10.3389/fimmu.2018.02642] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Accepted: 10/26/2018] [Indexed: 01/22/2023] Open
Abstract
Danger signals mediated through ST2, the interleukin-33 (IL-33) receptor, amplify CD8+ T cell-mediated inflammation in the murine model of familial hemophagocytic lymphohistiocytosis type 2 (FHL2), and blockade of ST2 provides a potential therapeutic strategy in this disease. However, the long-term effects of disrupting IL-33/ST2 signaling on the CD8+ T cell compartment are unknown. Here, we examined the evolution of the T cell response in murine FHL type 2 in the absence of ST2 signaling and found that CD8+ T cells gradually undergo exhaustion, similar to a related nonfatal FHL model. ST2 inhibition indirectly promotes CD8+ T cell exhaustion, and in contrast to other forms of FHL, reversal of exhaustion does not affect mortality. Disruption of IL-33 signaling exerts a more significant impact on the CD8+ T cell compartment early in the course of disease by intrinsically limiting CD8+ T cell proliferative and cytokine production capacity. Our data thus suggest that while ST2 blockade ultimately enables the development of CD8+ T cell exhaustion in late-stage murine FHL2, exhaustion is merely an effect, rather than the cause, of extended survival in these mice. The acute impact of ST2 inhibition on both the quantity and quality of the effector CD8+ T cell response more likely underlies the protective benefits of this treatment. This study provides evidence that redefines the relationship between CD8+ T cell exhaustion and mortality in murine FHL and supports the therapeutic use of ST2 blockade during the acute stage of disease.
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Affiliation(s)
- Julia E Rood
- Division of Rheumatology, Children's Hospital of Philadelphia, Philadelphia, PA, United States.,Institute for Immunology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States
| | - Thomas N Burn
- Division of Rheumatology, Children's Hospital of Philadelphia, Philadelphia, PA, United States.,Institute for Immunology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States
| | - Vanessa Neal
- Division of Rheumatology, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Niansheng Chu
- Division of Rheumatology, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Edward M Behrens
- Division of Rheumatology, Children's Hospital of Philadelphia, Philadelphia, PA, United States.,Institute for Immunology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States
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Lemiale V, Valade S, Calvet L, Mariotte E. Management of Hemophagocytic Lympho-Histiocytosis in Critically Ill Patients. J Intensive Care Med 2018; 35:118-127. [PMID: 30384814 DOI: 10.1177/0885066618810403] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Hemophagocytic syndrome remains a rare but life-threatening complication and is associated with intensive care unit (ICU) admission. The pathophysiology is based on a defect of cytotoxicity in T cells that results in a state of hyperinflammation in the presence of a trigger. As a consequence, patients may develop multiorgan failure. The diagnosis of hemophagocytic syndrome (HS) remains difficult and relies on persistant high-grade fevers in the absence of infection and on constellation of laboratory parameters. However, prompt diagnosis and treatment (supportive care and specific treatment) are associated with improved outcome. Interaction with other specialists (hematologist, internist) may improve the diagnosis and treatment strategy. This article describes diagnostic tools, organ failures associated with HS, main etiologies, and management.
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Affiliation(s)
| | | | - Laure Calvet
- Medical ICU, AP_HP Saint Louis hospital, Paris, France
| | - Eric Mariotte
- Medical ICU, AP_HP Saint Louis hospital, Paris, France
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McCrory MC, Wang SS, Shetty AK, McLean TW, Lantz PE, Cannon ML. Sudden Cardiac Arrest Due to Hemophagocytic Lymphohistiocytosis in a Child. J Emerg Med 2018; 55:e119-e123. [DOI: 10.1016/j.jemermed.2018.08.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Revised: 07/29/2018] [Accepted: 08/03/2018] [Indexed: 12/22/2022]
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Understanding Disseminated Intravascular Coagulation and Hepatobiliary Dysfunction Multiple Organ Failure in Hyperferritinemic Critical Illness. Pediatr Crit Care Med 2018; 19:1006-1009. [PMID: 30281573 PMCID: PMC6173201 DOI: 10.1097/pcc.0000000000001712] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Wang X, Tang N, Chang W, Lu Y, Li D. Hemophagocytic lymphohistiocytosis and congenital factor VII deficiency: a case report. BMC MEDICAL GENETICS 2018; 19:163. [PMID: 30208845 PMCID: PMC6134588 DOI: 10.1186/s12881-018-0673-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Accepted: 08/27/2018] [Indexed: 12/28/2022]
Abstract
Background Hemophagocytic lymfohistiocytosis (HLH) is a rare, life-threatening hyperinflammation, characterized by immune system over-activation resulting in hemophagocytosis. HLH could appear as a primary disease caused by mutations of immune-regulatory genes, or develop as a result of viral or bacterial infections, or malignancy. Congenital factor VII (FVII) deficiency is a rare autosomal recessive disorder characterized by prolonged prothrombin time (PT) and low FVII, which may increase bleeding risk. Case presentation A 50-year-old woman was admitted for a fever persisted for 20 days, presenting with cytopenia, high hyperferritinemia, low activity of NK cells. Bone marrow aspiration showed hemophagocytosis. CT scanning found pulmonary infection. EBV and CMV were not detected. Genetic scanning did not find pathogenic mutation of a HLH NGS panel including 26 genes. This patient was treated as recommended by the HLH 2004 Guidelines. Coagulation tests identified FVII deficiency. Genetic analysis of F7 gene in the patient and her family members identified recurrent compound heterozygous F7 c.64 + 5G > A and c.1224 T > G (p.His408Gln) mutations in this patient and her brother who showed postoperative hemorrhage after surgical resection of renal cell carcinoma. Heterozygotes in this family were asymptomatic. Conclusions To our knowledge, this is the first report of HLH in combination with congenital FVII deficiency in Chinese population.
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Affiliation(s)
- Xiong Wang
- Department of Laboratory Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Ning Tang
- Department of Laboratory Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Wei Chang
- Department of Hematology, China Resource & WISCO General Hospital, Wuhan University of Science and Technology, Wuhan, 430081, China.
| | - Yanjun Lu
- Department of Laboratory Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China.
| | - Dengju Li
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China.
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Secondary Hemophagocytic Lymphohistiocytosis, Macrophage Activation Syndrome, and Hyperferritinemic Sepsis-Induced Multiple-Organ Dysfunction Syndrome in the Pediatric ICU. PEDIATRIC CRITICAL CARE 2018. [PMCID: PMC7121947 DOI: 10.1007/978-3-319-96499-7_14] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Children with secondary hemophagocytic lymphohistiocytosis present diagnostic and therapeutic challenges to the intensivist. Management of this condition can be facilitated with a collaborative approach among a team of intensivists, immunologists, rheumatologists, hematologists, and infectious disease specialists. Controversy over management approach commonly centers on incomplete understanding at the time of clinical presentation regarding individual patient differences in inflammation pathobiology that require different therapies. This review provides the clinician with the rationale for personalizing care for these critically ill children.
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Karras A. Atteinte rénale du syndrome d’activation macrophagique. MEDECINE INTENSIVE REANIMATION 2018. [DOI: 10.3166/rea-2018-0041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Le syndrome d’activation macrophagique (SAM) ou syndrome hémophagocytaire est une pathologie compliquant soit certains déficits immunitaires d’origine génétique, soit certaines maladies hématologiques (essentiellement des lymphomes non hodgkiniens), infectieuses (herpèsvirus, bactéries, parasites) ou auto-immunes (lupus, maladie de Still). Il se caractérise par une suractivation aiguë du système immunitaire et plus particulièrement des lymphocytes T cytotoxiques et des cellules histiocytaires/macrophagiques, déclenchant une production massive de cytokines pro-inflammatoires avec fièvre, pancytopénie, organomégalie, altérations du bilan hépatique et de la coagulation. Une défaillance multiviscérale est fréquente, nécessitant la prise en charge en réanimation et mettant souvent en jeu le pronostic vital, avec une mortalité qui reste dans certains cas à près de 50 %. Le SAM implique souvent le rein, par le biais d’une nécrose tubulaire aiguë, d’une néphropathie interstitielle inflammatoire ou d’une glomérulopathie sévère, responsable de syndrome néphrotique. La mise en évidence de ce syndrome n’est pas toujours facile chez un patient avec un tableau de sepsis ou de choc septique, mais elle peut guider la prise en charge thérapeutique, notamment l’initiation d’un traitement par chimiothérapie ou immunosuppresseurs, selon l’étiologie identifiée.
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Néel A, Wahbi A, Tessoulin B, Boileau J, Carpentier D, Decaux O, Fardet L, Geri G, Godmer P, Goujard C, Maisonneuve H, Mari A, Pouchot J, Ziza JM, Bretonnière C, Hamidou M. Diagnostic and management of life-threatening Adult-Onset Still Disease: a French nationwide multicenter study and systematic literature review. Crit Care 2018; 22:88. [PMID: 29642928 PMCID: PMC5896069 DOI: 10.1186/s13054-018-2012-2] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Accepted: 03/12/2018] [Indexed: 11/18/2022] Open
Abstract
Background Adult-onset Still disease (AOSD) is a rare systemic inflammatory disorder. A few patients develop organ complications that can be life-threatening. Our objectives were to describe the disease course and phenotype of life-threatening AOSD, including response to therapy and long-term outcome. Methods A multicenter case series of intensive care medicine (ICU) patients with life-threatening AOSD and a systematic literature review. Results Twenty patients were included. ICU admission mostly occurred at disease onset (90%). Disease manifestations included fever (100%), sore throat (65%), skin rash (65%), and arthromyalgia (55%). Serum ferritin was markedly high (median: 29,110 ng/mL). Acute respiratory failure, shock and multiple organ failure occurred in 15 (75%), 10 (50%), and 7 (35%) cases, respectively. Hemophagocytosis was demonstrated in eight cases. Two patients died. Treatment delay was significant. All patients received corticosteroids. Response rate was 50%. As second-line, intravenous immunoglobulins were ineffective. Anakinra was highly effective. After ICU discharge, most patients required additional treatment. Literature analysis included 79 cases of AOSD with organ manifestations, which mainly included reactive hemophagocytic syndrome (42%), acute respiratory failure (34%), and cardiac complications (23%). Response rate to corticosteroids was 68%. Response rates to IVIgs, cyclosporin, and anakinra were 50%, 80%, and 100%, respectively. Conclusions AOSD should be recognized as a rare cause of sepsis mimic in patients with fever of unknown origin admitted to the ICU. The diagnosis relies on a few simple clinical clues. Early intensive treatment may be discussed. IVIgs should be abandoned. Long-term prognosis is favorable. Electronic supplementary material The online version of this article (10.1186/s13054-018-2012-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Antoine Néel
- Service de Médecine Interne, PHU3, CHU Hôtel-Dieu, 44093, Nantes, France
| | - Anaïs Wahbi
- Service de Médecine Interne, PHU3, CHU Hôtel-Dieu, 44093, Nantes, France.
| | - Benoit Tessoulin
- Service d'Hématologie, PHU1, CHU Hôtel-Dieu, 44093, Nantes, France
| | - Julien Boileau
- Service de Médecine, CH de Morlaix, 29672, Morlaix, France
| | | | - Olivier Decaux
- Service de Médecine Interne, CHU de Rennes, 35033, Rennes, France
| | - Laurence Fardet
- Service de Dermatologie, Hôpital Henri Mondor, 94000, Créteil, France
| | - Guillaume Geri
- Service de Réanimation Médicale, CHU Cochin, AP-HP, 75012, Paris, France
| | | | - Cécile Goujard
- Service de Médecine Interne, CHU Bicêtre, AP-HP, 94270, Kremlin-Bicêtre, France
| | - Hervé Maisonneuve
- Service de Médecine Interne, CHD Vendée, 85925, La Roche-sur-Yon, France
| | - Arnaud Mari
- Service de Réanimation, Hôpital Yves Le Foll, 22000, St Brieuc, France
| | - Jacques Pouchot
- Service de Médecine Interne, Hôpital Européen Georges Pompidou, AP-HP, 75908, Paris, France
| | - Jean-Marc Ziza
- Service de Médecine Interne-Rhumatologie, groupe hospitalier Diaconesses-Croix-Saint-Simon, 75020, Paris, France
| | - Cédric Bretonnière
- Service de Réanimation Médicale, PHU3, CHU de Nantes, 44093, Nantes, France.,UPRES EA 3826, Faculté de Médecine, Université de Nantes, 44035, Nantes, France
| | - Mohamed Hamidou
- Service de Médecine Interne, PHU3, CHU Hôtel-Dieu, 44093, Nantes, France
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