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Ma W, Zhou L, Li W, Li X, Huang Y, Gao S, Yu J, Fang Y, Xu Y. Brain MRI imaging markers associated with death in children with central nervous system involvement of hemophagocytic lymphohistiocytosis. Eur Radiol 2024; 34:873-884. [PMID: 37624411 DOI: 10.1007/s00330-023-10147-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 07/15/2023] [Accepted: 07/27/2023] [Indexed: 08/26/2023]
Abstract
OBJECTIVES To investigate the association of brain MRI and clinical variables with death in children with central nervous system involvement of hemophagocytic lymphohistiocytosis (CNS-HLH). METHODS Clinical and brain MRI data of children with CNS-HLH from January 2012 to March 2022 were reviewed retrospectively. Patients were divided into the deceased group and the surviving group. The intergroup differences of seven brain MRI variables, twelve clinical variables, and underlying diseases were studied. RESULTS One hundred and fourteen patients were included in this study, consisting of 59 who died and 55 who survived. The included clinical variables did not show statistically independent correlation with patients' deaths. For MRI variables, a multivariate analysis demonstrated restricted diffusion of lesion (OR = 9.64, 95% CI: 3.39-27.43, p < 0.001) and count of affected brain regions (CABR) (OR = 1.24, 95% CI: 1.03-1.49, p = 0.02) were independent risk factors for death. ROC curve showed CABR (AUC = 0.79, 95% CI: 0.70-0.87, p < 0.001) is highly predictive for mortality with an optimal cutoff value of 4.5 (sensitivity 76%, specificity 73%). For HLH subtypes, familial HLH (F-HLH, OR = 9.90, 95% CI: 2.01-48.87, p = 0.005) and immune-compromise-related HLH (IC-HLH, OR = 4.95, 95% CI: 1.40-17.46, p = 0.01) presented statistically stronger association with death than infection-related HLH. F-HLH and IC-HLH preferred to have large lesions, restricted diffusion, and more brain regions involved than other subtypes. CONCLUSION Brain MRI features exhibit independent prediction for mortality in children with CNS-HLH, and HLH subtypes pose effects on patient outcomes and brain MRI findings. CLINICAL RELEVANCE STATEMENT The number of affected brain regions and diffusion restriction of lesion exhibit significant correlation with mortality in children diagnosed with CNS-hemophagocytic lymphohistiocytosis, and may serve as candidate MRI markers for the prediction of the disorder's severity. KEY POINTS • The brain MRI markers, restricted diffusion of lesion and count of affected brain regions, significantly correlated with death. • Familial and immune-compromise-related hemophagocytic lymphohistiocytosis presented statistically stronger association with death than infection-related subtype. • Brain MRI is potential in death-predicting for children with central nervous system involvement of hemophagocytic lymphohistiocytosis.
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Affiliation(s)
- Wei Ma
- Department of Radiology, The Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Children's Hospital of Chongqing Medical University, 136 Zhongshan Er Lu, Yuzhong District, Chongqing, 400000, China
- Department of Radiology, The People's Hospital of Yubei District of Chongqing City, Yubei District, Chongqing, 400000, China
| | - Liang Zhou
- Department of Emergency, Children's Hospital of Chongqing Medical University, Yuzhong District, Chongqing, 400000, China
| | - Wei Li
- Department of Radiology, The Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Children's Hospital of Chongqing Medical University, 136 Zhongshan Er Lu, Yuzhong District, Chongqing, 400000, China
| | - Xiujuan Li
- Department of Neurology, Children's Hospital of Chongqing Medical University, Yuzhong District, Chongqing, 400000, China
| | - Yan Huang
- Department of Radiology, The People's Hospital of Yubei District of Chongqing City, Yubei District, Chongqing, 400000, China
| | - Sijie Gao
- Department of Radiology, The Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Children's Hospital of Chongqing Medical University, 136 Zhongshan Er Lu, Yuzhong District, Chongqing, 400000, China
| | - Jie Yu
- Department of Hematology, Children's Hospital of Chongqing Medical University, Yuzhong District, Chongqing, 400000, China
| | - Yuan Fang
- Department of Radiology, The People's Hospital of Yubei District of Chongqing City, Yubei District, Chongqing, 400000, China
| | - Ye Xu
- Department of Radiology, The Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Children's Hospital of Chongqing Medical University, 136 Zhongshan Er Lu, Yuzhong District, Chongqing, 400000, China.
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Tan HEI, Lakshmanan R, Warne R, Walwyn T, Roebuck D. Neuroimaging manifestations of paediatric histiocytoses. J Med Imaging Radiat Oncol 2023. [PMID: 37964685 DOI: 10.1111/1754-9485.13602] [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: 09/28/2023] [Accepted: 10/23/2023] [Indexed: 11/16/2023]
Abstract
Histiocytoses are rare multi-system disorders marked by abnormal histiocyte cell proliferation, affecting children with diverse clinical presentations. Classified into five groups in 2016, including Langerhans-related (L), cutaneous (C), malignant (M), Rosai-Dorfman disease (R) and haemophagocytic lymphohistiocytosis (H), newer entities such as ALK-positive histiocytosis have also emerged, heralding the era of molecular (sub)classification. Common entities include Langerhans cell histiocytosis (LCH), Erdheim-Chester disease (ECD), Rosai-Dorfman disease (RDD) and haemophagocytic lymphohistiocytosis (HLH). This pictorial essay aids radiologists in recognising and differentiating paediatric histiocytoses based on unique neuroimaging features.
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Affiliation(s)
- Hsern Ern Ivan Tan
- Department of Medical Imaging, Perth Children's Hospital, Perth, Western Australia, Australia
- Department of Medical Imaging, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - Rahul Lakshmanan
- Department of Medical Imaging, Perth Children's Hospital, Perth, Western Australia, Australia
- University of Western Australia, Perth, Western Australia, Australia
| | - Richard Warne
- Department of Medical Imaging, Perth Children's Hospital, Perth, Western Australia, Australia
| | - Thomas Walwyn
- University of Western Australia, Perth, Western Australia, Australia
- Department of Oncology, Perth Children's Hospital, Perth, Western Australia, Australia
| | - Derek Roebuck
- Department of Medical Imaging, Perth Children's Hospital, Perth, Western Australia, Australia
- University of Western Australia, Perth, Western Australia, Australia
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Khalatbari H, Shulkin BL, Parisi MT. Emerging Trends in Radionuclide Imaging of Infection and Inflammation in Pediatrics: Focus on FDG PET/CT and Immune Reactivity. Semin Nucl Med 2023; 53:18-36. [PMID: 36307254 DOI: 10.1053/j.semnuclmed.2022.10.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 10/06/2022] [Indexed: 11/06/2022]
Abstract
The most common indication for 18F-FDG PET/CT is tumor imaging, which may be performed for initial diagnosis, staging, therapeutic response monitoring, surveillance, or suspected recurrence. In the routine practice of pediatric nuclear medicine, most infectious, inflammatory, and autoimmune processes that are detected on 18F-FDG PET/CT imaging - except for imaging in fever or inflammation of unknown origin - are coincidental and not the main indication for image acquisition. However, interpreting these "coincidental" findings is of utmost importance to avoid erroneously attributing these findings to a neoplastic process. We review the recent literature on fever of unknown origin as well as inflammation of unknown origin in pediatrics and then focus on the 18F FDG PET/CT imaging findings seen in two specific entities with increased immune reactivity: hemophagocytic lymphohistiocytosis syndrome and the immune-related adverse events associated with checkpoint inhibitors. We will subsequently close with two sections highlighting related topics and relevant references for further reading.
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Affiliation(s)
- Hedieh Khalatbari
- Department of Radiology, Seattle Children's Hospital, Seattle, WA; Department of Radiology, University of Washington School of Medicine, Seattle, WA
| | - Barry L Shulkin
- Department of Diagnostic Radiology, St. Jude Children's Research Hospital, Memphis, TN.
| | - Marguerite T Parisi
- Department of Radiology, Seattle Children's Hospital, Seattle, WA; Department of Radiology, University of Washington School of Medicine, Seattle, WA
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Aydın K, Kılıç B, Topçu Y, Telhan L, Dolu MH, Kartal A. Brain Magnetic Resonance Imaging Findings of Pediatric Hemophagocytic Lymphohistiocytosis Could Be Diagnostic and Life-Saving. Pediatr Neurol 2022; 133:40-47. [PMID: 35753148 DOI: 10.1016/j.pediatrneurol.2022.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 01/09/2022] [Accepted: 05/25/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Hemophagocytic lymphohistiocytosis (HLH) is a rare and fatal disease and may also present with central nervous system findings at the beginning without specific diagnostic criteria. Brain magnetic resonance imaging (MRI) findings are diverse and can also be diagnostic. We aimed to emphasize the importance of brain MRI findings in the early diagnosis of this fatal disease. METHODS MRI findings, clinical presentations, treatment response, and prognosis of seven patients with HLH were described. RESULTS There were seven pediatric patients who were initially diagnosed with HLH with neurological findings without systemic signs of HLH: four as primary, two as secondary, and one as possible primary HLH. All patients had contrast-enhancing diffuse cerebellar and brainstem lesions; patchy periventricular and callosal cerebral lesions were observed. Thalamus involvement was found in three (42.8%), corpus callosum involvement in six (85.7%), and cervical spinal involvement in one (14.2%). Patients were followed up with these MRI findings, with prediagnoses of toxic, metabolic, infectious, vascular, and demyelinating diseases. Not all patients met the HLH diagnostic criteria due to incomplete systemic/laboratory findings; therefore, only two were immediately directed for hematopoietic stem cell therapy. Four died shortly after admission, one patient could not be followed up after HLH treatment, and two patients who fulfilled the HLH diagnostic criteria underwent hematopoietic stem cell transplantation and survived. CONCLUSIONS Brain MRI findings, especially in the presence of neurological findings, allow for early diagnosis, which can be life-saving. These common features in brain MRI findings should be evaluated with this suspicion and included in HLH diagnostic criteria.
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Affiliation(s)
- Kürşad Aydın
- Department of Pediatric Neurology, Istanbul Medipol University Faculty of Medicine, Istanbul, Turkey
| | - Betül Kılıç
- Department of Pediatric Neurology, Istanbul Medipol University Faculty of Medicine, Istanbul, Turkey.
| | - Yasemin Topçu
- Department of Pediatric Neurology, Istanbul Medipol University Faculty of Medicine, Istanbul, Turkey
| | - Leyla Telhan
- Department of Pediatric Intensive Care Unit, Istanbul Medipol University Faculty of Medicine, Istanbul, Turkey
| | - Merve Hilal Dolu
- Department of Pediatric Neurology, Ondokuz Mayıs University Faculty of Medicine, Samsun, Turkey
| | - Ayşe Kartal
- Department of Pediatric Neurology, Selçuk University Faculty of Medicine, Konya, Turkey
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Cooray S, Sabanathan S, Hacohen Y, Worth A, Eleftheriou D, Hemingway C. Treatment Strategies for Central Nervous System Effects in Primary and Secondary Haemophagocytic Lymphohistiocytosis in Children. Curr Treat Options Neurol 2022. [DOI: 10.1007/s11940-022-00705-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Abstract
Purpose of Review
This review presents an appraisal of current therapeutic options for the treatment of central nervous system haemophagocytic lymphohistiocytosis (CNS-HLH) in the context of systemic disease, as well as when CNS features occur in isolation. We present the reader with a diagnostic approach to CNS-HLH and commonly used treatment protocols. We discuss and evaluate newer treatments on the horizon.
Recent Findings
Mortality is high in patients who do not undergo HSCT, and while larger studies are required to establish benefit in many treatments, a number of new treatments are currently being evaluated. Alemtuzumab is being used as a first-line treatment for CNS-HLH in a phase I/II multicentre prospective clinical trial as an alternative to traditional HLH-1994 and 2004 protocols. It has also been used successfully as a second-line agent for the treatment of isolated CNS-HLH that is refractory to standard treatment. Ruxolitinib and emapalumab are new immunotherapies that block the Janus kinase—Signal Transducer and Activator of Transcription (JAK-STAT) pathway that have shown efficacy in refractory HLH, including for CNS-HLH disease.
Summary
Treatment of CNS-HLH often requires HLH-94 or 2004 protocols followed by haematopoietic stem cell transplantation (HSCT) to maintain remission, although relapse can occur, particularly with reduced intensity conditioning if donor chimerism falls. CNS features have been shown to improve or stabilise following HSCT in CNS-HLH in the context of systemic disease and in isolated CNS-HLH. Encouraging reports of early cohort studies suggest alemtuzumab and the Janus kinase (JAK) inhibitor ruxolitinib offer potential salvage therapy for relapsed and refractory CNS-HLH. Newer immunotherapies such as tocilizumab and natalizumab have been shown to be beneficial in sporadic cases. CNS-HLH due to primary gene defects may be amenable to gene therapy in the future.
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Familial Hemophagocytic Lymphohistiocytosis Secondary to PRF1 Mutation. Case Rep Hematol 2022; 2021:7213939. [PMID: 35003815 PMCID: PMC8731261 DOI: 10.1155/2021/7213939] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Accepted: 12/17/2021] [Indexed: 12/03/2022] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening hyperinflammatory syndrome that causes systemic inflammation which can progress to multiorgan failure and death. Symptoms and signs commonly seen in HLH include high fever, hepatosplenomegaly, pancytopenia, and hypertriglyceridemia. This report describes the 8-month clinical course of a 17-year-old male with G6PD deficiency who presented with intermittent high fever of unknown origin for 8 months accompanied by pancytopenia and bilateral lower limb weakness. A pathogenic homozygous missense mutation (c.1081A > T p.(Arg361Trp)) in the PRF1 gene was detected by whole exome sequencing (WES). The brain and the whole spine MRI showed leptomeningeal enhancement at different levels involving both the brain and the spine. Therefore, a diagnosis of familial HLH type 2 with CNS involvement was confirmed. Accordingly, treatment with dexamethasone, cyclosporin, and etoposide in addition to intrathecal methotrexate and hydrocortisone was given. The patient showed a dramatic response with significant neurological improvement of the bilateral lower limb weakness. Genetic analysis has helped the patient's family with appropriate genetic counselling. This case highlights the importance of immediate treatment with immunosuppressants and the high clinical suspicion of physicians regarding HLH in areas where consanguinity is common.
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Hiraldo JDG, Domínguez-Mayoral A, García-Gómez FJ, Fouz-Rosón N, Rivas-Infante E, Cano MAM, Fernández AR, Morillo SG, Fernández NA, de León JAP, Mascarell GN, Lebrón CV. Central nervous system involvement in adult-onset relapsing hemophagocytic lymphohistiocytosis responsive to maintenance treatment with anakinra. J Neuroimmunol 2021; 355:577552. [PMID: 33845282 DOI: 10.1016/j.jneuroim.2021.577552] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Revised: 03/22/2021] [Accepted: 03/22/2021] [Indexed: 12/13/2022]
Abstract
A 43 year-old male presented with a relapsing and progressive systemic inflammatory disorder with central nervous system (CNS) involvement. After a two years follow up, he was diagnosed with hemophagocytic lymphohistiocytosis (HLH), based on clinical, laboratory and radiological findings. Treatment was started with anakinra, a recombinant humanised interleukin-1 (IL-1) receptor antagonist. Clinical response was good. Laboratory and radiological findings showed no disease activity throughout a five years follow-up period. Several immunosuppressive agents have been used in HLH without any good outcomes. This is the first case report of HLH with CNS involvement responsive to chronic treatment with anakinra.
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Affiliation(s)
| | | | | | - Natalia Fouz-Rosón
- Department of Pneumology, Hospital Universitario Virgen Macarena, Seville, Spain
| | - Eloy Rivas-Infante
- Department of Anatomic Pathology, Hospital Universitario Virgen del Rocío, Seville, Spain
| | | | | | | | | | | | | | - Carmen Vargas Lebrón
- Department of Rheumatology, Hospital Universitario Virgen Macarena, Seville, Spain
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Lehrer H, Scigliano E, Chan A. Central Nervous System Hemophagocytic Lymphohistiocytosis (CNS-HLH) from Leptomeningeal Anaplastic Large Cell Lymphoma : Mild Clinical Neurologic Syndrome with Extensive Multifocal White Matter Disease. Clin Neuroradiol 2021; 31:881-883. [PMID: 33576835 DOI: 10.1007/s00062-021-00998-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 01/15/2021] [Indexed: 11/26/2022]
Affiliation(s)
- Helaina Lehrer
- Neurology Department, Icahn School of Medicine at Mount Sinai, 1 Gustave Levy Place, 1137, 10029-0312, New York, NY, USA.
| | - Eileen Scigliano
- Hematology-Oncology Department, Icahn School of Medicine at Mount Sinai, 1 Gustave Levy Place, 10029, New York, NY, USA
| | - Amy Chan
- Hematology-Oncology Department, Icahn School of Medicine at Mount Sinai, 1 Gustave Levy Place, 10029, New York, NY, USA
- Dartmouth-Hitchcock Medical Center, 1 Medical Center Drive, 03756, Lebanon, NH, USA
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Ma W, Li XJ, Li W, Xiao L, Ji XJ, Xu Y. MRI findings of central nervous system involvement in children with haemophagocytic lymphohistiocytosis: correlation with clinical biochemical tests. Clin Radiol 2020; 76:159.e9-159.e17. [PMID: 33036779 DOI: 10.1016/j.crad.2020.09.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Accepted: 09/09/2020] [Indexed: 11/16/2022]
Abstract
AIM To investigate the brain magnetic resonance imaging (MRI) features of children with haemophagocytic lymphohistiocytosis (HLH) with central nervous system (CNS) involvement, and to investigate the correlation with clinical biochemical tests. MATERIAL AND METHODS Clinical and MRI data were collected from 118 children with HLH-CNS between January 2012 and June 2019. Patients were grouped according to their MRI findings, and statistical methods were used to test for correlations between the MRI findings and biochemical variables. RESULTS Patients were divided into three groups, including normal appearance (Group 1, 17/118), diffuse parenchymal volume loss (Group 2, 44/118), and brain parenchyma lesions (Group 3, 57/118) containing three subtypes of brain lesions and HLH-CNS complications. Comparing biochemical values among the three groups revealed a significant difference for all values (p<0.05), except for cell counts in the cerebrospinal fluid (CSF). A pairwise comparison further showed significant inter-group differences for most of the variables. Spearman's rank correlation coefficient also demonstrated that CSF cell counts (r=0.193, p=0.036), CSF microprotein content (r=0.379, p<0.001), serum aspartate aminotransferase (AST; r=0.521, p<0.001), serum lactate dehydrogenase (LDH; r=0.514, p<0.001) and activated partial thromboplastin time (APTT; r=0.326, p<0.001) correlated positively with the MRI groups, while platelet count (PLT; r=-0.633, p<0.001) and plasma fibrinogen (FIB; r=-0.258, p=0.005) correlated negatively. CONCLUSION Classification of brain MRI findings of HLH-CNS correlates well with the results of several key biochemical tests. Brain MRI is a promising method to elucidate illness severity and clinical outcomes.
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Affiliation(s)
- W Ma
- Department of Radiology, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - X J Li
- Department of Neurology, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - W Li
- Department of Radiology, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - L Xiao
- Clinical Laboratory, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - X J Ji
- Department of Ultrasound, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Y Xu
- Department of Radiology, Children's Hospital of Chongqing Medical University, Chongqing, China.
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Neuroinflammatory Disease as an Isolated Manifestation of Hemophagocytic Lymphohistiocytosis. J Clin Immunol 2020; 40:901-916. [PMID: 32638196 DOI: 10.1007/s10875-020-00814-6] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Accepted: 06/25/2020] [Indexed: 02/07/2023]
Abstract
Isolated neuroinflammatory disease has been described in case reports of familial hemophagocytic lymphohistiocytosis (FHL), but the clinical spectrum of disease manifestations, response to therapy and prognosis remain poorly defined. We combined an international survey with a literature search to identify FHL patients with (i) initial presentation with isolated neurological symptoms; (ii) absence of cytopenia and splenomegaly at presentation; and (iii) systemic HLH features no earlier than 3 months after neurological presentation. Thirty-eight (20 unreported) patients were identified with initial diagnoses including acute demyelinating encephalopathy, leukoencephalopathy, CNS vasculitis, multiple sclerosis, and encephalitis. Median age at presentation was 6.5 years, most commonly with ataxia/gait disturbance (75%) and seizures (53%). Diffuse multifocal white matter changes (79%) and cerebellar involvement (61%) were common MRI findings. CSF cell count and protein were increased in 22/29 and 15/29 patients, respectively. Fourteen patients progressed to systemic inflammatory disease fulfilling HLH-2004 criteria at a mean of 36.9 months after initial neurological presentation. Mutations were detected in PRF1 in 23 patients (61%), RAB27A in 10 (26%), UNC13D in 3 (8%), LYST in 1 (3%), and STXBP2 in 1 (3%) with a mean interval to diagnosis of 28.3 months. Among 19 patients who underwent HSCT, 11 neurologically improved, 4 were stable, one relapsed, and 3 died. Among 14 non-transplanted patients, only 3 improved or had stable disease, one relapsed, and 10 died. Isolated CNS-HLH is a rare and often overlooked cause of inflammatory brain disease. HLH-directed therapy followed by HSCT seems to improve survival and outcome.
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Clinical and imaging features in adult patients with bone marrow haemophagocytosis with and without haemophagocytic lymphohistiocytosis: a single-institution experience. Clin Radiol 2020; 75:641.e1-641.e8. [PMID: 32354424 DOI: 10.1016/j.crad.2020.03.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2019] [Accepted: 03/25/2020] [Indexed: 11/22/2022]
Abstract
AIM To evaluate clinical, laboratory, imaging findings, and outcomes of adult patients with bone marrow haemophagocytosis (BMH) who meet the diagnostic criteria for haemophagocytic lymphohistiocytosis (HLH) with those who do not meet the criteria. MATERIALS AND METHODS A pathology database search was performed from 2009 to 2019 to identify adult patients with BMH. Electronic medical records of 41 patients were reviewed to distinguish those who fulfil the HLH-2004 diagnostic guidelines, which identified 22 patients (11 men; mean age, 53.5 years) who met the criteria (HLH+) and 19 patients (13 men; mean age, 54.7 years) who did not meet the criteria (HLH-). Multi-modality imaging was reviewed to record imaging features. Clinical, laboratory, imaging findings, and outcomes were compared between the two groups using Fisher's exact test and Wilcoxon test. RESULTS Malignancy (non-Hodgkin's lymphoma) was the major trigger for both groups. 86% of HLH+ and 31% of HLH- patients presented with fever. Compared to the HLH- group, the HLH+ group exhibited higher serum ferritin, triglycerides, and lower fibrinogen levels (p<0.05). Alveolar opacities and hepatosplenomegaly were the most common imaging findings identified in both groups. Median overall survival of HLH+ and HLH- were 123.5 (interquartile range [IQR]: 40.7-681.7 days) and 189 days (IQR: 52-1680 days), respectively. Distribution of imaging features and overall survival did not differ between the groups. CONCLUSION Malignancy is the major trigger for BMH in both HLH+ and HLH- groups. HLH+ and HLH- groups have similar imaging manifestations or clinical outcomes. Therefore, presence of BMH alone is correlated with high morbidity and mortality.
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13
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Wang Y, Camelo-Piragua S, Abdullah A, Ibrahim M, Parmar HA. Neuroimaging features of CNS histiocytosis syndromes. Clin Imaging 2019; 60:131-140. [PMID: 31874337 DOI: 10.1016/j.clinimag.2019.10.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Revised: 10/01/2019] [Accepted: 10/07/2019] [Indexed: 01/24/2023]
Abstract
Histiocytosis syndromes (HS) are group of heterogeneous disorders characterized by abnormal accumulation and infiltration of histiocytes, cells derived from hematopoietic cells of monocyte/macrophage lineage. Overall these disorders are rare. When they do occur they involve many organ systems including the central nervous system (CNS). While imaging findings can provide important clues, diagnosis of this disorder is challenging and definitive diagnosis often necessitates pathologic examination. In this review, we describe imaging features of HS involving the CNS, with the aim to increase our understanding of these disorders. The entities discussed in this review will include: Langerhans cell histiocytosis (LCH), Rosai-Dorfman Disease (RDD), Erdheim Chester Disease (ECD), hemophagocytic lymphohistiocytosis (HLH), and crystal-storing histiocytosis (CSH).
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Affiliation(s)
- Yuting Wang
- Department of Radiology, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, Chengdu, China; Department of Radiology, University of Michigan Health System, Ann Arbor, MI, United States of America
| | - Sandra Camelo-Piragua
- Department of Pathology, University of Michigan Health System, Ann Arbor, MI, United States of America
| | - Asif Abdullah
- Department of Radiology, University of Michigan Health System, Ann Arbor, MI, United States of America
| | - Mohannad Ibrahim
- Department of Radiology, University of Michigan Health System, Ann Arbor, MI, United States of America
| | - Hemant A Parmar
- Department of Radiology, University of Michigan Health System, Ann Arbor, MI, United States of America.
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An 18-Year-Old Male With X-linked Lymphoproliferative Syndrome Type 1 Who Developed Primary Central Nervous System Lymphoma 6 Months After Primary Epstein-Barr Virus Infection. J Pediatr Hematol Oncol 2019; 41:e538-e541. [PMID: 30676439 DOI: 10.1097/mph.0000000000001424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
X-linked lymphoproliferative syndrome type 1 (XLP1) is a rare congenital immunodeficiency disease. We report the case of an 18-year-old male who developed hemophagocytic lymphohistiocytosis (HLH) with neurologic complications after primary Epstein-Barr virus (EBV) infection and subsequently developed EBV-related central nervous system lymphoma (CNSL). Given the vulnerability to EBV, he was finally diagnosed with XLP1 and treated with whole-brain irradiation along with chemotherapy and subsequent allogeneic hematopoietic stem cell transplantation from a SH2D1A wild-type sibling donor. Although the prognosis for CNSL is generally dismal, reconstitution of the immune system from a normal donor contributed to the patient remaining in remission for 30 months.
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Mbizvo GK, Lentell IC, Leen C, Roddie H, Derry CP, Duncan SE, Rannikmäe K. Epilepsia partialis continua complicated by disseminated tuberculosis and hemophagocytic lymphohistiocytosis: a case report. J Med Case Rep 2019; 13:191. [PMID: 31230590 PMCID: PMC6589876 DOI: 10.1186/s13256-019-2092-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Accepted: 04/18/2019] [Indexed: 11/11/2022] Open
Abstract
Background We describe a patient copresenting with epilepsia partialis continua, tuberculosis, and hemophagocytic lymphohistiocytosis. To our knowledge, this is the first documented case of this triad. Case presentation A 54-year-old black South African woman presented to a hospital in Scotland with an acute history of right-sided facial twitching, breathlessness, and several months of episodic night sweats. Clinical examination revealed pyrexia and continuous, stereotyped, right-sided facial contractions. These worsened with speech and continued through sleep. A clinical diagnosis of epilepsia partialis continua was made, and we provide a video of her seizures. Computed tomographic imaging of the chest and serous fluid analyses were consistent with a diagnosis of disseminated Mycobacterium tuberculosis. An additional diagnosis of hemophagocytic lymphohistiocytosis was made following the identification of pancytopenia and hyperferritinemia in peripheral blood, with hemophagocytosis evident in bone marrow investigation. We provide images of her hematopathology. The patient was extremely unwell and was hospitalized for 6 months, including two admissions to the intensive care unit for ventilatory support. She was treated successfully with high doses of antiepileptic drugs (benzodiazepines, levetiracetam, and phenytoin) and 12 months of oral antituberculosis therapy, and she underwent chemotherapy with 8 weeks of etoposide and dexamethasone for hemophagocytic lymphohistiocytosis, followed by 12 months of cyclosporine and prednisolone. Conclusions This combination of pathologies is unusual, and this case report helps educate clinicians on how such a patient may present and be managed. A lack of evidence surrounding the coexpression of this triad may represent absolute rarity, underdiagnosis, or incomplete case ascertainment due to early death caused by untreated tuberculosis or hemophagocytic lymphohistiocytosis. Further research is needed. Electronic supplementary material The online version of this article (10.1186/s13256-019-2092-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Gashirai K Mbizvo
- Muir Maxwell Epilepsy Centre, Centre for Clinical Brain Sciences, The University of Edinburgh, 20 Sylvan Place, Edinburgh, EH9 1UW, UK. .,Department of Clinical Neurosciences, Western General Hospital, Edinburgh, UK.
| | - Isabel C Lentell
- Haematology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Clifford Leen
- Regional Infectious Diseases Unit, Western General Hospital, Edinburgh, UK
| | - Huw Roddie
- Department of Haematology, Western General Hospital, Edinburgh, UK
| | - Christopher P Derry
- Department of Clinical Neurosciences, Western General Hospital, Edinburgh, UK.,Department of Clinical Neurosciences and Sleep Medicine, Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, UK
| | - Susan E Duncan
- Muir Maxwell Epilepsy Centre, Centre for Clinical Brain Sciences, The University of Edinburgh, 20 Sylvan Place, Edinburgh, EH9 1UW, UK.,Department of Clinical Neurosciences, Western General Hospital, Edinburgh, UK
| | - Kristiina Rannikmäe
- Forth Valley Royal Hospital, Larbert, and Usher Institute of Population Health Sciences and Informatics, The University of Edinburgh, Edinburgh, UK
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Song Y, Pei RJ, Wang YN, Zhang J, Wang Z. Central Nervous System Involvement in Hemophagocytic Lymphohistiocytosis in Adults: A Retrospective Analysis of 96 Patients in a Single Center. Chin Med J (Engl) 2018; 131:776-783. [PMID: 29578120 PMCID: PMC5887735 DOI: 10.4103/0366-6999.228234] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Background Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening clinical syndrome. Central nervous system (CNS) involvement is a severe complication, which can lead to rapid disease development and higher morality. However, this has not been given enough attention in adult HLH. Therefore, we carried out this study to analyze the clinical features, laboratory findings, treatment outcomes, and other characteristics of adult HLH with CNS involvement. Methods A retrospective analysis of 96 adult patients with HLH combined with CNS involvement between June 2003 and December 2016 was conducted. Clinical features, cerebrospinal fluid (CSF) features, image changes, and therapeutic outcomes were analyzed. Results Among the 96 patients, 86 had various CNS symptoms and 33 (38.4%) had already presented symptoms before the HLH diagnosis was confirmed. A total of 59 patients received CSF examinations and showed abnormalities in 23 patients (39.0%). Seventy patients received imaging examinations and the results showed fifty patients with imaging changes (71.4%). Fifty-seven patients received multiple rounds of repeated intrathecal injection therapy and 35 patients improved (61.4%). As for the multiple analyses of effective factors on survival time, the results showed that the effects of combined Epstein-Barr virus (EBV) infection (P = 0.026, Exp(B) = 2.309, 95% confidence interval [CI] [1.108, 4.823) and intrathecal injection therapy (P = 0.013, Exp(B) = 0.422, 95% CI [0.214, 0.831]) on the survival time of the CNS-HLH patients were significant. Conclusions Complication with EBV infection is a risk factor, and intrathecal injection is a protective factor. CNS involvement in HLH is not rare, which can result in a poor prognosis. Multiple rounds of repeated intrathecal injection therapy can improve the prognosis of CNS-HLH patients.
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Affiliation(s)
- Yue Song
- Department of Hematology, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
| | - Rui-Jun Pei
- Department of Hematology, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
| | - Yi-Ni Wang
- Department of Hematology, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
| | - Jia Zhang
- Department of Hematology, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
| | - Zhao Wang
- Department of Hematology, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
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18
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Eraslan C, Aydın E, Maharramova E, Şahin A, Hekimci Özdemir H, Yılmaz Karapınar D, Çallı C, Kitiş Ö. Hemofagositik lenfohistiyositoz hastalarında kraniyal MRG bulguları. EGE TIP DERGISI 2018. [DOI: 10.19161/etd.414385] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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19
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Cai G, Wang Y, Liu X, Han Y, Wang Z. Central nervous system involvement in adults with haemophagocytic lymphohistiocytosis: a single-center study. Ann Hematol 2017; 96:1279-1285. [PMID: 28589450 DOI: 10.1007/s00277-017-3035-5] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2017] [Accepted: 05/25/2017] [Indexed: 01/11/2023]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a rare multisystem disorder characterized by proliferation and diffuse infiltration multiple organs with histiocytes, including the central nervous system (CNS). Neurological manifestations of HLH have been recognized in different studies with children, but they remain relatively ill-defined in adults with HLH. From March 2008 to October 2014, 289 adult patients with HLH were admitted to our center. Clinical, radiological, and cerebral spinal fluid (CSF) data of the patients with CNS involvement were reviewed, and a retrospective study in our single-center was carried out. CNS involvement was observed in 29 patients (10%) either in their diagnosis process or during disease course. CNS symptoms included disturbance of consciousness, cranial nerve palsies, seizures, headache, limb paralysis, irritability, meningism, and memory loss. CSF analysis was conducted in 17 patients (59%). Among them, 11 patients (65%) were reported as having abnormal CSF. Neuroradiological studies were performed in 25 patients (86%). Among the 13 cases that underwent CT scan, one patient hemorrhaged. Single or multiple hypodense foci were detected in the other 2 patients. Magnetic resonance imaging (MRI) abnormalities were found in 15 patients, including focal lesions in cortical and adjacent subcortical regions with or without variable nodular or ring contrast-enhancement, multiple lesions in white matter, diffuse white matter signal changes, and meningeal enhancement. Basal ganglia, cerebellum, and brainstem lesions were also observed. CNS involvement could also be found in adult patients with HLH, but not as frequent as it was in children. The clinical manifestations could be diversified. By carrying out rigorous CNS examinations, an early diagnosis could be made and it was of the utmost importance for the prevention of further lesions.
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Affiliation(s)
- Guilan Cai
- Department of Neurology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Yini Wang
- Department of Hematology, Beijing Friendship Hospital, Capital Medical University, Beijing, 100050, China
| | - Xiaojing Liu
- Department of Neurology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Yanfei Han
- Department of Neurology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Zhao Wang
- Department of Hematology, Beijing Friendship Hospital, Capital Medical University, Beijing, 100050, China.
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20
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Guo Y, Bai Y, Gu L. Clinical features and prognostic factors of adult secondary hemophagocytic syndrome: Analysis of 47 cases. Medicine (Baltimore) 2017; 96:e6935. [PMID: 28562543 PMCID: PMC5459708 DOI: 10.1097/md.0000000000006935] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
This study aimed to investigate the relationship between clinical features and prognosis of adult secondary hemophagocytic syndrome (HPS).A retrospective analysis was conducted on the pathogenesis, clinical manifestations, laboratory examinations, treatment options, and prognosis of 47 patients with adult secondary HPS diagnosed from January 2013 to December 2015.The average age at disease onset was (46.26 ± 18.98) years with a male:female ratio of 1:1.14. Thirteen patients died, with the highest mortality rate in patients with HPS underlying blood system malignancy (33.33%, 2/6). The mortality rate in patients with HPS underlying autoimmune disorders was the lowest (18.75%, 3/16). The Kaplan-Meier analysis indicated that signs of hemorrhage, pulmonary and nervous system involvement, serous effusion, and decrease in the blood platelet count were associated with death. The Cox regression analysis revealed that signs of hemorrhage, pulmonary involvement, serous effusion, and nervous system involvement were independent risk factors of patient death.Adult secondary HPS has multiple etiologies and diversified clinical features. The risk of death increases in patients with signs of hemorrhage, serous effusion, pulmonary involvement, and nervous system involvement.
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Affiliation(s)
- Yiqun Guo
- Department of Infectious Diseases and Clinical Microbiology
| | - Yu Bai
- Department of Internal medicine, Beijing Chao-yang Hospital, Capital Medical University, Beijing, China
| | - Li Gu
- Department of Infectious Diseases and Clinical Microbiology
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21
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Lounder DT, Khandelwal P, Chandra S, Jordan MB, Kumar AR, Grimley MS, Davies SM, Bleesing JJ, Marsh RA. Incidence and Outcomes of Central Nervous System Hemophagocytic Lymphohistiocytosis Relapse after Reduced-Intensity Conditioning Hematopoietic Stem Cell Transplantation. Biol Blood Marrow Transplant 2017; 23:857-860. [DOI: 10.1016/j.bbmt.2017.02.011] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2016] [Accepted: 02/15/2017] [Indexed: 10/20/2022]
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22
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Co DO, Bordini BJ, Meyers AB, Inglese C. Immune-Mediated Diseases of the Central Nervous System: A Specificity-Focused Diagnostic Paradigm. Pediatr Clin North Am 2017; 64:57-90. [PMID: 27894452 DOI: 10.1016/j.pcl.2016.08.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Immune-mediated diseases of the central nervous system show wide variability both symptomatically and with respect to underlying pathophysiology. Recognizing aberrant immunologic activity as the cause of neurologic dysfunction requires establishing as precise a neuroanatomic and functional phenotype as possible, and a diagnostic and therapeutic strategy that stabilizes the patient, excludes broad categories of disease via rapidly available diagnostic assays, and maintains a broad differential diagnosis that includes immune-mediated conditions. This process is aided by recognizing the appropriate clinical circumstances under which immune-mediated disease should be suspected, and how to differentiate these conditions from other causes of similar neurologic dysfunction.
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Affiliation(s)
- Dominic O Co
- Section of Pediatric Rheumatology, Department of Pediatrics, Medical College of Wisconsin, 8701 West Watertown Plank Road, Milwaukee, WI 53226, USA.
| | - Brett J Bordini
- Section of Hospital Medicine, Department of Pediatrics, Medical College of Wisconsin, 8701 West Watertown Plank Road, Milwaukee, WI 53226, USA
| | - Arthur B Meyers
- Department of Radiology, University of Central Florida College of Medicine, 6850 Lake Nona Blvd, Orlando, FL 32827, USA
| | - Christopher Inglese
- Section of Pediatric Neurology, Department of Neurology, Medical College of Wisconsin, 8701 West Watertown Plank Road, Milwaukee, WI 53226, USA
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23
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Bosemani T, Poretti A. Tumor and Tumorlike Masses in Pediatric Patients that Involve Multiple Spaces. Neuroimaging Clin N Am 2017; 27:135-153. [DOI: 10.1016/j.nic.2016.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Horne A, Wickström R, Jordan MB, Yeh EA, Naqvi A, Henter JI, Janka G. How to Treat Involvement of the Central Nervous System in Hemophagocytic Lymphohistiocytosis? Curr Treat Options Neurol 2017; 19:3. [PMID: 28155064 PMCID: PMC5290057 DOI: 10.1007/s11940-017-0439-4] [Citation(s) in RCA: 83] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OPINION STATEMENT Central nervous system (CNS)-hemophagocytic lymphohistiocytosis (HLH) is not a disease in itself, but it is part of a systemic immune response. The vast majority of patients with CNS-HLH also have systemic HLH and a large number of patients with primary and secondary HLH have CNS involvement. Reactivations within the CNS are frequent during the course of HLH treatment and may occur concomitant with or independent of systemic relapses. It is also important to consider primary HLH as an underlying cause of "unknown CNS inflammation" as these patients may present with only CNS disease. To initiate proper treatment, a correct diagnosis must be made. A careful review of the patient's history and a thorough neurological examination are essential. In addition to the blood tests required to make a diagnosis of HLH, a lumbar puncture with cerebrospinal fluid (CSF) analysis and magnetic resonance imaging (MRI) should always be done in all cases regardless of the presence or absence of neurological signs or symptom. Treatment options for CNS-HLH include, but are not limited to, those commonly used in systemic HLH, including corticosteroids, etoposide, cyclosporine A, alemtuzumab, and ATG. In addition, intrathecal treatment with methotrexate and corticosteroids has become a standard care and is likely to be beneficial. Therapy must be initiated without inappropriate delay to prevent late effects in HLH. An interesting novel approach is an anti-IFN-gamma antibody (NI-0501), which is currently being tested. Hematopoietic stem cell transplantation (HSCT) also represents an important CNS-HLH treatment; patients with primary HLH may benefit from immediate HSCT even if there is active disease at time of transplantation, though care should be taken to monitor CNS inflammation through HSCT and treat if needed. Since CNS-HLH is a condition leading to the most severe late effects of HLH, early expert consultation is recommended.
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Affiliation(s)
- AnnaCarin Horne
- Department of Women's and Children's Health, Karolinska Institute, Division of Pediatrics Karolinska University Hospital, Stockholm, Sweden.
| | - Ronny Wickström
- Department of Women's and Children's Health, Karolinska Institute, Division of Pediatrics Karolinska University Hospital, Stockholm, Sweden
| | - Michael B Jordan
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center and the University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - E Ann Yeh
- Division of Neurology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Ahmed Naqvi
- Division of Hematology/Oncology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Jan-Inge Henter
- Department of Women's and Children's Health, Karolinska Institute, Division of Pediatrics Karolinska University Hospital, Stockholm, Sweden
| | - Gritta Janka
- Department of Pediatric Hematology and Oncology, University Medical Center Hamburg Eppendorf, Hamburg, Germany
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Foley JM, Borders H, Kurt BA. A Diagnostic Dilemma: Similarity of Neuroradiological Findings in Central Nervous System Hemophagocytic Lymphohistiocytosis and Aspergillosis. Pediatr Blood Cancer 2016; 63:1296-9. [PMID: 26970537 DOI: 10.1002/pbc.25967] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2015] [Revised: 02/02/2016] [Accepted: 02/07/2016] [Indexed: 11/07/2022]
Abstract
Central nervous system (CNS) involvement in the context of hemophagocytic lymphohistiocytosis (HLH) is not uncommon. Given the immunosuppressive nature of HLH therapy, infectious complications are also seen. We describe a 9-year-old male who developed acute neurological decline secondary to aspergillosis while undergoing HLH therapy. The significant overlap observed in CNS neuroimaging of HLH and aspergillosis and the subtleties that may help differentiate the two are discussed. The importance of obtaining tissue for definitive diagnosis is underscored.
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Affiliation(s)
- Jessica M Foley
- Division of Pediatric Hematology, Oncology and BMT, Spectrum Health Helen DeVos Children's Hospital, Grand Rapids, Michigan
| | - Heather Borders
- Department of Radiology, Spectrum Health, Grand Rapids, Michigan
| | - Beth A Kurt
- Division of Pediatric Hematology, Oncology and BMT, Spectrum Health Helen DeVos Children's Hospital, Grand Rapids, Michigan
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Umeda K, Adachi S, Horikoshi Y, Imai K, Terui K, Endo M, Mitsui T, Kato K, Koh K, Kajiwara R, Ito R, Otsuka Y, Inoue M, Ishii E, Yabe H. Allogeneic hematopoietic stem cell transplantation for Chediak-Higashi syndrome. Pediatr Transplant 2016; 20:271-5. [PMID: 26511512 DOI: 10.1111/petr.12626] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/28/2015] [Indexed: 11/27/2022]
Abstract
The clinical outcome of allogeneic HSCT was retrospectively analyzed in eight patients with CHS. In total, six of these eight patients are alive. Four of five patients transplanted with MAC achieved prompt engraftment, and three of the four patients, including two patients with AP before transplant, are alive without disease. In contrast, three patients transplanted with RIC without active AP disease achieved prompt engraftment and survive long term. RIC-HSCT might be an alternative treatment for CHS similar to other types of HLH, at least for patients without active AP disease.
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Affiliation(s)
- Katsutsugu Umeda
- Department of Pediatrics, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Souichi Adachi
- Human Health Sciences, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Yasuo Horikoshi
- Division of Hematology and Oncology, Shizuoka Children's Hospital, Shizuoka, Japan
| | - Kohsuke Imai
- Department of Community Pediatrics, Perinatal and Maternal Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Kiminori Terui
- Department of Pediatrics, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Mikiya Endo
- Department of Pediatrics, Iwate Medical University, Morioka, Japan
| | - Tetsuo Mitsui
- Department of Pediatrics, Yamagata University School of Medicine, Yamagata, Japan
| | - Keisuke Kato
- Division of Pediatric Hematology and Oncology, Ibaraki Children's Hospital, Mito, Japan
| | - Katsuyoshi Koh
- Department of Hematology/Oncology, Saitama Children's Medical Center, Saitama, Japan
| | - Ryosuke Kajiwara
- Department of Pediatrics, Yokohama City University School of Medicine, Yokohama, Japan
| | - Rieko Ito
- Division of Hematology and Oncology, Shizuoka Children's Hospital, Shizuoka, Japan
| | - Yoshitoshi Otsuka
- Department of Pediatrics, Hyogo College of Medicine, Nishinomiya, Japan
| | - Masami Inoue
- Department of Hematology/Oncology, Osaka Medical Center and Research Institute for Maternal and Child Health, Izumi, Japan
| | - Eiichi Ishii
- Department of Pediatrics, Ehime University Graduate School of Medicine, Toon, Japan
| | - Hiromasa Yabe
- Department of Cell Transplantation and Regenerative Medicine, Tokai University School of Medicine, Isehara, Japan
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Gratton SM, Powell TR, Theeler BJ, Hawley JS, Amjad FS, Tornatore C. Neurological involvement and characterization in acquired hemophagocytic lymphohistiocytosis in adulthood. J Neurol Sci 2015. [PMID: 26198020 DOI: 10.1016/j.jns.2015.07.017] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To describe the neurological and neuroradiological features of acquired hemophagocytic lymphohistiocytosis (HLH) in adulthood by reporting a series of cases. METHODS Ten consecutive patients who were diagnosed with HLH at Medstar Georgetown University Hospital and Walter Reed National Military Medical Center were evaluated for neurological involvement. All underwent clinical neurological evaluation, and when indicated CSF analysis and MR imaging of the brain. Data were gathered and analyzed retrospectively. RESULTS Seven of the ten patients with HLH had neurological involvement. Mean age at onset was 50 (range: 21 to 73). Four patients were males. Prominent clinical features included mild to severe encephalopathy and seizures. Other findings included hemiparesis and spastic tetraparesis. Neuroimaging revealed a wide spectrum of abnormalities including cortical and subcortical edema, gadolinium enhancement, hemorrhage, and diffusion restriction. Basal ganglia involvement was present in four out of seven patients. Three patients died due to multisystem organ failure, and the other patients displayed varying degrees of recovery. CONCLUSIONS The neurological features of acquired HLH in adults have not been previously reported. These seven patients demonstrate the spectrum of neurological involvement that can occur. The diagnosis of HLH should be considered in patients who are systemically ill with unexplained fevers and hyperferritinemia who have evidence of inflammation in the CNS.
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Affiliation(s)
- Sean M Gratton
- Medstar Georgetown University Hospital, Department of Neurology, PHC, 7th Floor, 3800 Reservoir Road, NW, Washington, DC 20007, United States.
| | - Tasha R Powell
- Walter Reed National Military Medical Center, Department of Neurology, Building 19, 8901 Rockville Pike, Bethesda, MD 20889, United States.
| | - Brett J Theeler
- Walter Reed National Military Medical Center, Department of Neurology, Building 19, 8901 Rockville Pike, Bethesda, MD 20889, United States; Walter Reed National Military Medical Center, John P. Murtha Cancer Center, Building 19, 8901 Rockville Pike, Bethesda, MD 20889, United States.
| | - Jason S Hawley
- Walter Reed National Military Medical Center, Department of Neurology, Building 19, 8901 Rockville Pike, Bethesda, MD 20889, United States.
| | - Faria S Amjad
- Medstar Georgetown University Hospital, Department of Neurology, PHC, 7th Floor, 3800 Reservoir Road, NW, Washington, DC 20007, United States.
| | - Carlo Tornatore
- Medstar Georgetown University Hospital, Department of Neurology, PHC, 7th Floor, 3800 Reservoir Road, NW, Washington, DC 20007, United States.
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A mutation in the STAT1 DNA-binding domain associated with hemophagocytic lymphohistocytosis. LYMPHOSIGN JOURNAL-THE JOURNAL OF INHERITED IMMUNE DISORDERS 2014. [DOI: 10.14785/lpsn-2014-0004] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Introduction: The transcription factor Signal Transducer and Activator of Transcription 1 (STAT1) is a key element in many of the signalling cascades involved in immune system function. Different mutations in STAT1 are associated with heterogeneous clinical phenotypes that range from early fatality due to overwhelming infection to limited involvement of the mucus membrane with recurrent Candida infections. Multiple genes related to immune function have been associated with the development of hemophagocytic lymphohistiocytosis (HLH), but the association between STAT1 mutation and HLH has not been described in detail. Methods: We report the genetic background of a patient with chronic mucocutaneous candidiasis (CMC) as well as an unusual clinical course. Results: In this study we describe a patient with a mutation in the STAT1 DNA-binding domain and a history of CMC who developed a refractory and fatal case of HLH despite having bone marrow transplantation. Conclusion: We describe a patient with refractory and fatal HLH who was found to have a mutation in the DNA-binding domain of STAT1. Statement of novelty: The association of chronic mucocutaneous candidiasis with HLH.
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Sankararaman S, Riel-Romero RM, Jeroudi M, Gonzalez-Toledo E. Epstein-Barr virus induced hemophagocytic lymphohistiocytosis in X-linked lymphoproliferative disease. J Neurosci Rural Pract 2014; 5:171-4. [PMID: 24966560 PMCID: PMC4064187 DOI: 10.4103/0976-3147.131669] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
X-linked lymphoproliferative disease (XLP) is a rare, often fatal genetic disorder characterized by extreme vulnerability to Epstein-Barr virus (EBV). EBV-induced hemophagocytic lymphohistiocytosis (HLH) is a known presentation in XLP. In EBV-induced HLH in XLP, the brain imaging findings in the acute phase include a non specific pattern. In this report, we highlight the magnetic resonance imaging and magnetic resonance spectroscopy findings in a child with EBV induced HLH in XLP.
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Affiliation(s)
- Senthilkumar Sankararaman
- Department of Pediatrics, Louisiana State University Health Sciences Center, 1501 Kings Highway, Shreveport, LA, USA
| | - Rosario Maria Riel-Romero
- Department of Pediatrics and Neurology, Louisiana State University Health Sciences Center, 1501 Kings Highway, Shreveport, LA, USA
| | - Majed Jeroudi
- Department of Pediatrics (Pediatric Hematology-Oncology Division), Louisiana State University Health Sciences Center, 1501 Kings Highway, Shreveport, LA, USA
| | - Eduardo Gonzalez-Toledo
- Department of Radiology (Neuroradiology Division), Louisiana State University Health Sciences Center, 1501 Kings Highway, Shreveport, LA, USA
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Jovanovic A, Kuzmanovic M, Kravljanac R, Micic D, Jovic M, Gazikalovic S, Pasic S. Central nervous system involvement in hemophagocytic lymphohistiocytosis: a single-center experience. Pediatr Neurol 2014; 50:233-7. [PMID: 24332871 DOI: 10.1016/j.pediatrneurol.2013.10.014] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2013] [Revised: 10/10/2013] [Accepted: 10/28/2013] [Indexed: 12/01/2022]
Abstract
BACKGROUND Hemophagocytic lymphohistiocytosis is a rare multisystem disorder characterized by proliferation and diffuse infiltration multiple organs with histiocytes, including the central nervous system. PATIENTS AND METHODS Thirty children diagnosed with hemophagocytic lymphohistiocytosis between 1997 and 2010 were reviewed and analyzed. Central nervous system disease involvement was defined as the presence of neurological symptoms and signs or elevated values of cerebrospinal fluid cells and/or proteins. RESULTS Among the 30 patients, 17 (56%) had central nervous system involvement. Fourteen patients (46%) presented with neurological symptoms including seizures, irritability, bulging fontanelle, cranial nerve palsy, or disturbance of consciousness, whereas the remaining three patients developed central nervous system symptoms during the course of the disease. Seventeen patients (56%) had cerebrospinal fluid abnormalities. Neuroradiological studies were performed in nine patients. The most common findings were edema, atrophy, subcortical necrosis, and high signal intensity on T2-weighted magnetic resonance imaging. All patients were treated according to the Hemophagocytic Lymphohistiocytosis-94 and Hemophagocytic Lymphohistiocytosis-2004 protocols. Patients with central nervous system involvement had greater mortality. In prediction of the outcome, the cutoff value for cerebrospinal fluid protein was 470 mg/L. The most common neurological sequela was psychomotor delay. CONCLUSION Central nervous system involvement in hemophagocytic lymphohistiocytosis is common and is associated with poor outcome.
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Affiliation(s)
- Ankica Jovanovic
- Department of Pediatric Hematology, Mother and Child Health Institute, Medical Faculty, University of Belgrade, Serbia; Department of Neurology, Mother and Child Health Institute, Medical Faculty, University of Belgrade, Serbia; Department of Radiology, Mother and Child Health Institute, Medical Faculty, University of Belgrade, Serbia; Department of Immunology, Mother and Child Health Institute, Medical Faculty, University of Belgrade, Serbia
| | - Milos Kuzmanovic
- Department of Pediatric Hematology, Mother and Child Health Institute, Medical Faculty, University of Belgrade, Serbia; Department of Neurology, Mother and Child Health Institute, Medical Faculty, University of Belgrade, Serbia; Department of Radiology, Mother and Child Health Institute, Medical Faculty, University of Belgrade, Serbia; Department of Immunology, Mother and Child Health Institute, Medical Faculty, University of Belgrade, Serbia
| | - Ruzica Kravljanac
- Department of Pediatric Hematology, Mother and Child Health Institute, Medical Faculty, University of Belgrade, Serbia; Department of Radiology, Mother and Child Health Institute, Medical Faculty, University of Belgrade, Serbia; Department of Immunology, Mother and Child Health Institute, Medical Faculty, University of Belgrade, Serbia
| | - Dragan Micic
- Department of Pediatric Hematology, Mother and Child Health Institute, Medical Faculty, University of Belgrade, Serbia; Department of Neurology, Mother and Child Health Institute, Medical Faculty, University of Belgrade, Serbia; Department of Radiology, Mother and Child Health Institute, Medical Faculty, University of Belgrade, Serbia; Department of Immunology, Mother and Child Health Institute, Medical Faculty, University of Belgrade, Serbia
| | - Milena Jovic
- Department of Neurology, Mother and Child Health Institute, Medical Faculty, University of Belgrade, Serbia; Department of Radiology, Mother and Child Health Institute, Medical Faculty, University of Belgrade, Serbia; Department of Immunology, Mother and Child Health Institute, Medical Faculty, University of Belgrade, Serbia
| | - Slobodan Gazikalovic
- Department of Pediatric Hematology, Mother and Child Health Institute, Medical Faculty, University of Belgrade, Serbia; Department of Neurology, Mother and Child Health Institute, Medical Faculty, University of Belgrade, Serbia; Department of Immunology, Mother and Child Health Institute, Medical Faculty, University of Belgrade, Serbia
| | - Srdjan Pasic
- Department of Pediatric Hematology, Mother and Child Health Institute, Medical Faculty, University of Belgrade, Serbia; Department of Neurology, Mother and Child Health Institute, Medical Faculty, University of Belgrade, Serbia; Department of Radiology, Mother and Child Health Institute, Medical Faculty, University of Belgrade, Serbia.
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31
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Gupta S, Weitzman S. Primary and secondary hemophagocytic lymphohistiocytosis: clinical features, pathogenesis and therapy. Expert Rev Clin Immunol 2014; 6:137-54. [PMID: 20383897 DOI: 10.1586/eci.09.58] [Citation(s) in RCA: 118] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Sumit Gupta
- Division of Haematology/Oncology, The Hospital for Sick Children, 555 University Avenue, Toronto, ON M5G 1X8, Canada.
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32
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Dias C, McDonald A, Sincan M, Rupps R, Markello T, Salvarinova R, Santos RF, Menghrajani K, Ahaghotu C, Sutherland DP, Fortuno ES, Kollmann TR, Demos M, Friedman JM, Speert DP, Gahl WA, Boerkoel CF. Recurrent subacute post-viral onset of ataxia associated with a PRF1 mutation. Eur J Hum Genet 2013; 21:1232-9. [PMID: 23443029 PMCID: PMC3798831 DOI: 10.1038/ejhg.2013.20] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2012] [Revised: 11/19/2012] [Accepted: 01/23/2013] [Indexed: 12/14/2022] Open
Abstract
Inflammation is an important contributor to pediatric and adult neurodegeneration. Understanding the genetic determinants of neuroinflammation provides valuable insight into disease mechanism. We characterize a disorder of recurrent immune-mediated neurodegeneration. We report two sisters who presented with neurodegeneration triggered by infections. The proband, a previously healthy girl, presented at 22.5 months with ataxia and dysarthria following mild gastroenteritis. MRI at onset showed a symmetric signal abnormality of the cerebellar and peritrigonal white matter. Following a progressive course of partial remissions and relapses, she died at 5 years of age. Her older sister had a similar course following varicella infection, she died within 13 months. Both sisters had unremarkable routine laboratory testing, with exception of a transient mild cytopenia in the proband 19 months after presentation. Exome sequencing identified a biallelic perforin1 mutation (PRF1; p.R225W) previously associated with familial hemophagocytic lymphohistiocytosis (FHL). In contrast to FHL, these girls did not have hematopathology or cytokine overproduction. However, 3 years after disease onset, the proband had markedly deficient interleukin-1 beta (IL-1β) production. These observations extend the spectrum of disease associated with perforin mutations to immune-mediated neurodegeneration triggered by infection and possibly due to primary immunodeficiency.
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Affiliation(s)
- Cristina Dias
- Department of Medical Genetics, University of British Columbia, Vancouver, British Columbia, Canada
- Genetics and Health Cluster, Child and Family Research Institute, BC Children's Hospital, Vancouver, British Columbia, Canada
| | - Allison McDonald
- Centre for Understanding and Preventing Infection in Children, Child and Family Research Institute, Vancouver, British Columbia, Canada
- Division of Infectious and Immunological Diseases, Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Murat Sincan
- NIH Undiagnosed Diseases Program, NIH Office of Rare Diseases Research and NHGRI, Bethesda, MD, USA
| | - Rosemarie Rupps
- Department of Medical Genetics, University of British Columbia, Vancouver, British Columbia, Canada
- Genetics and Health Cluster, Child and Family Research Institute, BC Children's Hospital, Vancouver, British Columbia, Canada
- Rare Disease Foundation, Vancouver, British Columbia, Canada
| | - Thomas Markello
- NIH Undiagnosed Diseases Program, NIH Office of Rare Diseases Research and NHGRI, Bethesda, MD, USA
| | - Ramona Salvarinova
- Division of Biochemical Diseases, Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Rui F Santos
- Department of Radiology, BC Children's Hospital & University of British Columbia, Vancouver, British Columbia, Canada
| | - Kamal Menghrajani
- NIH Undiagnosed Diseases Program, NIH Office of Rare Diseases Research and NHGRI, Bethesda, MD, USA
| | - Chidi Ahaghotu
- NIH Undiagnosed Diseases Program, NIH Office of Rare Diseases Research and NHGRI, Bethesda, MD, USA
| | - Darren P Sutherland
- Centre for Understanding and Preventing Infection in Children, Child and Family Research Institute, Vancouver, British Columbia, Canada
- Division of Infectious and Immunological Diseases, Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Edgardo S Fortuno
- Centre for Understanding and Preventing Infection in Children, Child and Family Research Institute, Vancouver, British Columbia, Canada
- Division of Infectious and Immunological Diseases, Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Tobias R Kollmann
- Centre for Understanding and Preventing Infection in Children, Child and Family Research Institute, Vancouver, British Columbia, Canada
- Division of Infectious and Immunological Diseases, Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Michelle Demos
- Division of Neurology, Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jan M Friedman
- Department of Medical Genetics, University of British Columbia, Vancouver, British Columbia, Canada
- Genetics and Health Cluster, Child and Family Research Institute, BC Children's Hospital, Vancouver, British Columbia, Canada
| | - David P Speert
- Centre for Understanding and Preventing Infection in Children, Child and Family Research Institute, Vancouver, British Columbia, Canada
- Division of Infectious and Immunological Diseases, Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada
| | - William A Gahl
- NIH Undiagnosed Diseases Program, NIH Office of Rare Diseases Research and NHGRI, Bethesda, MD, USA
| | - Cornelius F Boerkoel
- Department of Medical Genetics, University of British Columbia, Vancouver, British Columbia, Canada
- Genetics and Health Cluster, Child and Family Research Institute, BC Children's Hospital, Vancouver, British Columbia, Canada
- NIH Undiagnosed Diseases Program, NIH Office of Rare Diseases Research and NHGRI, Bethesda, MD, USA
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33
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Cai CX, Siringo FS, Odel JG, Lignelli-Dipple A, Lanzman BA, Gindin T, Filipovich AH. Downbeat nystagmus secondary to familial hemophagocytic lymphohistiocytosis. J Neuroophthalmol 2013; 34:57-60. [PMID: 24149285 DOI: 10.1097/wno.0000000000000064] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Hemophagocytic lymphohistiocytosis is a rare autosomal recessive disorder characterized by severe inflammation induced by defective natural killer cell function, which triggers a state of highly stimulated but ineffective immune response. This disorder can affect multiple organ systems, and neurologic manifestations include irritability, seizures, impaired consciousness, meningismus, and cranial nerve palsies. We describe a unique case of hemophagocytic lymphohistiocytosis in which downbeat nystagmus developed due to cerebellar swelling with compression of the cervicomedullary junction.
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Affiliation(s)
- Cindy X Cai
- Columbia University College of Physicians and Surgeons (CXC), New York, New York; Departments of Ophthalmology (FSS, JGO), Radiology (AL), and Pathology (TG); Columbia University Medical Center, New York Presbyterian Hospital, New York, New York; and Department of Clinical Immunology (AHF), Cincinnati Children's Hospital, University of Cincinnati, Cincinnati, Ohio
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34
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Guandalini M, Butler A, Mandelstam S. Spectrum of imaging appearances in Australian children with central nervous system hemophagocytic lymphohistiocytosis. J Clin Neurosci 2013; 21:305-10. [PMID: 24119957 DOI: 10.1016/j.jocn.2013.03.032] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2012] [Revised: 02/20/2013] [Accepted: 03/09/2013] [Indexed: 11/13/2022]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a rare multisystem disorder characterised by the proliferation and infiltration of lymphocytes and histiocytes. Central nervous system (CNS) infiltration is particularly devastating. Neuroradiological findings have been reported predominantly as individual case reports due to the rarity of the condition. To our knowledge there have been no published studies of imaging in Australian patients. This study aimed to retrospectively describe and illustrate the MRI appearances of CNS involvement by HLH in a cohort of seven Australian children from two paediatric centres between 2000 and 2011. MRI appearances demonstrate intersubject and intrasubject variability over time, likely reflecting the severity of CNS infiltration and associated demyelination. Familiarity with MRI patterns is important for assessing and monitoring disease activity.
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Affiliation(s)
- Michael Guandalini
- Department of Medical Imaging, Royal Children's Hospital Melbourne, Flemington Road, Parkville, VIC 3052, Australia.
| | - Andrew Butler
- Department of Medical Imaging, Royal Children's Hospital Brisbane, Herston, QLD, Australia
| | - Simone Mandelstam
- Department of Medical Imaging, Royal Children's Hospital Melbourne, Flemington Road, Parkville, VIC 3052, Australia; Florey Neuroscience Institutes, Melbourne Brain Centre, Melbourne, VIC, Australia; Department of Radiology, University of Melbourne, Parkville, VIC, Australia
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35
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Abstract
Haemophagocytic lymphohistiocytosis (HLH) is a hyperinflammatory disorder resulting from immune dysfunction reflecting either primary immune deficiency or acquired failure of normal immune homeostasis. Familial HLH includes autosomal recessive and X-linked disorders characterized by uncontrolled activation of T cells and macrophages and overproduction of inflammatory cytokines, secondary to defects in genes encoding proteins involved in granule-dependent cytolytic pathways. In older children and adults, HLH is associated more often with infections, malignancies, autoimmune diseases, and acquired immune deficiencies. HLH, macrophage activation syndrome, sepsis, and systemic inflammatory response syndrome are different clinical entities that probably represent a common immunopathological state, termed cytokine storm. These conditions may be clinically indistinguishable; all include massive inflammatory response, elevated serum cytokine levels, multi-organ involvement, haemophagocytic macrophages, and often death. Tissues of haematopoietic and lymphoid function are directly involved; other organs are secondarily damaged by circulating cytokines and chemokines. Haemophagocytic disorders are now increasingly diagnosed in the context of severe inflammatory reactions to viruses, malignancies and systemic connective tissue diseases. Many of these cases may reflect underlying genetic predispositions to HLH. The detection of gene defects has contributed considerably to our understanding of HLH, but the mechanisms leading to acquired HLH have yet to be fully determined.
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Affiliation(s)
- G Naheed Usmani
- Division of Pediatric Hematology and Oncology, University of Massachusetts Medical Center, Worcester, MA, USA
| | - Bruce A Woda
- Department of Pathology, UMass Memorial Medical Center, Worcester, MA, USA
| | - Peter E Newburger
- Department of Pediatrics, University of Massachusetts Medical School, Worcester, MA, USA
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36
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Afectación difusa del cerebelo en la edad pediátrica: hallazgos en resonancia magnética. RADIOLOGIA 2013; 55:253-60. [DOI: 10.1016/j.rx.2011.09.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2011] [Revised: 09/02/2011] [Accepted: 09/05/2011] [Indexed: 11/24/2022]
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37
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Rubin JP, Kuntz NL. Diagnostic Criteria for Pediatric Multiple Sclerosis. Curr Neurol Neurosci Rep 2013; 13:354. [DOI: 10.1007/s11910-013-0354-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
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38
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Kim MM, Yum MS, Choi HW, Ko TS, Im HJ, Seo JJ, Koh KN. Central nervous system (CNS) involvement is a critical prognostic factor for hemophagocytic lymphohistiocytosis. THE KOREAN JOURNAL OF HEMATOLOGY 2012; 47:273-80. [PMID: 23320006 PMCID: PMC3538799 DOI: 10.5045/kjh.2012.47.4.273] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/18/2012] [Revised: 10/04/2012] [Accepted: 11/06/2012] [Indexed: 11/17/2022]
Abstract
Background Hemophagocytic lymphohistiocytosis (HLH) is a rare multisystem disorder that frequently involves the central nervous system (CNS). We compared the clinical characteristics, treatment, and prognosis of patients with HLH according to the degree of CNS involvement. Methods The clinical manifestations, initial laboratory data, treatment, and outcomes for 50 patients diagnosed with HLH and treated at Asan Medical Center between January 1995 and August 2011 were retrospectively reviewed and analyzed. CNS involvement was defined as the presence of neurological symptoms or an elevated white blood cell (WBC) count in the cerebrospinal fluid (CSF). Results Among these 50 patients, 23 (46%) developed CNS disease. Among patients with CNS disease, 19 had neurological symptoms, including seizures, altered consciousness, facial palsy, dysarthria, and dysphagia. Four patients had elevated CSF WBC counts without neurological symptoms. Twelve patients had abnormal brain imaging results, including high signal intensity lesions on T2-weighted magnetic resonance imaging (MRI) findings, ventriculomegaly, hemorrhage, atrophy, and leptomeningeal enhancement. Patients with CNS disease had lower ferritin, aspartate aminotransferase (AST), and alanine aminotransferase (ALT) levels as well as reduced 5-year survival as compared to those without CNS disease. Conclusion CNS involvement is common among patients with HLH. Overall, patients with CNS disease achieve poorer outcomes than patients without CNS involvement. To improve outcomes, physicians must carefully monitor the neurological manifestations in patients with HLH and administer the appropriate course of intensified chemotherapy to patients with CNS disease.
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Affiliation(s)
- Myung-Mi Kim
- Department of Pediatrics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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39
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Chong KW, Lee JH, Choong CT, Paeds MM, Chan DWS, Fortier MV, Chan MY. Hemophagocytic lymphohistiocytosis with isolated central nervous system reactivation and optic nerve involvement. J Child Neurol 2012; 27:1336-9. [PMID: 22378674 DOI: 10.1177/0883073811435237] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Hemophagocytic lymphohistiocytosis is a rare childhood disorder characterized by uncontrolled proliferation of benign lymphocytes and histiocytes in multiple organs. Neurological presentations of central nervous system involvement are highly variable. The authors present a case of familial hemophagocytic lymphohistiocytosis in an 8-month-old girl with isolated central nervous system reactivation and optic nerve involvement. She presented with fever and hepatosplenomegaly at 2 months of age. Genetic studies confirmed familial hemophagocytic lymphohistiocytosis. There were no clinical features of central nervous system involvement at presentation. While on maintenance chemotherapy awaiting bone marrow transplant, she presented with new-onset seizures. Magnetic resonance imaging of the brain revealed extensive areas of abnormal signal and a thickened and enhancing left optic nerve. Ocular manifestations of hemophagocytic lymphohistiocytosis have rarely been described. To the authors' knowledge, this is the first case report of magnetic resonance imaging findings of optic nerve involvement in a child with hemophagocytic lymphohistiocytosis.
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Affiliation(s)
- Kok Wee Chong
- Department of Pediatric Medicine, KK Women's & Children's Hospital, 100 Bukit Timah Road, Singapore.
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40
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Li H, Li X, Liao XX, Zhan H, Xiong Y, Hu CL, Wei HY, Jing XL. Drug associated vanishing bile duct syndrome combined with hemophagocytic lymphohistiocytosis. World J Gastrointest Endosc 2012; 4:376-8. [PMID: 22912913 PMCID: PMC3423520 DOI: 10.4253/wjge.v4.i8.376] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2011] [Revised: 03/02/2012] [Accepted: 08/08/2012] [Indexed: 02/05/2023] Open
Abstract
A 28-year-old woman with untreated autoimmune disorder, demonstrated skin rash and fever after taking Amoxicillin-clavulanate and developed progressive jaundice. A bone marrow aspiration indicated an increased number of macrophages with hemophagocytosis and liver biopsy showed pure centrilobular cholestasis with necrosis and some absence of portal bile ducts. Furthermore, a serological test for Epstein-Barr virus was positive. Under treatment by liver dialysis and administration of steroids led to rapidly defervescence and clinical improvement. However, liver enzymes were still markedly elevated with persistent anemia, even after immunosuppressive treatment. The patient is currently waiting for liver transplantation. This is the first description of vanishing bile duct syndrome combined with hemophagocytic lymphohistiocytosis, with underlying causes including infection, drug-induced factors and untreated autoimmune disorder.
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Affiliation(s)
- Hui Li
- Hui Li, Xin Li, Xiao-Xing Liao, Hong Zhan, Yan Xiong, Chun-Lin Hu, Hong-Yan Wei, Xiao-Li Jing, Department of Emergency, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou 510080, Guangdong Province, China
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41
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Rangarajan HG, Grochowski D, Mulberry MF, Gheorghe G, Camitta BM, Talano JAM. Treatment of recurrent CNS disease post-bone marrow transplant in familial HLH. Pediatr Blood Cancer 2012; 59:189-90. [PMID: 21755594 DOI: 10.1002/pbc.23248] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2011] [Accepted: 05/31/2011] [Indexed: 11/06/2022]
Abstract
CNS involvement in Hemophagocytic Lymphohistiocytosis (HLH) has been reported in 63-73% of children at diagnosis [Haddad et al. (1997); Blood 89: 794-800; Horne et al. (2008); Br J Haematol 140: 327-335]. Patients can present with neurologic symptoms, abnormal CSF cytology, abnormal neuro-imaging, or a combination of these findings. CNS involvement is usually associated with a poor prognosis and increased mortality. The 3 year overall survival is 44% in patients with CNS involvement compared to 67% in patients without CNS involvement at diagnosis [Horne et al. (2008); Br J Haematol 140: 327-335]. We describe a treatment strategy employing systemic dexamethasone to control CNS disease in a patient with familial HLH and persistent CNS disease post Bone Marrow Transplant.
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Affiliation(s)
- Hemalatha G Rangarajan
- Department of Pediatrics, Division of Hematology/Oncology/Blood and Marrow Transplant, Medical College of Wisconsin, Milwaukee, Wisconsin 53226, USA.
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42
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Rego I, Severino M, Micalizzi C, Faraci M, Pende D, Dufour C, Aricò M, Rossi A. Neuroradiologic findings and follow-up with magnetic resonance imaging of the genetic forms of haemophagocytic lymphohistiocytosis with CNS involvement. Pediatr Blood Cancer 2012; 58:810-4. [PMID: 22106034 DOI: 10.1002/pbc.23405] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2011] [Accepted: 09/27/2011] [Indexed: 11/08/2022]
Abstract
Haemophagocytic lymphohistiocytosis (HLH) is a rare hyperinflammatory syndrome caused by deficient down-regulation of the immune response. Presence of central nervous system (CNS) involvement at diagnosis is a poor prognostic sign, and should be carefully investigated. Herein, we describe the neuroradiological findings, clinical data, and treatment outcome in 12 patients with genetic HLH and CNS complications. Neuroimaging was important in identifying CNS involvement, monitoring treatment responses, and detecting treatment complications.
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Affiliation(s)
- Ines Rego
- Neuroradiology Department, G. Gaslini Children's Hospital, Genoa, Italy
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43
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Sieni E, Cetica V, Mastrodicasa E, Pende D, Moretta L, Griffiths G, Aricò M. Familial hemophagocytic lymphohistiocytosis: a model for understanding the human machinery of cellular cytotoxicity. Cell Mol Life Sci 2012; 69:29-40. [PMID: 21990010 PMCID: PMC11114696 DOI: 10.1007/s00018-011-0835-y] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2011] [Revised: 09/13/2011] [Accepted: 09/13/2011] [Indexed: 02/03/2023]
Abstract
Cytotoxic T lymphocytes, natural killer cells, and NKT cells are effector cells able to kill infected cells. In some inherited human disorders, a defect in selected proteins involved in the cellular cytotoxicity mechanism results in specific clinical syndromes, grouped under the name of familial hemophagocytic lymphohistiocytosis. Recent advances in genetic studies of these patients has allowed the identification of different genetic subsets. Additional genetic immune deficiencies may also induce a similar clinical picture. International cooperation and prospective trials resulted in refining the diagnostic and therapeutic approach to these rare diseases with improved outcome but also with improved knowledge of the mechanisms underlying granule-mediated cellular cytotoxicity in humans.
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Affiliation(s)
- Elena Sieni
- Dipartimento Oncoematologia Pediatrica e Cure Domiciliari, Azienda Ospedaliero-Universitaria Meyer, Viale Pieraccini, 24, 50139 Florence, Italy
| | - Valentina Cetica
- Dipartimento Oncoematologia Pediatrica e Cure Domiciliari, Azienda Ospedaliero-Universitaria Meyer, Viale Pieraccini, 24, 50139 Florence, Italy
| | - Elena Mastrodicasa
- S.C. di Oncoematologia Pediatrica con Trapianto di CSE, Ospedale “S.M. della Misericordia” A.O, Perugia, Italy
| | - Daniela Pende
- A.O.U. San Martino-IST, Istituto Nazionale Ricerca sul Cancro, Genoa, Italy
| | | | - Gillian Griffiths
- Cambridge Institute for Medical Research, Addenbrooke’s Hospital, Cambridge, CB2 0XY UK
| | - Maurizio Aricò
- Dipartimento Oncoematologia Pediatrica e Cure Domiciliari, Azienda Ospedaliero-Universitaria Meyer, Viale Pieraccini, 24, 50139 Florence, Italy
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44
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Dehkordy SF, Aghamohammadi A, Ochs HD, Rezaei N. Primary immunodeficiency diseases associated with neurologic manifestations. J Clin Immunol 2011; 32:1-24. [PMID: 22038677 DOI: 10.1007/s10875-011-9593-8] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2011] [Accepted: 09/09/2011] [Indexed: 01/04/2023]
Abstract
Primary immunodeficiency diseases (PID) are a heterogeneous group of inherited disorders of the immune system, predisposing individuals to recurrent infections, allergy, autoimmunity, and malignancies. A considerable number of these conditions have been found to be also associated with neurologic signs and symptoms. These manifestations are considered core features of some immunodeficiency syndromes, such as ataxia-telangiectasia and purine nucleoside phosphorylase deficiency, or occur less prominently in some others. Diverse pathological mechanisms including defective responses to DNA damage, metabolic errors, and autoimmune phenomena have been associated with neurologic abnormalities; however, several issues remain to be elucidated. Greater awareness of these associated features and gaining a better understanding of the contributing mechanisms will lead to prompt diagnosis and treatment and possibly development of novel preventive and therapeutic strategies. In this review, we aim to provide a brief description of the clinical and genetic characteristics of PID associated with neurologic complications.
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Affiliation(s)
- Soodabeh Fazeli Dehkordy
- Research Center for Immunodeficiencies, Pediatrics Center of Excellence, Children's Medical Center, Tehran University of Medical Sciences, Tehran, 14194, Iran
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45
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Jordan MB, Allen CE, Weitzman S, Filipovich AH, McClain KL. How I treat hemophagocytic lymphohistiocytosis. Blood 2011; 118:4041-52. [PMID: 21828139 PMCID: PMC3204727 DOI: 10.1182/blood-2011-03-278127] [Citation(s) in RCA: 716] [Impact Index Per Article: 55.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2011] [Accepted: 07/27/2011] [Indexed: 12/12/2022] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a syndrome of pathologic immune activation, occurring as either a familial disorder or a sporadic condition, in association with a variety of triggers. This immune dysregulatory disorder is prominently associated with cytopenias and a unique combination of clinical signs and symptoms of extreme inflammation. Prompt initiation of immunochemotherapy is essential for survival, but timely diagnosis may be challenging because of the rarity of HLH, its variable presentation, and the time required to perform diagnostic testing. Therapy is complicated by dynamic clinical course, high risk of treatment-related morbidity, and disease recurrence. Here, we review the clinical manifestations and patterns of HLH and describe our approach to the diagnosis and therapy for this elusive and potentially lethal condition.
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Affiliation(s)
- Michael B Jordan
- Divisions of Immunobiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
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46
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Chitnis T, Krupp L, Yeh A, Rubin J, Kuntz N, Strober JB, Chabas D, Weinstock-Guttmann B, Ness J, Rodriguez M, Waubant E. Pediatric multiple sclerosis. Neurol Clin 2011; 29:481-505. [PMID: 21439455 DOI: 10.1016/j.ncl.2011.01.004] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
In the past 5 years, there has been an exponential growth in the knowledge about multiple sclerosis (MS) in children and adolescents. Recent publications have shed light on its diagnosis, pathogenesis, clinical course, and treatment. However, there remain several key areas that require further exploration. This article summarizes the current state of knowledge on pediatric MS and discusses future avenues of investigation.
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Affiliation(s)
- Tanuja Chitnis
- Harvard Medical School, Partners Pediatric Multiple Sclerosis Center, Massachusetts General Hospital for Children, 55 Fruit Street, Boston, MA 02114, USA
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47
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Abstract
Familial hemophagocytic lymphohistiocytosis is a rare and inherited disease that affects both males and females equally and is most often fatal if not treated. Diagnosis is challenging because it mimics severe sepsis by demonstrating hepatomegaly, splenomegaly, persistent fever, central nervous system involvement, and cytopenias. The etiologies of hemophagocytic lymphohistiocytosis have been well established through the identification of 3 causative genetic mutations. Therapies for hemophagocytic lymphohistiocytosis focus on restoring health by diminishing the disease sequelae with a goal of hematopoietic stem cell transplant, the only known curative therapy for hemophagocytic lymphohistiocytosis. Current research is being conducted to identify other causative genetic mutations and newer, more effective treatment modalities.
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Hemophagocytic lymphohistiocytosis with neurological presentation: MRI findings and a nearly miss diagnosis. Neurol Sci 2011; 32:473-7. [PMID: 21234777 DOI: 10.1007/s10072-010-0467-2] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2010] [Accepted: 12/10/2010] [Indexed: 10/18/2022]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a rare disease with rarer neurological presentation. When this occurs, diagnosis may be delayed. This report aims to call attention to clinical, laboratory, and radiological features that should prompt the correct diagnosis. A 13-year-old girl presented with progressive increase in intracranial pressure and ataxia. MRI showed a diffuse tumor-like swelling of the cerebellum with tonsillar herniation and patchy white matter post-contrast enhancement. Regression of swelling with steroids ruled out glioma and medulloblastoma, and brain lymphoma was considered. Diagnosis of HLH was reached 2 months after onset when uncontrolled fever and severe elevation of liver enzymes occurred. Two bone marrow biopsies were needed to demonstrate hemophagocytosis. Familial HLH was confirmed by perforin gene mutations. Bone marrow transplantation was performed. The early diagnosis of HLH may be life saving. Awareness of the disease is necessary to investigate its characteristic findings, thus avoiding a delay in diagnosis.
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Yang S, Zhang L, Jia C, Ma H, Henter JI, Shen K. Frequency and development of CNS involvement in Chinese children with hemophagocytic lymphohistiocytosis. Pediatr Blood Cancer 2010; 54:408-15. [PMID: 19908295 DOI: 10.1002/pbc.22239] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND We investigated the characteristics, frequency, and prognosis of central nervous system (CNS) involvement in patients with hemophagocytic lymphohistiocytosis (HLH). PROCEDURE Neurological manifestations were prospectively assessed in 92 children with HLH treated from January 2004 to August 2008 at our center; 82 (89%) had associated viral infections (69 Epstein-Barr virus), one empyema, while no associated disease was identified in the remaining nine. Prior to treatment, all underwent cerebrospinal fluid (CSF) evaluation, brain computer tomography (CT) and/or magnetic resonance imaging (MRI). RESULTS At diagnosis, 43 (47%) children had CNS involvement. Twelve patients (13%) had neurological symptoms, including seizures, ataxia, coma, cranial nerve palsy, and hemiplegia. All patients improved after 8 weeks of therapy, but one later developed progressive neurological symptoms and six discontinued therapy due to progressive systemic symptoms and/or other reasons. Fifteen patients had CSF abnormalities that all normalized completely after 6 weeks of treatment. Thirty-six patients (39%) had neuroradiological abnormalities; with 5 still under treatment, 15 lost to follow-up, and 16 followed after completion of therapy. Of these 16, 12 improved, 3 were unchanged, and 1 progressed. Among all 21 children with CNS involvement followed after completion of therapy, 10 recovered completely, 10 improved (3 had remaining neuroradiological abnormalities), and 1 progressed clinically and neuroradiologically. CONCLUSION Most patients reported here suffered from secondary HLH and since CNS involvement is frequent in HLH, brain MRI at diagnosis is recommended in all HLH patients. Clinical and CSF abnormalities often improved within 8 weeks of therapy, but CT/MRI abnormalities normalized more slowly and less frequently.
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Affiliation(s)
- Shuang Yang
- Hemopathy Center, Beijing Children's Hospital, Capital Medical University, Beijing, China.
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Decaminada N, Cappellini M, Mortilla M, Del Giudice E, Sieni E, Caselli D, Aricò M, Fonda C. Familial hemophagocytic lymphohistiocytosis: clinical and neuroradiological findings and review of the literature. Childs Nerv Syst 2010; 26:121-7. [PMID: 19649640 DOI: 10.1007/s00381-009-0957-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2009] [Indexed: 12/18/2022]
Abstract
BACKGROUND Familial hemophagocytic lymphohistiocytosis (FHL) is a rare multisystem congenital disorder characterized by uncontrolled proliferation and infiltration of activated lymphocytes and histiocytes, secreting high amounts of inflammatory cytokines; this may affect multiple organs including liver, spleen, lymph nodes, bone marrow, and central nervous system (CNS; Janka, Eur J Pediatr 166:95-109, 1). OBJECTIVE The objective of this study is to describe the characteristics of the encephalopathy and to correlate the neuroradiological findings with the clinical symptoms and the treatment response in a child with FHL type 3 studied by total body computed tomography and by brain magnetic resonance (MR) and MR spectroscopy. RESULTS VF, a 14-month-old female, developed a full-blown FHL, with facial nerve palsy as the only CNS complication. Brain MR imaging showed several focal areas of pathological signal in the subcortical and periventricular white matter, left thalamus, cerebellum, and brain stem. Proton MR spectroscopy also demonstrated no elevated peak of Cho, no lactate peak, and elevated glutamine/glutamate complex. Moreover, an elevated N-acetyl aspartate (NAA) peak was detected. The follow-up MR study after hematopoietic stem cells transplantation showed a dramatic reduction of the lesions and normalization of the metabolic pattern at spectroscopy. CONCLUSION Brain lesions and metabolic alterations documented by MR and spectroscopy during active FHL reverted during disease control achieved by therapy.
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Affiliation(s)
- Norma Decaminada
- Department of Radiology, Azienda Ospedaliero-Universitaria Meyer, Meyer Children Hospital, Florence, Italy,
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