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AlJabban A, Evans MG, Fell GG, Guccione JP, Edwards RA, Pinkus GS, Padera RF, Pozdnyakova O, Kim AS. Autopsy findings from patients diagnosed with COVID-19 demonstrate unique morphological patterns in bone marrow and lymph node. J Clin Pathol 2024; 77:622-627. [PMID: 37290912 DOI: 10.1136/jcp-2023-208875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Accepted: 04/30/2023] [Indexed: 06/10/2023]
Abstract
AIMS The identification of haemophagocytosis in bone marrow (BM) is recurrently identified in patients with severe COVID-19. These initial COVID-19 autopsy studies have afforded valuable insight into the pathophysiology of this disease; however, only a limited number of case series have focused on lymphoid or haematopoietic tissues. METHODS BM and lymph node (LN) specimens were obtained from adult autopsies performed between 1 April 2020 and 1 June 2020, for which the decedent had tested positive for SARS-CoV-2. Tissue sections (H&E, CD3, CD20, CD21, CD138, CD163, MUM1, kappa/lambda light chains in situ hybridisation) were examined by two haematopathologists, who recorded morphological features in a blinded fashion. Haemophagocytic lymphohistiocytosis (HLH) was assessed based on HLH 2004 criteria. RESULTS The BM demonstrated a haemophagocytic pattern in 9 out of 25 patients (36%). The HLH pattern was associated with longer hospitalisation, BM plasmacytosis, LN follicular hyperplasia and lower aspartate aminotransferase (AST), as well as ferritin at demise. LN examination showed increased plasmacytoid cells in 20 of 25 patients (80%). This pattern was associated with a low absolute monocyte count at diagnosis, lower white cell count and lower absolute neutrophil count at demise, and lower ferritin and AST at demise. CONCLUSIONS Autopsy results demonstrate distinct morphological patterns in BM, with or without haemophagocytic macrophages, and in LN, with or without increased plasmacytoid cells. Since only a minority of patients met diagnostic criteria for HLH, the observed BM haemophagocytic macrophages may be more indicative of an overall inflammatory state.
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Affiliation(s)
- Ali AlJabban
- Department of Pathology, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Department of Clinical Investigation, Harvard Medical School, Boston, Massachusetts, USA
| | - Mark G Evans
- Department of Pathology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Geoffrey G Fell
- Department of Biostatistics, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Jack P Guccione
- Los Angeles County Department of Medical Examiner-Coroner, Los Angeles, California, USA
| | - Robert A Edwards
- Department of Pathology and Laboratory Medicine, University of California Irvine, Irvine, California, USA
| | - Geraldine S Pinkus
- Department of Pathology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Robert F Padera
- Department of Pathology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Olga Pozdnyakova
- Department of Pathology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Annette S Kim
- Department of Pathology, Brigham and Women's Hospital, Boston, Massachusetts, USA
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2
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Cron RQ. IL-1 Family Blockade in Cytokine Storm Syndromes. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2024; 1448:553-563. [PMID: 39117838 DOI: 10.1007/978-3-031-59815-9_36] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/10/2024]
Abstract
Interleukin-1 is a prototypic proinflammatory cytokine that is elevated in cytokine storm syndromes (CSSs), such as secondary hemophagocytic lymphohistiocytosis (sHLH) and macrophage activation syndrome (MAS). IL-1 has many pleotropic and redundant roles in both innate and adaptive immune responses. Blockade of IL-1 with recombinant human interleukin-1 receptor antagonist has shown efficacy in treating CSS. Recently, an IL-1 family member, IL-18, has been demonstrated to be contributory to CSS in autoinflammatory conditions, such as in inflammasomopathies (e.g., NLRC4 mutations). Anecdotally, recombinant IL-18 binding protein can be of benefit in treating IL-18-driven CSS. Lastly, another IL-1 family member, IL-33, has been postulated to contribute to CSS in an animal model of disease. Targeting of IL-1 and related cytokines holds promise in treating a variety of CSS.
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Dubinsky SDJ, Watt KM, Imburgia CE, Mcknite AM, Hunt JP, Rice C, Rower JE, Edginton AN. Anakinra Removal by Continuous Renal Replacement Therapy: An Ex Vivo Analysis. Crit Care Explor 2023; 5:e1010. [PMID: 38107537 PMCID: PMC10723863 DOI: 10.1097/cce.0000000000001010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2023] Open
Abstract
OBJECTIVES Patients with sepsis are at significant risk for multiple organ dysfunction, including the lungs and kidneys. To manage the morbidity associated with kidney impairment, continuous renal replacement therapy (CRRT) may be required. The extent of anakinra pharmacokinetics in CRRT remains unknown. The objectives of this study were to investigate the anakinra-circuit interaction and quantify the rate of removal from plasma. DESIGN The anakinra-circuit interaction was evaluated using a closed-loop ex vivo CRRT circuit. CRRT was performed in three phases based on the method of solute removal: 1) hemofiltration, 2) hemodialysis, and 3) hemodiafiltration. Standard control samples of anakinra were included to assess drug degradation. SETTING University research laboratory. PATIENTS None. INTERVENTIONS Anakinra was administered to the CRRT circuit and serial prefilter blood samples were collected along with time-matched control and hemofiltrate samples. Each circuit was run in triplicate to assess inter-run variability. Concentrations of anakinra in each reference fluid were measured by enzyme-linked immunosorbent assay. Transmembrane filter clearance was estimated by the product of the sieving coefficient/dialysate saturation constant and circuit flow rates. MEASUREMENTS AND MAIN RESULTS Removal of anakinra from plasma occurred within minutes for each CRRT modality. Average drug remaining (%) in plasma following anakinra administration was lowest with hemodiafiltration (34.9%). The average sieving coefficient was 0.34, 0.37, and 0.41 for hemodiafiltration, hemofiltration, and hemodialysis, respectively. Transmembrane clearance was fairly consistent across each modality with the highest during hemodialysis (5.53 mL/min), followed by hemodiafiltration (4.99 mL/min), and hemofiltration (3.94 mL/min). Percent drug remaining within the control samples (93.1%) remained consistent across each experiment, indicating negligible degradation within the blood. CONCLUSIONS The results of this analysis are the first to demonstrate that large molecule therapeutic proteins such as anakinra, are removed from plasma with modern CRRT technology. Current dosing recommendations for patients with severe renal impairment may result in subtherapeutic anakinra concentrations in those receiving CRRT.
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Affiliation(s)
- Samuel D J Dubinsky
- University of Waterloo, School of Pharmacy, Faculty of Science, Waterloo, ON, Canada
| | - Kevin M Watt
- Department of Pediatrics, University of Utah, School of Medicine, Salt Lake City, UT
- Department of Pharmacology and Toxicology, University of Utah, Salt Lake City, UT
| | - Carina E Imburgia
- Department of Pediatrics, University of Utah, School of Medicine, Salt Lake City, UT
| | - Autumn M Mcknite
- Department of Pharmacology and Toxicology, University of Utah, Salt Lake City, UT
| | - J Porter Hunt
- Department of Pediatrics, University of Utah, School of Medicine, Salt Lake City, UT
| | - Cassandra Rice
- Department of Pharmacology and Toxicology, Center for Human Toxicology, University of Utah, Salt Lake City, UT
| | - Joseph E Rower
- Department of Pharmacology and Toxicology, Center for Human Toxicology, University of Utah, Salt Lake City, UT
| | - Andrea N Edginton
- University of Waterloo, School of Pharmacy, Faculty of Science, Waterloo, ON, Canada
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4
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Abdelhay A, Mahmoud A, Mostafa M, Jain T, Elseidy S, Fahmawi S, Alkasem M, Ammari O. Delay in treatment of adult hemophagocytic lymphohistiocytosis is associated with worse in-hospital outcomes. Ann Hematol 2023; 102:2989-2996. [PMID: 37392369 DOI: 10.1007/s00277-023-05271-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 05/09/2023] [Indexed: 07/03/2023]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening condition characterized by uncontrolled activation of the immune system leading to multiorgan failure. Timely initiation of HLH-specific treatment is believed to be essential and lifesaving. Due to the rarity of the condition in adults, there is no data available in the literature to investigate the effects of treatment delay in this age group. We used data from the National Inpatient Sample (NIS) to evaluate the inpatient practices of HLH treatment initiation over 13 years (2007-2019) and their association with clinically relevant inpatient outcomes. Patients were divided into early treatment group (<6 days) and late treatment group (≥ 6 days). We compared outcomes using multivariate logistic regression models adjusting for age, sex, race, and HLH-triggering conditions. There were 1327 and 1382 hospitalizations in the early and late treatment groups, respectively. Hospitalization in the late treatment group had higher rates of in-hospital mortality (OR 2.00 [1.65-2.43]), circulatory shock (OR 1.33 [1.09-1.63]), requiring mechanical ventilation (OR 1.41 [1.18-1.69]), venous thromboembolism (OR 1.70 [1.27-2.26]), infectious complications (OR 2.24 [1.90-2.64]), acute kidney injury (OR 2.27 [1.92-2.68]), and requiring new hemodialysis (OR 1.45 [1.17-1.81]). Additionally, we observed no significant trend in the mean time to treatment over the study period. This study shows the importance of early initiation of HLH treatment and highlights the adverse outcomes of treatment delay.
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Affiliation(s)
- Ali Abdelhay
- Department of Internal Medicine, Rochester General Hospital, 1425 Portland Avenue, Rochester, NY, 14621, USA.
| | - Amir Mahmoud
- Department of Internal Medicine, Rochester General Hospital, 1425 Portland Avenue, Rochester, NY, 14621, USA
| | - Mariam Mostafa
- Department of Internal Medicine, Rochester General Hospital, 1425 Portland Avenue, Rochester, NY, 14621, USA
| | - Tripti Jain
- Department of Internal Medicine, Rochester General Hospital, 1425 Portland Avenue, Rochester, NY, 14621, USA
| | - Sheref Elseidy
- Department of Internal Medicine, Rochester General Hospital, 1425 Portland Avenue, Rochester, NY, 14621, USA
| | - Suhib Fahmawi
- Department of Internal Medicine, East Tennessee State University, Johnson City, TN, USA
| | - Mouaz Alkasem
- School of Medicine, University of Jordan, Amman, Jordan
| | - Omar Ammari
- Department of Internal Medicine, Henry Ford Hospital, Detroit, MI, USA
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5
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Abdelhay A, Mahmoud AA, Al Ali O, Hashem A, Orakzai A, Jamshed S. Epidemiology, characteristics, and outcomes of adult haemophagocytic lymphohistiocytosis in the USA, 2006-19: a national, retrospective cohort study. EClinicalMedicine 2023; 62:102143. [PMID: 37599909 PMCID: PMC10432999 DOI: 10.1016/j.eclinm.2023.102143] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 07/20/2023] [Accepted: 07/24/2023] [Indexed: 08/22/2023] Open
Abstract
Background Haemophagocytic lymphohistiocytosis (HLH) is a rare and life-threatening syndrome characterized by an excessive inflammatory response. Limited data exist on adult HLH. Methods In this national, retrospective cohort study, we analysed data from the US National Inpatient Sample database collected between October 1, 2006 and December 31, 2019. Using the International Classification of Diseases (ICD) codes, we identified all adult patients who were admitted non-electively with the diagnosis of HLH. We described demographic characteristics, triggers, and associated conditions. Trends of diagnosis, treatment, and in-hospital mortality were analysed using joinpoint models. In-hospital mortality rates were compared using multivariable logistic regression models that adjusted for demographic characteristics and associated conditions. Finally, we described resource utilization outcomes including cost of hospitalization and length of stay. Findings We identified 16,136 non-elective adult HLH admissions. The population pyramid showed a bimodal distribution, with peaks in young adults (16-30 years) and older adults (56-70 years). Joinpoint regression analysis revealed a significant increase in HLH incidence per 100,000 admissions over the study period (Average Annual Percent Change [APC] = 25.3%, p < 0.0001), and no significant change in rates of in-hospital mortality (slope = -0.01; p = 0.95) or administration of in-hospital HLH treatment (slope = 0.46, p = 0.20). The most common associated conditions were malignancy (4953 admissions [30.7%]), infections (3913 admissions [24.3%]), autoimmune conditions (3362 admissions [20.8%]), organ transplant status (639 admissions [4%]), and congenital immunodeficiency syndromes (399 admissions [2.5%]). In-hospital mortality was higher in older adults and males. Furthermore, Congenital immunodeficiency syndromes had the worst in-hospital mortality rate (mortality rate 31.1%, adjusted OR 2.36 [1.56-3.59]), followed by malignancies (mortality rate 28.4%, adjusted OR 1.80 [1.46-2.22]), infections (mortality rate 21.4%, adjusted OR 1.33 [1.10-1.62]), other/no trigger (mortality rate 13.6%, adjusted OR 0.73 [0.58-0.92]), autoimmune (mortality rate 13%, adjusted OR 0.72 [0.57-0.92]), and post-organ transplant status (mortality rate 14.1%, adjusted OR 0.64 [0.43-0.97]). The overall mean length of stay was 14.3 ± 13.9 days, and the mean cost of hospitalization was $54,900 ± 59,800. Interpretation We provide insight into the burden of adult HLH in the USA. The incidence has been increasing and the outcomes remain dismal. This signifies the growing need for the development of updated diagnosis and treatment protocols that are specific to adult HLH. Funding None.
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Affiliation(s)
- Ali Abdelhay
- Department of Internal Medicine, Rochester General Hospital, Rochester, NY, USA
| | - Amir A. Mahmoud
- Department of Internal Medicine, Rochester General Hospital, Rochester, NY, USA
| | - Omar Al Ali
- Department of Internal Medicine, Rochester General Hospital, Rochester, NY, USA
| | - Anas Hashem
- Department of Internal Medicine, Rochester General Hospital, Rochester, NY, USA
| | - Abdullah Orakzai
- Department of Internal Medicine, Rochester General Hospital, Rochester, NY, USA
| | - Saad Jamshed
- Division of Hematology and Oncology, Rochester Regional Health, Rochester, NY, USA
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Lee JC, Logan AC. Diagnosis and Management of Adult Malignancy-Associated Hemophagocytic Lymphohistiocytosis. Cancers (Basel) 2023; 15:1839. [PMID: 36980725 PMCID: PMC10046521 DOI: 10.3390/cancers15061839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 03/08/2023] [Accepted: 03/16/2023] [Indexed: 03/22/2023] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a syndrome of severe, dysregulated inflammation driven by the inability of T cells to clear an antigenic target. When associated with malignancy (mHLH), the HLH syndrome is typically associated with extremely poor survival. Here, we review the diagnosis of secondary HLH (sHLH) syndromes in adults, with emphasis on the appropriate workup and treatment of mHLH. At present, the management of HLH in adults, including most forms of mHLH, is based on the use of corticosteroids and etoposide following the HLH-94 regimen. In some cases, this therapeutic approach may be cohesively incorporated into malignancy-directed therapy, while in other cases, the decision about whether to treat HLH prior to initiating other therapies may be more complicated. Recent studies exploring the efficacy of other agents in HLH, in particular ruxolitinib, offer hope for better outcomes in the management of mHLH. Considerations for the management of lymphoma-associated mHLH, as well as other forms of mHLH and immunotherapy treatment-related HLH, are discussed.
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Affiliation(s)
- Jerry C. Lee
- Hematology, Blood and Marrow Transplantation, and Cellular Therapy Program, Division of Hematology/Oncology, University of California, San Francisco, CA 94143, USA;
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Lee J, Pham B, Karanjawala ZE, Adesina O. Postpartum fevers, a rare presentation of secondary hemophagocytic lymphohistiocytosis. Clin Case Rep 2023; 11:e7070. [PMID: 36941837 PMCID: PMC10023518 DOI: 10.1002/ccr3.7070] [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: 05/09/2022] [Revised: 01/05/2023] [Accepted: 02/13/2023] [Indexed: 03/20/2023] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a rare disease of excessive immune system activation. We report a case of HLH in a 20-year-old primigravid woman who presented with postpartum fevers. She was successfully treated with dexamethasone and anakinra, a deviation from the HLH-94 protocol, to preserve her ability to breastfeed.
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Affiliation(s)
- Jacqueline Lee
- Department of Internal Medicine University of California Davis School of Medicine Sacramento California USA
| | - Brian Pham
- Division of Hematology and Oncology University of California Davis School of Medicine Sacramento California USA
| | - Zarir E Karanjawala
- Division of Hematopathology University of California Davis School of Medicine Sacramento California USA
| | - Oyebimpe Adesina
- Division of Hematology and Oncology University of California Davis School of Medicine Sacramento California USA
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8
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Stoian M, Procopiescu B, Șeitan S, Scarlat G. Post-COVID-19 syndrome: Insights into a novel post-infectious systemic disorder. J Med Life 2023; 16:195-202. [PMID: 36937488 PMCID: PMC10015558 DOI: 10.25122/jml-2022-0329] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Accepted: 01/17/2023] [Indexed: 03/21/2023] Open
Abstract
Coronavirus disease 2019 (COVID-19) is currently considered a complex systemic infectious and inflammatory disease, determined by the infection with severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), and the cause of one of the most important epidemiological phenomena in the last century - the COVID-19 pandemic. This infectious-inflammatory disease may generate a wide range of clinical manifestations and biological modifications, explained by the ubiquitous nature of the SARS-CoV-2 receptors, represented by the angiotensin-converting enzyme-2 (ACE-2), and by the host's violent immune and proinflammatory reaction to the viral infection. These manifestations include immunological disturbances, which, according to certain clinical findings, may persist post-infection, in the form of a presumed systemic inflammatory entity, defined by several clinical concepts with a common pathological significance: post-COVID-19 multisystem (or systemic) inflammatory syndrome, post-COVID syndrome or long-COVID. Although the pathophysiological mechanisms of the post-COVID-19 syndrome are elusive at the present moment, there are currently several studies that describe a systemic inflammatory or autoimmune phenomenon following the remission of the COVID-19 infection in some patients, which suggests the existence of molecular and cellular immune abnormalities, most probably due to the host's initial violent immune response to the viral infection, in the form of three overlapping entities: secondary hemophagocytic lymph histiocytosis (HLH), macrophage activation syndrome (MAS) and cytokine release syndrome (CRS). Thus, this is reminiscent of different classic autoimmune diseases, in which various infections are risk factors in developing the autoimmune process.
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Affiliation(s)
- Marilena Stoian
- Department of Internal Medicine, Dr. Ion Cantacuzino Clinical Hospital, Bucharest, Romania
- Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
- Corresponding Author: Marilena Stoian, Department of Internal Medicine, Dr. Ion Cantacuzino Clinical Hospital, Bucharest, Romania. Carol Davila University of Medicine and Pharmacy, Bucharest, Romania. E-mail:
| | - Bianca Procopiescu
- Department of Internal Medicine, Dr. Ion Cantacuzino Clinical Hospital, Bucharest, Romania
| | - Silviu Șeitan
- Department of Internal Medicine, Dr. Ion Cantacuzino Clinical Hospital, Bucharest, Romania
| | - Gabriel Scarlat
- Department of Internal Medicine, Dr. Ion Cantacuzino Clinical Hospital, Bucharest, Romania
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9
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Rubio-Perez J, Rodríguez-Perez ÁR, Díaz-Blázquez M, Moreno-García V, Dómine-Gómez M. Treatment-related hemophagocytic lymphohistiocytosis due to atezolizumab: a case report and review of the literature. J Med Case Rep 2022; 16:365. [PMID: 36195892 PMCID: PMC9531226 DOI: 10.1186/s13256-022-03585-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 08/21/2022] [Indexed: 11/15/2022] Open
Abstract
Background Immune checkpoint inhibitors avoid inhibition of T-cell responses, upregulating antitumor immune response. Moreover, a dysregulation with hyperactive immune response can be caused, some of them underdiagnosed. Hemophagocytic lymphohistiocytosis is a rare and often fatal syndrome of uncontrolled and ineffective hyperinflammatory response that triggers an inflammatory cascade that can lead in many cases to death. Case presentation We report the case of a 67-year-old Caucasian man with stage IV lung adenocarcinoma who developed hemophagocytic lymphohistiocytosis after initiation of atezolizumab, an antagonist of programmed death-ligand 1. Even with early diagnosis and proper treatment, death occurs in approximately half of all cases reported. Conclusion Key markers are needed to better identify patients at risk of developing severe immune-related adverse events. In addition to key markers, a higher degree of suspicion and early intervention are needed to improve outcomes in acquired hemophagocytic lymphohistiocytosis, especially with the increasingly and expanding use of immune activation.
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Affiliation(s)
- Jaime Rubio-Perez
- Medical Oncology Department, University Hospital Fundacion Jimenez Diaz, Instituto de investigación sanitaria FJD, Madrid, Spain.
| | - Ángel Ricardo Rodríguez-Perez
- Medical Oncology Department, University Hospital Fundacion Jimenez Diaz, Instituto de investigación sanitaria FJD, Madrid, Spain.
| | - María Díaz-Blázquez
- Anatomic Pathology Unit Department, University Hospital Fundacion Jimenez Diaz, Madrid, Spain
| | - Victor Moreno-García
- Medical Oncology Department, University Hospital Fundacion Jimenez Diaz, Instituto de investigación sanitaria FJD, Madrid, Spain.,START Madrid-FJD, University Hospital Fundacion Jimenez Diaz, Madrid, Spain
| | - Manuel Dómine-Gómez
- Medical Oncology Department, University Hospital Fundacion Jimenez Diaz, Instituto de investigación sanitaria FJD, Madrid, Spain
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10
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Anakinra for the Treatment of Hemophagocytic Lymphohistiocytosis: 21 Cases. J Clin Med 2022; 11:jcm11195799. [PMID: 36233667 PMCID: PMC9572845 DOI: 10.3390/jcm11195799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Revised: 09/26/2022] [Accepted: 09/29/2022] [Indexed: 11/07/2022] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening cytokine storm syndrome. There are no definitive guidelines for the management of secondary HLH (sHLH). A recent report by a National Health Service (NHS) clinical panel has recommended anakinra as a treatment option. We aimed to analyse the efficacy and safety of anakinra for the treatment of all-cause sHLH. We conducted a multicentric retrospective study in two French University hospitals and included all patients who had a diagnosis of sHLH and who received anakinra. Among 21 patients (median age, 45 years), 13 were men. Anakinra was used as first-line therapy in 10 patients, and as monotherapy in 5 patients. We found that anakinra was effective in 19/21 patients (90.5%), with fever resolution in 19 patients (90.5%) within a median of 1.0 day (1, 2). At the Day 7 assessment, the mean CRP concentration decreased significantly (p < 0.001), as did the mean ferritin (p = 0.011). Anakinra was generally safe and well tolerated and was discontinued for side effects in only three patients (14.3%). Anakinra is an efficient and safe treatment to control sHLH of various causes. These data, together with the recent report of the NHS panel, call for the rapid conduct of prospective randomized clinical trials.
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11
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Taylor ML, Hoyt KJ, Han J, Benson L, Case S, Chandler MT, Chang MH, Platt C, Cohen EM, Day-Lewis M, Dedeoglu F, Gorman M, Hausmann JS, Janssen E, Lee PY, Lo J, Priebe GP, Lo MS, Meidan E, Nigrovic PA, Roberts JE, Son MBF, Sundel RP, Alfieri M, Yeun JC, Shobiye DM, Degar B, Chang JC, Halyabar O, Hazen MM, Henderson LA. An Evidence-Based Guideline Improves Outcomes for Patients With Hemophagocytic Lymphohistiocytosis and Macrophage Activation Syndrome. J Rheumatol 2022; 49:1042-1051. [PMID: 35840156 PMCID: PMC9588491 DOI: 10.3899/jrheum.211219] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/22/2022] [Indexed: 06/15/2023]
Abstract
OBJECTIVE To compare clinical outcomes in children with hemophagocytic lymphohistiocytosis (HLH) and macrophage activation syndrome (MAS) who were managed before and after implementation of an evidence-based guideline (EBG). METHODS A management algorithm for MAS-HLH was developed at our institution based on literature review, expert opinion, and consensus building across multiple pediatric subspecialties. An electronic medical record search retrospectively identified hospitalized patients with MAS-HLH in the pre-EBG (October 15, 2015, to December 4, 2017) and post-EBG (January 1, 2018, to January 21, 2020) time periods. Predetermined outcome metrics were evaluated in the 2 cohorts. RESULTS After the EBG launch, 57 children were identified by house staff as potential patients with MAS-HLH, and rheumatology was consulted for management. Ultimately, 17 patients were diagnosed with MAS-HLH by the treating team. Of these, 59% met HLH 2004 criteria, and 94% met 2016 classification criteria for MAS complicating systemic juvenile idiopathic arthritis. There was a statistically significant reduction in mortality from 50% before implementation of the EBG to 6% in the post-EBG cohort (P = 0.02). There was a significant improvement in time to 50% reduction in C-reactive protein level in the post-EBG vs pre-EBG cohorts (log-rank P < 0.01). There were trends toward faster time to MAS-HLH diagnosis, faster initiation of immunosuppressive therapy, shorter length of hospital stay, and more rapid normalization of MAS-HLH-related biomarkers in the patients post-EBG. CONCLUSION While the observed improvements may be partially attributed to advances in treatment of MAS-HLH that have accumulated over time, this analysis also suggests that a multidisciplinary treatment pathway for MAS-HLH contributed meaningfully to favorable patient outcomes.
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Affiliation(s)
- Maria L Taylor
- M.L. Taylor, BS, M.T. Chandler, MD, C. Platt, MD, PhD, E.M. Cohen, MD, M. Day-Lewis, RN, MSN, CPNP, F. Dedeoglu, MD, E. Janssen, MD, PhD, P.Y. Lee, MD, PhD, J. Lo, MD, M.S. Lo, MD, PhD, E. Meidan, MD, J.E. Roberts, MD, M.B.F. Son, MD, R.P. Sundel, MD, J.C. Chang, MD, MSCE, O. Halyabar, MD, M.M. Hazen, MD, L.A. Henderson, MD, MMSc, Division of Immunology, Boston Children's Hospital, Boston, Massachusetts
| | - Kacie J Hoyt
- K.J. Hoyt, MSc, Division of Immunology, Boston Children's Hospital, Boston, Massachusetts, and Virginia Tech Carilion School of Medicine, Roanoke, Virginia
| | - Joseph Han
- J. Han, BS, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Leslie Benson
- L. Benson, MD, M. Gorman, MD, Division of Neurology, Boston Children's Hospital, Boston, Massachusetts
| | - Siobhan Case
- S. Case, MD, M.H. Chang, MD, PhD, P.A. Nigrovic, MD, Division of Immunology, Boston Children's Hospital, and Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital, Boston, Massachusetts
| | - Mia T Chandler
- M.L. Taylor, BS, M.T. Chandler, MD, C. Platt, MD, PhD, E.M. Cohen, MD, M. Day-Lewis, RN, MSN, CPNP, F. Dedeoglu, MD, E. Janssen, MD, PhD, P.Y. Lee, MD, PhD, J. Lo, MD, M.S. Lo, MD, PhD, E. Meidan, MD, J.E. Roberts, MD, M.B.F. Son, MD, R.P. Sundel, MD, J.C. Chang, MD, MSCE, O. Halyabar, MD, M.M. Hazen, MD, L.A. Henderson, MD, MMSc, Division of Immunology, Boston Children's Hospital, Boston, Massachusetts
| | - Margaret H Chang
- S. Case, MD, M.H. Chang, MD, PhD, P.A. Nigrovic, MD, Division of Immunology, Boston Children's Hospital, and Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital, Boston, Massachusetts
| | - Craig Platt
- M.L. Taylor, BS, M.T. Chandler, MD, C. Platt, MD, PhD, E.M. Cohen, MD, M. Day-Lewis, RN, MSN, CPNP, F. Dedeoglu, MD, E. Janssen, MD, PhD, P.Y. Lee, MD, PhD, J. Lo, MD, M.S. Lo, MD, PhD, E. Meidan, MD, J.E. Roberts, MD, M.B.F. Son, MD, R.P. Sundel, MD, J.C. Chang, MD, MSCE, O. Halyabar, MD, M.M. Hazen, MD, L.A. Henderson, MD, MMSc, Division of Immunology, Boston Children's Hospital, Boston, Massachusetts
| | - Ezra M Cohen
- M.L. Taylor, BS, M.T. Chandler, MD, C. Platt, MD, PhD, E.M. Cohen, MD, M. Day-Lewis, RN, MSN, CPNP, F. Dedeoglu, MD, E. Janssen, MD, PhD, P.Y. Lee, MD, PhD, J. Lo, MD, M.S. Lo, MD, PhD, E. Meidan, MD, J.E. Roberts, MD, M.B.F. Son, MD, R.P. Sundel, MD, J.C. Chang, MD, MSCE, O. Halyabar, MD, M.M. Hazen, MD, L.A. Henderson, MD, MMSc, Division of Immunology, Boston Children's Hospital, Boston, Massachusetts
| | - Megan Day-Lewis
- M.L. Taylor, BS, M.T. Chandler, MD, C. Platt, MD, PhD, E.M. Cohen, MD, M. Day-Lewis, RN, MSN, CPNP, F. Dedeoglu, MD, E. Janssen, MD, PhD, P.Y. Lee, MD, PhD, J. Lo, MD, M.S. Lo, MD, PhD, E. Meidan, MD, J.E. Roberts, MD, M.B.F. Son, MD, R.P. Sundel, MD, J.C. Chang, MD, MSCE, O. Halyabar, MD, M.M. Hazen, MD, L.A. Henderson, MD, MMSc, Division of Immunology, Boston Children's Hospital, Boston, Massachusetts
| | - Fatma Dedeoglu
- M.L. Taylor, BS, M.T. Chandler, MD, C. Platt, MD, PhD, E.M. Cohen, MD, M. Day-Lewis, RN, MSN, CPNP, F. Dedeoglu, MD, E. Janssen, MD, PhD, P.Y. Lee, MD, PhD, J. Lo, MD, M.S. Lo, MD, PhD, E. Meidan, MD, J.E. Roberts, MD, M.B.F. Son, MD, R.P. Sundel, MD, J.C. Chang, MD, MSCE, O. Halyabar, MD, M.M. Hazen, MD, L.A. Henderson, MD, MMSc, Division of Immunology, Boston Children's Hospital, Boston, Massachusetts
| | - Mark Gorman
- L. Benson, MD, M. Gorman, MD, Division of Neurology, Boston Children's Hospital, Boston, Massachusetts
| | - Jonathan S Hausmann
- J.S. Hausmann, MD, Division of Immunology, Boston Children's Hospital, and Division of Rheumatology and Clinical Immunology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Erin Janssen
- M.L. Taylor, BS, M.T. Chandler, MD, C. Platt, MD, PhD, E.M. Cohen, MD, M. Day-Lewis, RN, MSN, CPNP, F. Dedeoglu, MD, E. Janssen, MD, PhD, P.Y. Lee, MD, PhD, J. Lo, MD, M.S. Lo, MD, PhD, E. Meidan, MD, J.E. Roberts, MD, M.B.F. Son, MD, R.P. Sundel, MD, J.C. Chang, MD, MSCE, O. Halyabar, MD, M.M. Hazen, MD, L.A. Henderson, MD, MMSc, Division of Immunology, Boston Children's Hospital, Boston, Massachusetts
| | - Pui Y Lee
- M.L. Taylor, BS, M.T. Chandler, MD, C. Platt, MD, PhD, E.M. Cohen, MD, M. Day-Lewis, RN, MSN, CPNP, F. Dedeoglu, MD, E. Janssen, MD, PhD, P.Y. Lee, MD, PhD, J. Lo, MD, M.S. Lo, MD, PhD, E. Meidan, MD, J.E. Roberts, MD, M.B.F. Son, MD, R.P. Sundel, MD, J.C. Chang, MD, MSCE, O. Halyabar, MD, M.M. Hazen, MD, L.A. Henderson, MD, MMSc, Division of Immunology, Boston Children's Hospital, Boston, Massachusetts
| | - Jeffrey Lo
- M.L. Taylor, BS, M.T. Chandler, MD, C. Platt, MD, PhD, E.M. Cohen, MD, M. Day-Lewis, RN, MSN, CPNP, F. Dedeoglu, MD, E. Janssen, MD, PhD, P.Y. Lee, MD, PhD, J. Lo, MD, M.S. Lo, MD, PhD, E. Meidan, MD, J.E. Roberts, MD, M.B.F. Son, MD, R.P. Sundel, MD, J.C. Chang, MD, MSCE, O. Halyabar, MD, M.M. Hazen, MD, L.A. Henderson, MD, MMSc, Division of Immunology, Boston Children's Hospital, Boston, Massachusetts
| | - Gregory P Priebe
- G.P. Priebe, MD, Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Mindy S Lo
- M.L. Taylor, BS, M.T. Chandler, MD, C. Platt, MD, PhD, E.M. Cohen, MD, M. Day-Lewis, RN, MSN, CPNP, F. Dedeoglu, MD, E. Janssen, MD, PhD, P.Y. Lee, MD, PhD, J. Lo, MD, M.S. Lo, MD, PhD, E. Meidan, MD, J.E. Roberts, MD, M.B.F. Son, MD, R.P. Sundel, MD, J.C. Chang, MD, MSCE, O. Halyabar, MD, M.M. Hazen, MD, L.A. Henderson, MD, MMSc, Division of Immunology, Boston Children's Hospital, Boston, Massachusetts
| | - Esra Meidan
- M.L. Taylor, BS, M.T. Chandler, MD, C. Platt, MD, PhD, E.M. Cohen, MD, M. Day-Lewis, RN, MSN, CPNP, F. Dedeoglu, MD, E. Janssen, MD, PhD, P.Y. Lee, MD, PhD, J. Lo, MD, M.S. Lo, MD, PhD, E. Meidan, MD, J.E. Roberts, MD, M.B.F. Son, MD, R.P. Sundel, MD, J.C. Chang, MD, MSCE, O. Halyabar, MD, M.M. Hazen, MD, L.A. Henderson, MD, MMSc, Division of Immunology, Boston Children's Hospital, Boston, Massachusetts
| | - Peter A Nigrovic
- S. Case, MD, M.H. Chang, MD, PhD, P.A. Nigrovic, MD, Division of Immunology, Boston Children's Hospital, and Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital, Boston, Massachusetts
| | - Jordan E Roberts
- M.L. Taylor, BS, M.T. Chandler, MD, C. Platt, MD, PhD, E.M. Cohen, MD, M. Day-Lewis, RN, MSN, CPNP, F. Dedeoglu, MD, E. Janssen, MD, PhD, P.Y. Lee, MD, PhD, J. Lo, MD, M.S. Lo, MD, PhD, E. Meidan, MD, J.E. Roberts, MD, M.B.F. Son, MD, R.P. Sundel, MD, J.C. Chang, MD, MSCE, O. Halyabar, MD, M.M. Hazen, MD, L.A. Henderson, MD, MMSc, Division of Immunology, Boston Children's Hospital, Boston, Massachusetts
| | - Mary Beth F Son
- M.L. Taylor, BS, M.T. Chandler, MD, C. Platt, MD, PhD, E.M. Cohen, MD, M. Day-Lewis, RN, MSN, CPNP, F. Dedeoglu, MD, E. Janssen, MD, PhD, P.Y. Lee, MD, PhD, J. Lo, MD, M.S. Lo, MD, PhD, E. Meidan, MD, J.E. Roberts, MD, M.B.F. Son, MD, R.P. Sundel, MD, J.C. Chang, MD, MSCE, O. Halyabar, MD, M.M. Hazen, MD, L.A. Henderson, MD, MMSc, Division of Immunology, Boston Children's Hospital, Boston, Massachusetts
| | - Robert P Sundel
- M.L. Taylor, BS, M.T. Chandler, MD, C. Platt, MD, PhD, E.M. Cohen, MD, M. Day-Lewis, RN, MSN, CPNP, F. Dedeoglu, MD, E. Janssen, MD, PhD, P.Y. Lee, MD, PhD, J. Lo, MD, M.S. Lo, MD, PhD, E. Meidan, MD, J.E. Roberts, MD, M.B.F. Son, MD, R.P. Sundel, MD, J.C. Chang, MD, MSCE, O. Halyabar, MD, M.M. Hazen, MD, L.A. Henderson, MD, MMSc, Division of Immunology, Boston Children's Hospital, Boston, Massachusetts
| | - Maria Alfieri
- M. Alfieri, MPH, J. Chan Yeun, MSPH, D.M. Shobiye, MPH, Department of Pediatric Quality Program, Boston Children's Hospital, Boston, Massachusetts
| | - Jenny Chan Yeun
- M. Alfieri, MPH, J. Chan Yeun, MSPH, D.M. Shobiye, MPH, Department of Pediatric Quality Program, Boston Children's Hospital, Boston, Massachusetts
| | - Damilola M Shobiye
- M. Alfieri, MPH, J. Chan Yeun, MSPH, D.M. Shobiye, MPH, Department of Pediatric Quality Program, Boston Children's Hospital, Boston, Massachusetts
| | - Barbara Degar
- B. Degar, MD, Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Joyce C Chang
- M.L. Taylor, BS, M.T. Chandler, MD, C. Platt, MD, PhD, E.M. Cohen, MD, M. Day-Lewis, RN, MSN, CPNP, F. Dedeoglu, MD, E. Janssen, MD, PhD, P.Y. Lee, MD, PhD, J. Lo, MD, M.S. Lo, MD, PhD, E. Meidan, MD, J.E. Roberts, MD, M.B.F. Son, MD, R.P. Sundel, MD, J.C. Chang, MD, MSCE, O. Halyabar, MD, M.M. Hazen, MD, L.A. Henderson, MD, MMSc, Division of Immunology, Boston Children's Hospital, Boston, Massachusetts
| | - Olha Halyabar
- M.L. Taylor, BS, M.T. Chandler, MD, C. Platt, MD, PhD, E.M. Cohen, MD, M. Day-Lewis, RN, MSN, CPNP, F. Dedeoglu, MD, E. Janssen, MD, PhD, P.Y. Lee, MD, PhD, J. Lo, MD, M.S. Lo, MD, PhD, E. Meidan, MD, J.E. Roberts, MD, M.B.F. Son, MD, R.P. Sundel, MD, J.C. Chang, MD, MSCE, O. Halyabar, MD, M.M. Hazen, MD, L.A. Henderson, MD, MMSc, Division of Immunology, Boston Children's Hospital, Boston, Massachusetts
| | - Melissa M Hazen
- M.L. Taylor, BS, M.T. Chandler, MD, C. Platt, MD, PhD, E.M. Cohen, MD, M. Day-Lewis, RN, MSN, CPNP, F. Dedeoglu, MD, E. Janssen, MD, PhD, P.Y. Lee, MD, PhD, J. Lo, MD, M.S. Lo, MD, PhD, E. Meidan, MD, J.E. Roberts, MD, M.B.F. Son, MD, R.P. Sundel, MD, J.C. Chang, MD, MSCE, O. Halyabar, MD, M.M. Hazen, MD, L.A. Henderson, MD, MMSc, Division of Immunology, Boston Children's Hospital, Boston, Massachusetts
| | - Lauren A Henderson
- M.L. Taylor, BS, M.T. Chandler, MD, C. Platt, MD, PhD, E.M. Cohen, MD, M. Day-Lewis, RN, MSN, CPNP, F. Dedeoglu, MD, E. Janssen, MD, PhD, P.Y. Lee, MD, PhD, J. Lo, MD, M.S. Lo, MD, PhD, E. Meidan, MD, J.E. Roberts, MD, M.B.F. Son, MD, R.P. Sundel, MD, J.C. Chang, MD, MSCE, O. Halyabar, MD, M.M. Hazen, MD, L.A. Henderson, MD, MMSc, Division of Immunology, Boston Children's Hospital, Boston, Massachusetts;
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12
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Naymagon L. Anakinra for the treatment of adult secondary HLH: a retrospective experience. Int J Hematol 2022; 116:947-955. [PMID: 35948764 PMCID: PMC9365216 DOI: 10.1007/s12185-022-03430-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2022] [Revised: 07/25/2022] [Accepted: 07/26/2022] [Indexed: 11/30/2022]
Abstract
Anti-cytokine therapies have been gaining attention as a means of improving outcomes in adult secondary HLH (asHLH), which currently has poor outcomes when treated with standard etoposide-based therapies. Anakinra is an interleukin-1 antagonist that is increasingly being used in the management of asHLH. Here is described a multi-hospital series of 16 adult patients with secondary HLH treated with anakinra. Provoking factors of secondary HLH included hematologic malignancy (n = 7, 44%), bacterial infection (n = 7, 44%), viral infection (n = 5, 31%), rheumatologic disorder (n = 4, 25%), and unknown (n = 1, 6%). Five patients remained alive at time of last follow-up (OS = 31%). Median OS was 1.7 months from initiation of anakinra (range 0.2–59). OS among patients with rheumatologic causes of secondary HLH was 75%, whereas only 17% of patients with other provoking factors survived (p = 0.0293). Anakinra was well tolerated, with only 1 patient experiencing associated toxicity (grade 3 liver injury). Anakinra may be useful in the management of asHLH provoked by rheumatologic conditions, although its benefit in asHLH provoked by other factors may be limited.
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Affiliation(s)
- Leonard Naymagon
- Mount Sinai School of Medicine, Tisch Cancer Institute, New York, NY, USA.
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13
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Hemophagocytic lymphohistiocytosis diagnosed by bone marrow trephine biopsy in living post-COVID-19 patients: case report and mini-review. J Mol Histol 2022; 53:753-762. [PMID: 35699822 PMCID: PMC9192937 DOI: 10.1007/s10735-022-10088-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 05/31/2022] [Indexed: 12/15/2022]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) constitutes a life-threatening inflammatory syndrome. Postmortem histological findings of bone marrow (BM) from COVID-19 patients showed histiocytosis and hemophagocytosis and supported the hypothesis that secondary HLH (sHLH) may be triggered by SARS-CoV-2 infection. However, there are a limited number of sHLH cases in which trephine has been performed in living post-COVID-19 patients. Here we present a recent case and a mini-review of sHLH diagnosed by trephine biopsy in living patients after COVID-19. An 81-year-old man with a past medical history of hypertension, diabetes, ischemic stroke, was referred to the hospital to evaluate leukocytosis, pyuria, and elevation of inflammatory markers four weeks after recovering from COVID-19. Computed tomography of the abdomen did not reveal focal signs of infection or hepatosplenomegaly. The patient received intravenous meropenem and two packed red blood cell units. Leukocytes and C-reactive protein were gradually decreased. A BM biopsy was performed and the patient was discharged on cefixime. BM smear revealed severe anemia, lymphopenia, and dysplastic morphologic findings of erythroblasts, neutrophils, and megakaryocytes. Trephine biopsy revealed hypercellular marrow dyserythropoiesis, plasmacytosis, lymphocytosis, histiocytosis, hemophagocytosis, and the absence of granulomas or carcinoma. Immunohistochemistry documented a mixed population of T lymphocytes (CD3+) and B lymphocytes (CD20+). Strong positivity for CD68 confirmed histiocytosis. CD138 κ, λ staining proved polyclonal plasmacytosis. Perl’s staining showed excess hemosiderin deposits. Based on our findings, we document sHLH in trephine BM biopsy of a living post-COVID-19 patient and persistent leukocytosis, underscoring the diagnostic value of trephine biopsy in preventing life-threatening conditions such as COVID-19.
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14
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Núñez-Torrón C, Ferrer-Gómez A, Moreno Moreno E, Pérez-Mies B, Villarrubia J, Chamorro S, López-Jiménez J, Palacios J, Piris-Villaespesa M, García-Cosío M. Secondary haemophagocytic lymphohistiocytosis in COVID-19: correlation of the autopsy findings of bone marrow haemophagocytosis with HScore. J Clin Pathol 2022; 75:383-389. [PMID: 33722841 PMCID: PMC7970658 DOI: 10.1136/jclinpath-2020-207337] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Revised: 01/19/2021] [Accepted: 02/15/2021] [Indexed: 01/08/2023]
Abstract
BACKGROUND Secondary haemophagocytic lymphohistiocytosis (sHLH) is characterised by a hyper activation of immune system that leads to multiorgan failure. It is suggested that excessive immune response in patients with COVID-19 could mimic this syndrome. Some COVID-19 autopsy studies have revealed the presence of haemophagocytosis images in bone marrow, raising the possibility, along with HScore parameters, of sHLH. AIM Our objective is to ascertain the existence of sHLH in some patients with severe COVID-19. METHODS We report the autopsy histological findings of 16 patients with COVID-19, focusing on the presence of haemophagocytosis in bone marrow, obtained from rib squeeze and integrating these findings with HScore parameters. CD68 immunohistochemical stains were used to highlight histiocytes and haemophagocytic cells. Clinical evolution and laboratory parameters of patients were collected from electronic clinical records. RESULTS Eleven patients (68.7%) displayed moderate histiocytic hyperplasia with haemophagocytosis (HHH) in bone marrow, three patients (18.7%) displayed severe HHH and the remainder were mild. All HScore parameters were collected in 10 patients (62.5%). Among the patients in which all parameters were evaluable, eight patients (80%) had an HScore >169. sHLH was not clinically suspected in any case. CONCLUSIONS Our results support the recommendation of some authors to use the HScore in patients with severe COVID-19 in order to identify those who could benefit from immunosuppressive therapies. The presence of haemophagocytosis in bone marrow tissue, despite not being a specific finding, has proved to be a very useful tool in our study to identify these patients.
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Affiliation(s)
| | | | | | - Belen Pérez-Mies
- Pathology, Hospital Ramón y Cajal, Madrid, Spain
- Faculty of Medicine, University of Alcalá de Henares, Madrid, Spain
- CIBER-ONC, Instituto de Salud Carlos III, Madrid, Spain
| | | | | | - Javier López-Jiménez
- Hematology, Hospital Ramón y Cajal, Madrid, Spain
- Faculty of Medicine, University of Alcalá de Henares, Madrid, Spain
| | - J Palacios
- Pathology, Hospital Ramón y Cajal, Madrid, Spain
- Faculty of Medicine, University of Alcalá de Henares, Madrid, Spain
- CIBER-ONC, Instituto de Salud Carlos III, Madrid, Spain
| | | | - Mónica García-Cosío
- Pathology, Hospital Ramón y Cajal, Madrid, Spain
- Faculty of Medicine, University of Alcalá de Henares, Madrid, Spain
- CIBER-ONC, Instituto de Salud Carlos III, Madrid, Spain
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15
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Bishton MJ, Stilwell P, Card TR, Lanyon P, Ban L, Elliss-Brookes L, Manson J, Nanduri V, Earp K, Flower L, Amarnani R, Rankin J, Sen ES, Tattersall RS, Crooks CJ, Aston J, Siskova V, West J, Bythell M. A validation study of the identification of haemophagocytic lymphohistiocytosis in England using population-based health data. Br J Haematol 2021; 194:1039-1044. [PMID: 34386978 DOI: 10.1111/bjh.17768] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Accepted: 07/28/2021] [Indexed: 11/29/2022]
Abstract
We assessed the validity of coded healthcare data to identify cases of haemophagocytic lymphohistiocytosis (HLH). Hospital Episode Statistics (HES) identified 127 cases within five hospital Trusts 2013-2018 using ICD-10 codes D76.1, D76.2 and D76.3. Hospital records were reviewed to validate diagnoses. Out of 74 patients, 73 were coded D76.1 or D76.2 (positive predictive value 89·0% [95% Confidence Interval {CI} 80·2-94·9%]) with confirmed/probable HLH. For cases considered not HLH, 44/53 were coded D76.3 (negative predictive value 97·8% [95% CI 88·2-99·9%]). D76.1 or D76.2 had 68% sensitivity in detecting HLH compared to an established active case-finding HLH register in Sheffield. Office for National Statistics (ONS) mortality data (2003-2018) identified 698 patients coded D76.1, D76.2 and D76.3 on death certificates. Five hundred and forty-one were coded D76.1 or D76.2 of whom 524 (96·9%) had HLH in the free-text cause of death. Of 157 coded D76.3, 66 (42·0%) had HLH in free text. D76.1 and D76.2 codes reliably identify HLH cases, and provide a lower bound on incidence. Non-concordance between D76.3 and HLH excludes D76.3 as an ascertainment source from HES. Our results suggest electronic healthcare data in England can enable population-wide registration and analysis of HLH for future research.
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Affiliation(s)
- Mark J Bishton
- Nottingham University Hospitals NHS Trust, University of Nottingham, Nottingham, UK
| | | | - Tim R Card
- Population and Lifespan Sciences, University of Nottingham, Nottingham, UK.,NIHR Biomedical Research Centre, Nottingham, UK
| | - Peter Lanyon
- Nottingham University Hospitals NHS Trust, University of Nottingham, Nottingham, UK
| | - Lu Ban
- Evidera by PPD, London, UK
| | | | | | | | - Kate Earp
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | | | | | - Judith Rankin
- Public Health England, London, UK.,Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Ethan S Sen
- Great North Children's Hospital, Newcastle upon Tyne, UK.,Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | | | - Colin J Crooks
- Public Health England, London, UK.,NIHR Biomedical Research Centre, Nottingham, UK.,Translational Medical Sciences, School of Medicine, University of Nottingham, Nottingham, UK
| | | | | | - Joe West
- Public Health England, London, UK.,Population and Lifespan Sciences, University of Nottingham, Nottingham, UK.,NIHR Biomedical Research Centre, Nottingham, UK
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16
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Ponnatt TS, Lilley CM, Mirza KM. Hemophagocytic Lymphohistiocytosis. Arch Pathol Lab Med 2021; 146:507-519. [PMID: 34347856 DOI: 10.5858/arpa.2020-0802-ra] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/08/2021] [Indexed: 11/06/2022]
Abstract
CONTEXT.— Hemophagocytic lymphohistiocytosis (HLH) is a rare, life-threatening disorder of immune regulation that can eventually result in end-organ damage and death. HLH is characterized by uncontrolled activation of cytotoxic T lymphocytes, natural killer cells, and macrophages that can lead to a cytokine storm. The diagnosis of HLH is often challenging due to the diverse clinical manifestations and the presence of several diagnostic mimics. The prognosis is generally poor, warranting rapid diagnosis and aggressive management. OBJECTIVE.— To provide a comprehensive review of the pathogenesis, clinical features, diagnosis, and management of HLH. DATA SOURCES.— Peer-reviewed literature. CONCLUSIONS.— HLH is a condition where a complete understanding of the pathogenesis, early diagnosis, and proper management has an important role in determining patient outcome. Genetic mutations causing impairment in the function of cytotoxic T lymphocytes and natural killer cells have been identified as the root cause of familial HLH; however, the specific pathogenesis of acquired HLH is unclear. The HLH-2004 protocol used in the diagnosis of HLH was originally developed for the pediatric population. The HLH-2004 protocol still forms the basis of the diagnosis of HLH in adults, although its use in adults has not been formally validated yet. Treatment of HLH is primarily based on the HLH-94 protocol, which involves suppressing the inflammatory response, but the treatment needs to be modified in adults depending on the underlying cause and comorbidities.
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Affiliation(s)
- Tanya Sajan Ponnatt
- From the Department of Pathology, Loyola University Chicago, Health Sciences Campus, Maywood, Illinois
| | - Cullen M Lilley
- From the Department of Pathology, Loyola University Chicago, Health Sciences Campus, Maywood, Illinois
| | - Kamran M Mirza
- From the Department of Pathology, Loyola University Chicago, Health Sciences Campus, Maywood, Illinois
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17
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Amezcua-Guerra LM, Audelo K, Guzmán J, Santiago D, González-Flores J, García-Ávila C, Torres Z, Baranda-Tovar F, Tavera-Alonso C, Sandoval J, González-Pacheco H. A simple and readily available inflammation-based risk scoring system on admission predicts the need for mechanical ventilation in patients with COVID-19. Inflamm Res 2021; 70:731-742. [PMID: 33973018 PMCID: PMC8109222 DOI: 10.1007/s00011-021-01466-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 04/05/2021] [Accepted: 04/28/2021] [Indexed: 12/15/2022] Open
Abstract
Objective To investigate whether a simplified inflammation-based risk scoring system comprising three readily available biomarkers (albumin, C-reactive protein, and leukocytes) may predict major adverse outcomes in patients with COVID-19. Methods Upon admission to the emergency room, the inflammation-based risk scoring system was applied and patients were classified as having mild, moderate, or severe inflammation. In-hospital occurrence of thrombosis, need for mechanical ventilation, and death were recorded. Results One-hundred patients (55 ± 13 years; 71% men) were included and classified as having mild (29%), moderate (12%), or severe (59%) inflammation. The need for mechanical ventilation differed among patients in each group (16%, 50%, and 71%, respectively; P < 0.0001), yielding a 4.1-fold increased risk of requiring mechanical ventilation in patients with moderate inflammation and 5.4 for those with severe inflammation. On the contrary, there were no differences for the occurrence of thrombosis (10%, 8%, and 22%, respectively; P = 0.142) or death (21%, 42%, and 39%, respectively; P = 0.106). In the multivariate analysis, only severe inflammation (hazard ratio [HR] = 4.1), D-dimer > 574 ng/mL (HR = 3.0), and troponin I ≥ 6.7 ng/mL (HR = 2.4) at hospital admission were independent predictors of the need for mechanical ventilation. Conclusion The inflammation-based risk scoring system predicts the need for mechanical ventilation in patients with severe COVID-19.
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Affiliation(s)
- Luis M Amezcua-Guerra
- Immunology, Instituto Nacional de Cardiología Ignacio Chávez, Juan Badiano 1, Sección XVI, 14080, Tlalpan, Mexico City, Mexico.
- Health Care, Universidad Autónoma Metropolitana Xochimilco, Mexico City, Mexico.
| | - Karen Audelo
- Health Care, Universidad Autónoma Metropolitana Xochimilco, Mexico City, Mexico
| | - Juan Guzmán
- Health Care, Universidad Autónoma Metropolitana Xochimilco, Mexico City, Mexico
| | - Diana Santiago
- Health Care, Universidad Autónoma Metropolitana Xochimilco, Mexico City, Mexico
| | - Julieta González-Flores
- Immunology, Instituto Nacional de Cardiología Ignacio Chávez, Juan Badiano 1, Sección XVI, 14080, Tlalpan, Mexico City, Mexico
| | - Carlos García-Ávila
- Immunology, Instituto Nacional de Cardiología Ignacio Chávez, Juan Badiano 1, Sección XVI, 14080, Tlalpan, Mexico City, Mexico
| | - Zaira Torres
- Immunology, Instituto Nacional de Cardiología Ignacio Chávez, Juan Badiano 1, Sección XVI, 14080, Tlalpan, Mexico City, Mexico
| | - Francisco Baranda-Tovar
- Cardiovascular Critical Care Unit, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City, Mexico
| | | | - Julio Sandoval
- Immunology, Instituto Nacional de Cardiología Ignacio Chávez, Juan Badiano 1, Sección XVI, 14080, Tlalpan, Mexico City, Mexico
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18
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Major A, Collins J, Craney C, Heitman AK, Bauer E, Zerante E, Stock W, Bishop MR, Jasielec J. Management of hemophagocytic lymphohistiocytosis (HLH) associated with chimeric antigen receptor T-cell (CAR-T) therapy using anti-cytokine therapy: an illustrative case and review of the literature. Leuk Lymphoma 2021; 62:1765-1769. [PMID: 33559517 DOI: 10.1080/10428194.2021.1881507] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Affiliation(s)
- Ajay Major
- Section of Hematology/Oncology at the University of Chicago, University of Chicago Comprehensive Cancer Center, Chicago, IL, USA
| | - Jennifer Collins
- Section of Hematology/Oncology at the University of Chicago, University of Chicago Comprehensive Cancer Center, Chicago, IL, USA
| | - Caroline Craney
- Section of Hematology/Oncology at the University of Chicago, University of Chicago Comprehensive Cancer Center, Chicago, IL, USA
| | - Alisa K Heitman
- Section of Hematology/Oncology at the University of Chicago, University of Chicago Comprehensive Cancer Center, Chicago, IL, USA
| | - Emily Bauer
- Section of Hematology/Oncology at the University of Chicago, University of Chicago Comprehensive Cancer Center, Chicago, IL, USA
| | - Elizabeth Zerante
- Section of Hematology/Oncology at the University of Chicago, University of Chicago Comprehensive Cancer Center, Chicago, IL, USA
| | - Wendy Stock
- The David and Etta Jonas Center for Cellular Therapy at the University of Chicago, Chicago, IL, USA
| | - Michael R Bishop
- The David and Etta Jonas Center for Cellular Therapy at the University of Chicago, Chicago, IL, USA
| | - Jagoda Jasielec
- The David and Etta Jonas Center for Cellular Therapy at the University of Chicago, Chicago, IL, USA
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19
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Hartog N, Faber W, Frisch A, Bauss J, Bupp CP, Rajasekaran S, Prokop JW. SARS-CoV-2 infection: molecular mechanisms of severe outcomes to suggest therapeutics. Expert Rev Proteomics 2021; 18:105-118. [PMID: 33779460 PMCID: PMC8022340 DOI: 10.1080/14789450.2021.1908894] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 03/22/2021] [Indexed: 02/06/2023]
Abstract
Introduction:The year 2020 was defined by the 29,903 base pairs of RNA that codes for the SARS-CoV-2 genome. SARS-CoV-2 infects humans to cause COVID-19, spreading from patient-to-patient yet impacts patients very divergently.Areas covered: Within this review, we address the known molecular mechanisms and supporting data for COVID-19 clinical course and pathology, clinical risk factors and molecular signatures, therapeutics of severe COVID-19, and reinfection/vaccination. Literature and published datasets were reviewed using PubMed, Google Scholar, and NCBI SRA tools. The combination of exaggerated cytokine signaling, pneumonia, NETosis, pyroptosis, thrombocytopathy, endotheliopathy, multiple organ dysfunction syndrome (MODS), and acute respiratory distress syndrome (ARDS) create a positive feedback loop of severe damage in patients with COVID-19 that impacts the entire body and may persist for months following infection. Understanding the molecular pathways of severe COVID-19 opens the door for novel therapeutic design. We summarize the current insights into pathology, risk factors, secondary infections, genetics, omics, and drugs being tested to treat severe COVID-19.Expert opinion: A growing level of support suggests the need for stronger integration of biomarkers and precision medicine to guide treatment strategies of severe COVID-19, where each patient has unique outcomes and thus require guided treatment.
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Affiliation(s)
- Nicholas Hartog
- Department of Pediatrics and Human Development, College of Human Medicine, Michigan State University, Grand Rapids, MI, USA
- Allergy & Immunology, Spectrum Health, Grand Rapids, MI, USA
| | - William Faber
- Department of Pediatrics and Human Development, College of Human Medicine, Michigan State University, Grand Rapids, MI, USA
- Department of Chemistry, Grand Rapids Community College, Grand Rapids, MI, USA
| | - Austin Frisch
- Department of Pediatrics and Human Development, College of Human Medicine, Michigan State University, Grand Rapids, MI, USA
| | - Jacob Bauss
- Department of Pediatrics and Human Development, College of Human Medicine, Michigan State University, Grand Rapids, MI, USA
| | - Caleb P Bupp
- Department of Pediatrics and Human Development, College of Human Medicine, Michigan State University, Grand Rapids, MI, USA
- Spectrum Health Medical Genetics, Grand Rapids, MI, USA
| | - Surender Rajasekaran
- Department of Pediatrics and Human Development, College of Human Medicine, Michigan State University, Grand Rapids, MI, USA
- Pediatric Intensive Care Unit, Helen DeVos Children’s Hospital, Grand Rapids, MI, USA
- Office of Research, Office of Research, Spectrum Health, Grand Rapids, MI, USA
| | - Jeremy W Prokop
- Department of Pediatrics and Human Development, College of Human Medicine, Michigan State University, Grand Rapids, MI, USA
- Department of Pharmacology and Toxicology, Michigan State University, East Lansing, MI, USA
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20
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Warmoth T, Ramesh M, Iwuji K, Pixley JS. Macrophage Activation Syndrome in Adults: A Retrospective Case Series. J Investig Med High Impact Case Rep 2021; 9:23247096211026406. [PMID: 34180255 PMCID: PMC8243089 DOI: 10.1177/23247096211026406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 04/20/2021] [Accepted: 05/20/2021] [Indexed: 11/19/2022] Open
Abstract
Macrophage activation syndrome (MAS) is a form of hemophagocytic lymphohistocytosis that occurs in patients with a variety of inflammatory rheumatologic conditions. Traditionally, it is noted in pediatric patients with systemic juvenile idiopathic arthritis and systemic lupus erythematous. It is a rapidly progressive and life-threatening syndrome of excess immune activation with an estimated mortality rate of 40% in children. It has become clear recently that MAS occurs in adult patients with underlying rheumatic inflammatory diseases. In this article, we describe 6 adult patients with likely underlying MAS. This case series will outline factors related to diagnosis, pathophysiology, and review present therapeutic strategies.
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Affiliation(s)
- Taylor Warmoth
- Texas Tech University Health Sciences
Center, Lubbock, TX, USA
| | - Malvika Ramesh
- Texas Tech University Health Sciences
Center, Lubbock, TX, USA
| | - Kenneth Iwuji
- Texas Tech University Health Sciences
Center, Lubbock, TX, USA
| | - John S. Pixley
- Texas Tech University Health Sciences
Center, Lubbock, TX, USA
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21
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Tang S, Li S, Zheng S, Ding Y, Zhu D, Sun C, Hu Y, Qiao J, Fang H. Understanding of cytokines and targeted therapy in macrophage activation syndrome. Semin Arthritis Rheum 2020; 51:198-210. [PMID: 33385860 DOI: 10.1016/j.semarthrit.2020.12.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Revised: 12/01/2020] [Accepted: 12/21/2020] [Indexed: 12/29/2022]
Abstract
Macrophage activation syndrome (MAS) is a potentially life-threatening complication of systemic autoinflammatory/autoimmune diseases, generally systemic juvenile idiopathic arthritis and adult-onset Still's disease. It is characterized by an excessive proliferation of macrophages and T lymphocytes. Recent research revealed that cytokine storm with elevated pro-inflammatory cytokines, including IFN-γ, IL-18, and IL-6, may be central to the pathogenesis of MAS. Though the mainstream of MAS treatment remains corticosteroids and cyclosporine, targeted therapies with anti-cytokine biologics are reported to be promising for controlling systemic inflammation in MAS.
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Affiliation(s)
- Shunli Tang
- Department of Dermatology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Sheng Li
- Department of Dermatology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Siting Zheng
- Department of Dermatology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yuwei Ding
- Department of Dermatology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Dingxian Zhu
- Department of Dermatology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Chuanyin Sun
- Department of Rheumatology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yongxian Hu
- Department of Hematology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Jianjun Qiao
- Department of Dermatology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.
| | - Hong Fang
- Department of Dermatology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.
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22
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Amigues I, Pearlman AH, Patel A, Reid P, Robinson PC, Sinha R, Kim AH, Youngstein T, Jayatilleke A, Konigon M. Coronavirus disease 2019: investigational therapies in the prevention and treatment of hyperinflammation. Expert Rev Clin Immunol 2020; 16:1185-1204. [PMID: 33146561 PMCID: PMC7879704 DOI: 10.1080/1744666x.2021.1847084] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 11/03/2020] [Indexed: 02/06/2023]
Abstract
Introduction: The mortality of coronavirus disease 2019 (COVID-19) is frequently driven by an injurious immune response characterized by the development of acute respiratory distress syndrome (ARDS), endotheliitis, coagulopathy, and multi-organ failure. This spectrum of hyperinflammation in COVID-19 is commonly referred to as cytokine storm syndrome (CSS). Areas covered: Medline and Google Scholar were searched up until 15th of August 2020 for relevant literature. Evidence supports a role of dysregulated immune responses in the immunopathogenesis of severe COVID-19. CSS associated with SARS-CoV-2 shows similarities to the exuberant cytokine production in some patients with viral infection (e.g.SARS-CoV-1) and may be confused with other syndromes of hyperinflammation like the cytokine release syndrome (CRS) in CAR-T cell therapy. Interleukin (IL)-6, IL-8, and tumor necrosis factor-alpha have emerged as predictors of COVID-19 severity and in-hospital mortality. Expert opinion: Despite similarities, COVID-19-CSS appears to be distinct from HLH, MAS, and CRS, and the application of HLH diagnostic scores and criteria to COVID-19 is not supported by emerging data. While immunosuppressive therapy with glucocorticoids has shown a mortality benefit, cytokine inhibitors may hold promise as 'rescue therapies' in severe COVID-19. Given the arguably limited benefit in advanced disease, strategies to prevent the development of COVID-19-CSS are needed.
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Affiliation(s)
- Isabelle Amigues
- Division of Rheumatology, Department of Medicine, National Jewish Health, Denver, CO, USA
| | - Alexander H Pearlman
- Division of Rheumatology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Aarat Patel
- Bon Secours Rheumatology Center and Division of Pediatric Rheumatology, Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Pankti Reid
- Division of Rheumatology, Department of Internal Medicine, Committee on Clinical Pharmacology and Pharmacogenomics, University of Chicago Medical Center, Chicago, IL, USA
| | - Philip C. Robinson
- School of Clinical Medicine, University of Queensland Faculty of Medicine, Queensland, Australia
| | - Rashmi Sinha
- Department of Medicine, Systemic Juvenile Idiopathic Arthritis Foundation, Cincinnati, OH, USA
| | - Alfred Hj Kim
- Division of Rheumatology, Department of Medicine, Washington University School of Medicine, Saint Louis, MO, USA
- Division of Immunobiology, Department of Pathology and Immunology, Washington University School of Medicine, Saint Louis, MO, USA
- Andrew M. And Jane M. Bursky Center of Human Immunology and Immunotherapy Programs, Washington University School of Medicine, Saint Louis, MO, USA
| | - Taryn Youngstein
- Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Arundathi Jayatilleke
- Division of Rheumatology, Department of Medicine, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
| | - Maximilian Konigon
- Division of Rheumatology, Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
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23
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Vounotrypidis P. COVID-19: An Archetype Innate Immunity Reaction and Modes of Treatment. Mediterr J Rheumatol 2020; 31:275-283. [PMID: 33196005 PMCID: PMC7656129 DOI: 10.31138/mjr.31.3.275] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 07/14/2020] [Accepted: 07/31/2020] [Indexed: 02/06/2023] Open
Abstract
The magnitude of the SARS-CoV-2 pandemic found health systems unprepared, not allowing for prompt evaluation, collaboration among specialities and treatment of severely ill patients admitted to intensive care units, with many of them having an unfortunate outcome. Current data demonstrate an acute immune dysregulation in severe forms of the disease. The above is concluded by clinical evolution and laboratory findings, indicating a severe inflammatory response of the innate immune system, initiating predominately with the involvement of the respiratory tract epithelial cells, occasionally progressing to thrombotic diathesis and related complications. Besides the clinical manifestations, the immune response expresses an extremely high acute phase reactants repertoire including hyperferritinemia, hyper-fibrinogenaemia, and a storm of cytokines that require an alternative view and collaboration with rheumatologists. Thrombotic diathesis in some cases may not attribute only to a possible disseminated intravascular coagulation, but also to an additional activation of adaptive immunity and the development of the antiphospholipid syndrome. Unifying speciality evaluation and treatment may improve patient outcomes by recognizing early the evolving syndromes, treating properly, in a stratifying manner, with medications that alleviate the inflammatory reaction. Corticosteroids, colchicine, hydroxychloroquine/chloroquine, and possibly potent immunosuppressants are in the armamentarium. Additionally, biologics that interrupt the innate immune dysfunction, such as IL-1, IL-6 and selective JAK inhibitors, are also used. Convalescent plasma therapy and human immunoglobulin may be restricted for those whom the proposed treatments are found inadequate. The above combined with antiretroviral medications may improve the outcome until the development of safe and effective vaccination.
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24
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The role of IL-6 and other mediators in the cytokine storm associated with SARS-CoV-2 infection. J Allergy Clin Immunol 2020; 146:518-534.e1. [PMID: 32896310 PMCID: PMC7471766 DOI: 10.1016/j.jaci.2020.07.001] [Citation(s) in RCA: 159] [Impact Index Per Article: 39.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 07/01/2020] [Accepted: 07/02/2020] [Indexed: 12/21/2022]
Abstract
The coronavirus disease 2019 pandemic caused by severe acute respiratory syndrome coronavirus 2 presents with a spectrum of clinical manifestations from asymptomatic or mild, self-limited constitutional symptoms to a hyperinflammatory state ("cytokine storm") followed by acute respiratory distress syndrome and death. The objective of this study was to provide an evidence-based review of the associated pathways and potential treatment of the hyperinflammatory state associated with severe acute respiratory syndrome coronavirus 2 infection. Dysregulated immune responses have been reported to occur in a smaller subset of those infected with severe acute respiratory syndrome coronavirus 2, leading to clinical deterioration 7 to 10 days after initial presentation. A hyperinflammatory state referred to as cytokine storm in its severest form has been marked by elevation of IL-6, IL-10, TNF-α, and other cytokines and severe CD4+ and CD8+ T-cell lymphopenia and coagulopathy. Recognition of at-risk patients could permit early institution of aggressive intensive care and antiviral and immune treatment to reduce the complications related to this proinflammatory state. Several reports and ongoing clinical trials provide hope that available immunomodulatory therapies could have therapeutic potential in these severe cases. This review highlights our current state of knowledge of immune mechanisms and targeted immunomodulatory treatment options for the current coronavirus disease 2019 pandemic.
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25
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Siegler EL, Kenderian SS. Neurotoxicity and Cytokine Release Syndrome After Chimeric Antigen Receptor T Cell Therapy: Insights Into Mechanisms and Novel Therapies. Front Immunol 2020; 11:1973. [PMID: 32983132 PMCID: PMC7485001 DOI: 10.3389/fimmu.2020.01973] [Citation(s) in RCA: 149] [Impact Index Per Article: 37.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Accepted: 07/21/2020] [Indexed: 12/11/2022] Open
Abstract
Chimeric antigen receptor T (CART) cell immunotherapy has been remarkably successful in treating certain relapsed/refractory hematological cancers. However, CART cell therapy is also associated with toxicities which present an obstacle to its wider adoption as a mainstay for cancer treatment. The primary toxicities following CART cell administration are cytokine release syndrome (CRS) and immune effector cell-associated neurotoxicity syndrome (ICANS). New insights into the mechanisms of these toxicities have spurred novel treatment options. In this review, we summarize the available literature on the clinical manifestations, mechanisms, and treatments of CART-associated CRS and ICANS.
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Affiliation(s)
- Elizabeth L Siegler
- T Cell Engineering, Mayo Clinic, Rochester, MN, United States.,Division of Hematology, Mayo Clinic, Rochester, MN, United States
| | - Saad S Kenderian
- T Cell Engineering, Mayo Clinic, Rochester, MN, United States.,Division of Hematology, Mayo Clinic, Rochester, MN, United States.,Department of Immunology, Mayo Clinic, Rochester, MN, United States.,Department of Molecular Medicine, Mayo Clinic, Rochester, MN, United States
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26
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Fuchs A, Orth HM, Germing U, Kondakci M, Holtfreter M, Feldt T, Jensen BEO, Häussinger D. Falciparum malaria-induced secondary hemophagocytic lymphohistiocytosis successfully treated with ruxolitinib. Int J Infect Dis 2020; 100:382-385. [PMID: 32777582 DOI: 10.1016/j.ijid.2020.07.062] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Revised: 07/22/2020] [Accepted: 07/24/2020] [Indexed: 11/24/2022] Open
Abstract
JAK/STAT signaling plays a major role in the pathogenesis of secondary hemophagocytic lymphohistiocytosis. This case report on a critically ill patient with secondary hemophagocytic lymphohistiocytosis due to falciparum malaria treated successfully with ruxolitinib, demonstrates that JAK1/2 inhibition might be a promising treatment option for severe cases.
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Affiliation(s)
- André Fuchs
- Department of Gastroenterology, Hepatology and Infectious Diseases, Düsseldorf University Hospital, Heinrich Heine University, Düsseldorf, Germany
| | - Hans-Martin Orth
- Department of Gastroenterology, Hepatology and Infectious Diseases, Düsseldorf University Hospital, Heinrich Heine University, Düsseldorf, Germany
| | - Ulrich Germing
- Department of Hematology, Oncology and Clinical Immunology, Düsseldorf University Hospital, Heinrich Heine University, Düsseldorf, Germany
| | - Mustafa Kondakci
- Department of Hematology, Oncology and Clinical Immunology, Düsseldorf University Hospital, Heinrich Heine University, Düsseldorf, Germany
| | - Martha Holtfreter
- Department of Gastroenterology, Hepatology and Infectious Diseases, Düsseldorf University Hospital, Heinrich Heine University, Düsseldorf, Germany
| | - Torsten Feldt
- Department of Gastroenterology, Hepatology and Infectious Diseases, Düsseldorf University Hospital, Heinrich Heine University, Düsseldorf, Germany
| | - Björn Erik-Ole Jensen
- Department of Gastroenterology, Hepatology and Infectious Diseases, Düsseldorf University Hospital, Heinrich Heine University, Düsseldorf, Germany.
| | - Dieter Häussinger
- Department of Gastroenterology, Hepatology and Infectious Diseases, Düsseldorf University Hospital, Heinrich Heine University, Düsseldorf, Germany
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27
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Suárez-Hormiga L, Jaén-Sánchez MN, Verdugo-Espinosa EA, Carranza-Rodríguez C, Hernández-Cabrera PM, Pisos-Álamo E, Francés-Urmeneta A, Pérez-Arellano JL. Hemophagocytic syndrome in patients infected with the human immunodeficiency virus: A study of 15 consecutive patients. REVISTA ESPANOLA DE QUIMIOTERAPIA 2020; 33:249-257. [PMID: 32560584 PMCID: PMC7374033 DOI: 10.37201/req/037.2020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Objectives Hemophagocytic syndrome (HPS) is characterized by various clinical and biological data derived from cytokine hyperproduction and cell proliferation. The objectives of this study were to evaluate the epidemiological, etiological, clinical and evolutionary characteristics of patients diagnosed with hemophagocytic syndrome and HIV infection, as well as their comparison with data from the literature. Methods- A retrospective descriptive observational study was performed, including all adult patients with a diagnosis of HPS and HIV infection treated in the Infectious Diseases and Tropical Medicine Unit of the Hospital Universitario Insular, Las Palmas, Gran Canaria from June 1, 1998 to December 31, 2018. Results An analysis of this series of case reports of 15 patients showed a higher percentage of males than females, with a mean age of 42 years. With respect to the diagnostic criteria for HPS, presence of fever, cytopenias and hyperferritinemia were a constant in all patients. Clinical neurological manifestations were frequent and clinical respiratory signs and symptoms absent. HPS was confirmed in some patients who were not severely immune-depressed and had undetectable viral loads. Furthermore, 40% of cases were not receiving ART. The most frequent triggering causes of HPS were viral, especially HHV-8. In addition, two new HPS triggers were identified: Blastocystis dermatitidis and Mycobacterium chelonae. Conclusion Administration of treatment in HPS is arbitrary. This, together with the high mortality rate and the fact that it is underdiagnosed, indicates the importance of conducting future studies.
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Affiliation(s)
| | | | | | - C Carranza-Rodríguez
- Cristina Carranza Rodríguez. Unidad de Enfermedades Infecciosas y Medicina Tropical. Hospital Universitario Insular de Gran Canaria. Av. Marítima del Sur s/n 35016 Las Palmas de Gran Canaria. Spain.
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28
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Mehta P, Cron RQ, Hartwell J, Manson JJ, Tattersall RS. Silencing the cytokine storm: the use of intravenous anakinra in haemophagocytic lymphohistiocytosis or macrophage activation syndrome. THE LANCET. RHEUMATOLOGY 2020; 2:e358-e367. [PMID: 32373790 PMCID: PMC7198216 DOI: 10.1016/s2665-9913(20)30096-5] [Citation(s) in RCA: 175] [Impact Index Per Article: 43.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The term cytokine storm syndromes describes conditions characterised by a life-threatening, fulminant hypercytokinaemia with high mortality. Cytokine storm syndromes can be genetic or a secondary complication of autoimmune or autoinflammatory disorders, infections, and haematological malignancies. These syndromes represent a key area of interface between rheumatology and general medicine. Rheumatologists often lead in management, in view of their experience using intensive immunosuppressive regimens and managing cytokine storm syndromes in the context of rheumatic disorders or infection (known as secondary haemophagocytic lymphohistiocytosis or macrophage activation syndrome [sHLH/MAS]). Interleukin (IL)-1 is pivotal in hyperinflammation. Anakinra, a recombinant humanised IL-1 receptor antagonist, is licenced at a dose of 100 mg once daily by subcutaneous injection for rheumatoid arthritis, systemic juvenile idiopathic arthritis, adult-onset Still's disease, and cryopyrin-associated periodic syndromes. In cytokine storm syndromes, the subcutaneous route is often problematic, as absorption can be unreliable in patients with critical illness, and multiple injections are needed to achieve the high doses required. As a result, intravenous anakinra is used in clinical practice for sHLH/MAS, despite this being an off-licence indication and route of administration. Among 46 patients admitted to our three international, tertiary centres for sHLH/MAS and treated with anakinra over 12 months, the intravenous route of delivery was used in 18 (39%) patients. In this Viewpoint, we describe current challenges in the management of cytokine storm syndromes and review the pharmacokinetic and safety profile of intravenous anakinra. There is accumulating evidence to support the rationale for, and safety of, intravenous anakinra as a first-line treatment in patients with sHLH/MAS. Intravenous anakinra has important clinical relevance when high doses of drug are required or if patients have subcutaneous oedema, severe thrombocytopenia, or neurological involvement. Cross-speciality management and collaboration, with the generation of international, multi-centre registries and biobanks, are needed to better understand the aetiopathogenesis and improve the poor prognosis of cytokine storm syndromes.
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Affiliation(s)
- Puja Mehta
- Centre for Inflammation and Tissue Repair, UCL Respiratory, Division of Medicine, University College London, London, UK
- Department of Rheumatology, University College London Hospital, London, UK
| | - Randy Q Cron
- Department of Paediatric Rheumatology, Children's Hospital of Alabama, University of Alabama, Birmingham, AL, USA
| | - James Hartwell
- Department of Pharmacy, University College London Hospital, London, UK
| | - Jessica J Manson
- Department of Rheumatology, University College London Hospital, London, UK
| | - Rachel S Tattersall
- Department of Rheumatology, Sheffield Teaching Hospitals NHS Foundation Trust and Sheffield Children's Hospital NHS Foundation trust, Sheffield, UK
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29
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Favorable Anakinra Responses in Severe Covid-19 Patients with Secondary Hemophagocytic Lymphohistiocytosis. Cell Host Microbe 2020; 28:117-123.e1. [PMID: 32411313 PMCID: PMC7221383 DOI: 10.1016/j.chom.2020.05.007] [Citation(s) in RCA: 175] [Impact Index Per Article: 43.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2020] [Revised: 05/02/2020] [Accepted: 05/11/2020] [Indexed: 01/08/2023]
Abstract
Dysregulation of inflammation is hypothesized to play a crucial role in the severe complications of COVID-19, with the IL-1/IL-6 pathway being central. Here, we report on the treatment of eight severe COVID-19 pneumonia patients—seven hospitalized in intensive care units (ICUs) in Greece and one non-ICU patient in the Netherlands—with the interleukin-1 receptor antagonist Anakinra. All patients scored positive for the hemophagocytosis score (HScore) and were diagnosed with secondary hemophagocytic lymphohistocytosis (sHLH) characterized by pancytopenia, hyper-coagulation, acute kidney injury, and hepatobiliary dysfunction. At the end of treatment, ICU patients had less need for vasopressors, significantly improved respiratory function, and lower HScore. Although three patients died, the mortality was lower than historical series of patients with sHLH in sepsis. These data suggest that administration of Anakinra may be beneficial for treating severe COVID-19 patients with sHLH as determined by the HScore, and they support the need for larger clinical studies to validate this concept. Anakinra treatment was administered to eight severe COVID-19 patients All patients had secondary hemophagocytic lymphohistiocytosis Respiratory function was improved at the end of treatment In one patient, the need for mechanical ventilation was prevented
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30
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Henderson LA, Canna SW, Schulert GS, Volpi S, Lee PY, Kernan KF, Caricchio R, Mahmud S, Hazen MM, Halyabar O, Hoyt KJ, Han J, Grom AA, Gattorno M, Ravelli A, De Benedetti F, Behrens EM, Cron RQ, Nigrovic PA. On the Alert for Cytokine Storm: Immunopathology in COVID-19. Arthritis Rheumatol 2020; 72:1059-1063. [PMID: 32293098 PMCID: PMC7262347 DOI: 10.1002/art.41285] [Citation(s) in RCA: 471] [Impact Index Per Article: 117.8] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 04/07/2020] [Indexed: 12/11/2022]
Abstract
Poor outcomes in COVID-19 correlate with clinical and laboratory features of cytokine storm syndrome. Broad screening for cytokine storm and early, targeted antiinflammatory therapy may prevent immunopathology and could help conserve limited health care resources. While studies are ongoing, extrapolating from clinical experience in cytokine storm syndromes may benefit the multidisciplinary teams caring for patients with severe COVID-19.
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Affiliation(s)
- Lauren A Henderson
- Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Scott W Canna
- UPMC Children's Hospital of Pittsburgh and University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Grant S Schulert
- Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Stefano Volpi
- Center for Autoinflammatory Diseases and Immunodeficiency, IRCCS Istituto Giannina Gaslini, and Università degli Studi di Genova, Genoa, Italy
| | - Pui Y Lee
- Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Kate F Kernan
- UPMC Children's Hospital of Pittsburgh and University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Roberto Caricchio
- Temple University Hospital and Lewis Katz School of Medicine, Philadelphia, Pennsylvania
| | - Shawn Mahmud
- University of Minnesota Medical Center and University of Minnesota School of Medicine, Minneapolis
| | - Melissa M Hazen
- Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Olha Halyabar
- Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Kacie J Hoyt
- Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Joseph Han
- Icahn School of Medicine at Mount Sinai, New York, New York
| | - Alexei A Grom
- Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Marco Gattorno
- Center for Autoinflammatory Diseases and Immunodeficiency, IRCCS Istituto Giannina Gaslini, and Università degli Studi di Genova, Genoa, Italy
| | - Angelo Ravelli
- Clinica Pediatrica e Reumatologia, IRCCS Istituto Giannina Gaslini, and Università degli Studi di Genova, Genoa, Italy
| | | | - Edward M Behrens
- Children's Hospital of Philadelphia and the University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Randy Q Cron
- Children's of Alabama, University of Alabama at Birmingham, Birmingham
| | - Peter A Nigrovic
- Boston Children's Hospital, Brigham and Women's Hospital, and Harvard Medical School, Boston, Massachusetts
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Wampler Muskardin TL. Intravenous Anakinra for Macrophage Activation Syndrome May Hold Lessons for Treatment of Cytokine Storm in the Setting of Coronavirus Disease 2019. ACR Open Rheumatol 2020; 2:283-285. [PMID: 32267072 PMCID: PMC7231517 DOI: 10.1002/acr2.11140] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 03/31/2020] [Indexed: 01/24/2023] Open
Abstract
Macrophage activation syndrome (MAS) and hemophagocytic lymphohistiocytosis (HLH) are increasingly recognized as being on a continuum of cytokine storm syndromes, with different initiating pathways culminating in cytotoxic dysfunction and uncontrolled activation and proliferation of T lymphocytes and macrophages. The activated immune cells produce large amounts of proinflammatory cytokines, including interleukin 1β (IL)‐1β. Management depends on the recognized diagnosis. In the setting of a cytokine storm syndrome and infection, collaborative involvement of specialists, including infectious disease and rheumatology is ideal. Anakinra, a recombinant IL‐1 receptor antagonist, has been used subcutaneously and intravenously in pediatric patients and is considered a first‐line treatment for MAS and secondary HLH (sHLH) among many pediatric rheumatologists. Previous reports of anakinra used in adults for treatment of MAS or sHLH are limited to subcutaneous administration. In this issue, Moneagudo et al. present a series of adult patients with sHLH treated with intravenous anakinra, including patients in whom subcutaneous anakinra was insufficient. As the authors suggest, there is a potential therapeutic use for anakinra in sHLH or the cytokine storm syndrome triggered by COVID19. Trial design will be key, with the patient subpopulation, timing of intervention, and doses tested important.
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Henderson LA, Cron RQ. Macrophage Activation Syndrome and Secondary Hemophagocytic Lymphohistiocytosis in Childhood Inflammatory Disorders: Diagnosis and Management. Paediatr Drugs 2020; 22:29-44. [PMID: 31732958 PMCID: PMC7334831 DOI: 10.1007/s40272-019-00367-1] [Citation(s) in RCA: 69] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Macrophage activation syndrome (MAS), a form of secondary hemophagocytic lymphohistiocytosis, is a frequently fatal complication of a variety of pediatric inflammatory disorders. MAS has been most commonly associated with systemic juvenile idiopathic arthritis (sJIA), as approximately 10% of children with sJIA develop fulminant MAS, with another 30-40% exhibiting a more subclinical form of the disease. Children with other rheumatologic conditions such as systemic lupus erythematosus and Kawasaki disease are also at risk for MAS. Moreover, MAS also complicates various genetic autoinflammatory disorders such as gain of function mutations in the cytosolic inflammasome NLRC4, pediatric hematologic malignancies (e.g., T-cell lymphoma), and primary immunodeficiencies characterized by immune dysregulation. Disease-specific and broadly inclusive diagnostic criteria have been developed to facilitate the diagnosis of MAS. Recently, simple screening tools such as the serum ferritin to erythrocyte sedimentation rate ratio have been proposed. Early diagnosis and rapid initiation of immunosuppression are essential for the effective management of MAS. With a better understanding of the pathophysiology of MAS and the advent of novel therapeutics, a broad immunosuppressive approach to treatment is giving way to targeted anti-cytokine therapies. These treatments include agents that block interleukin-1 (IL-1), IL-6, IL-18, interferon-γ, as well as inhibitors of downstream targets of cytokine signaling (e.g., Janus kinases). Increased early recognition of MAS among pediatric inflammatory disorders combined with the use of effective and less toxic cytokine-targeted therapies should lower the mortality of this frequently fatal disorder.
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Affiliation(s)
- Lauren A. Henderson
- Division of Immunology, Boston Children’s Hospital, 1 Blackfan Circle, 10th Floor Karp Family Research Building, Boston, MA 02115, USA
| | - Randy Q. Cron
- Division of Pediatric Rheumatology, Children’s of Alabama, 1600 7th Ave. S., CPPN, suite G10, Birmingham, AL 35233-1711, USA
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Sandler RD, Carter S, Kaur H, Francis S, Tattersall RS, Snowden JA. Haemophagocytic lymphohistiocytosis (HLH) following allogeneic haematopoietic stem cell transplantation (HSCT)-time to reappraise with modern diagnostic and treatment strategies? Bone Marrow Transplant 2020; 55:307-316. [PMID: 31455895 PMCID: PMC6995779 DOI: 10.1038/s41409-019-0637-7] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Revised: 05/28/2019] [Accepted: 06/07/2019] [Indexed: 12/23/2022]
Affiliation(s)
- Robert David Sandler
- Department of Rheumatology, Sheffield Teaching Hospitals NHS Foundation Trust, Royal Hallamshire Hospital, Sheffield, S10 2JF, UK.
| | - Stuart Carter
- Department of Rheumatology, Sheffield Teaching Hospitals NHS Foundation Trust, Royal Hallamshire Hospital, Sheffield, S10 2JF, UK
| | - Harpreet Kaur
- Department of Haematology, Sheffield Teaching Hospitals NHS Foundation Trust, Royal Hallamshire Hospital, Sheffield, S10 2JF, UK
| | - Sebastian Francis
- Department of Haematology, Sheffield Teaching Hospitals NHS Foundation Trust, Royal Hallamshire Hospital, Sheffield, S10 2JF, UK
| | - Rachel Scarlett Tattersall
- Department of Rheumatology, Sheffield Teaching Hospitals NHS Foundation Trust, Royal Hallamshire Hospital, Sheffield, S10 2JF, UK
| | - John Andrew Snowden
- Department of Haematology, Sheffield Teaching Hospitals NHS Foundation Trust, Royal Hallamshire Hospital, Sheffield, S10 2JF, UK
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Nikiforow S, Berliner N. To "Lump" or to "Split" in Macrophage Activation Syndrome and Hemophagocytic Lymphohistiocytosis. Arthritis Rheumatol 2019; 72:206-209. [PMID: 31524337 DOI: 10.1002/art.41106] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Accepted: 09/10/2019] [Indexed: 12/14/2022]
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Georgiadou S, Gatselis NK, Stefos A, Zachou K, Makaritsis K, Rigopoulou EI, Dalekos GN. Efficient management of secondary haemophagocytic lymphohistiocytosis with intravenous steroids and γ-immunoglobulin infusions. World J Clin Cases 2019; 7:3394-3406. [PMID: 31750324 PMCID: PMC6854401 DOI: 10.12998/wjcc.v7.i21.3394] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Revised: 09/20/2019] [Accepted: 10/15/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Secondary haemophagocytic lymphohistiocytosis (sHLH) is a rare life-threatening condition mainly associated with underlying infections, malignancies, and autoimmune or immune-mediated diseases.
AIM To analyse all sHLH cases that were diagnosed and managed under real-world circumstances in our department focusing on the treatment schedule and the outcome.
METHODS Prospectively collected data from all adult patients fulfilling the criteria of sHLH who diagnosed and managed from January 1, 2010 to June 1, 2018, in our department of the tertiary care university hospital of Larissa, Greece, were analysed retrospectively (n = 80; 52% male; median age: 55 years). The electronic records and/or written charts of the patients were reviewed for the demographic characteristics, clinical manifestations, underlying causes of sHLH, laboratory parameters, treatment schedule and 30-d-mortality rate. Most of patients had received after consent intravenous γ-immunoglobulin (IVIG) for 5 d (total dose 2 g/kg) in combination with intravenous steroid pulses followed by gradual tapering of prednisolone.
RESULTS Seventy-five patients (94%) reported fever > 38.5 °C, 47 (59%) had liver or spleen enlargement and 76 (95%) had ferritin > 500 ng/mL including 20 (25%) having considerably high levels (> 10000 ng/mL). Anaemia and thrombocytopenia occurred in 72% and leucopoenia in 47% of them. Underlying infections were diagnosed in 59 patients (74%) as follows: leishmaniasis alone in 15/80 (18.9%), leishmaniasis concurrently with Coxiella Burnetti or non-Hodgkin lymphoma in 2/80 (2.5%), bacterial infections in 14/80 (17.5%) including one case with concurrent non-Hodgkin lymphoma, viral infections in 13/80 (16.3%), fungal infections in 2/80 (2.5%), infections by mycobacteria in 1/80 (1.3%) and unidentified pathogens in 12/80 (15%). Seventy-two patients (90%) had received combination treatment with IVIG and intravenous steroids. Overall, sHLH resolved in 76% of patients, 15% died within the first month but 82.5% of patients were still alive 6 mo after diagnosis. Univariate analysis showed older age, anaemia, thrombocytopenia, low fibrinogen, disseminated intravascular coagulation (DIC), and delay of diagnosis as factors that negatively affected remission. However, multivariate analysis showed low platelets and DIC as the only independent predictors of adverse outcome.
CONCLUSION sHLH still carries a remarkable morbidity and mortality. Underlying infections were the major cause and therefore, they should be thoroughly investigated in patients with sHLH. Early recognition and combination treatment with IVIG and corticosteroids seem an efficient treatment option with successful outcome in this life-threatening condition.
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Affiliation(s)
- Sarah Georgiadou
- Department of Medicine and Research Laboratory of Internal Medicine, University Hospital of Larissa, Larissa 41110, Greece
| | - Nikolaos K Gatselis
- Department of Medicine and Research Laboratory of Internal Medicine, University Hospital of Larissa, Larissa 41110, Greece
- Institute of Internal Medicine and Hepatology, University Hospital of Larissa, Larissa 41447, Greece
| | - Aggelos Stefos
- Department of Medicine and Research Laboratory of Internal Medicine, University Hospital of Larissa, Larissa 41110, Greece
| | - Kalliopi Zachou
- Department of Medicine and Research Laboratory of Internal Medicine, University Hospital of Larissa, Larissa 41110, Greece
- Institute of Internal Medicine and Hepatology, University Hospital of Larissa, Larissa 41447, Greece
| | - Konstantinos Makaritsis
- Department of Medicine and Research Laboratory of Internal Medicine, University Hospital of Larissa, Larissa 41110, Greece
- Institute of Internal Medicine and Hepatology, University Hospital of Larissa, Larissa 41447, Greece
| | - Eirini I Rigopoulou
- Department of Medicine and Research Laboratory of Internal Medicine, University Hospital of Larissa, Larissa 41110, Greece
- Institute of Internal Medicine and Hepatology, University Hospital of Larissa, Larissa 41447, Greece
| | - George N Dalekos
- Department of Medicine and Research Laboratory of Internal Medicine, University Hospital of Larissa, Larissa 41110, Greece
- Institute of Internal Medicine and Hepatology, University Hospital of Larissa, Larissa 41447, Greece
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Hutchinson M, Tattersall RS, Manson JJ. Haemophagocytic lymphohisticytosis-an underrecognized hyperinflammatory syndrome. Rheumatology (Oxford) 2019; 58:vi23-vi30. [PMID: 31769857 PMCID: PMC6878843 DOI: 10.1093/rheumatology/kez379] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Revised: 04/26/2019] [Indexed: 12/16/2022] Open
Abstract
Haemophagocytic lymphohisticytosis (HLH) is a syndrome of uncontrolled, severe systemic inflammation (hyperinflammation) arising either from a genetic immune system defect [primary (pHLH)] or triggered as a complication of malignancy, infection, or rheumatologic disease [secondary (sHLH)]. Patients with HLH often have non-specific symptoms and become progressively and critically unwell, with fever, cytopenia and multi-organ failure. Untreated, HLH is almost universally fatal, but even when treated, mortality is high, particularly when HLH complicates malignancy. HLH is managed with immunosuppression, and this can seem difficult to justify in such unwell patients. This review aims to examine the diagnostic and treatment challenges posed by sHLH and to improve recognition among rheumatologists who, being expert in the management of multisystem diseases and in the use of immunosuppression, are ideally placed to deliver care and build an evidence base for better disease characterization and treatment.
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Affiliation(s)
| | - Rachel S Tattersall
- Department of Rheumatology, Sheffield Teaching Hospitals NHSFT and Sheffield Children's Hospital NHSFT, UK
| | - Jessica J Manson
- Department of Rheumatology, University College Hospital, London, UK
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Liang J, Xu D, Sun C, Chen W, Cao H, Lin J. Hemophagocytic Lymphohistiocytosis: Prevalence, Risk Factors, Outcome, and Outcome-related Factors in Adult Idiopathic Inflammatory Myopathies. J Rheumatol 2019; 47:1532-1540. [PMID: 31575703 DOI: 10.3899/jrheum.190542] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/19/2019] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To clarify the prevalence, risk factors, outcome, and outcome-related factors of hemophagocytic lymphohistiocytosis (HLH) in patients with dermatomyositis (DM), polymyositis (PM), or clinically amyopathic dermatomyositis (CADM). METHODS Data of patients with DM, PM, or CADM who were admitted to the First Affiliated Hospital of Zhejiang University from February 2011 to February 2019 were retrospectively collected. Patients diagnosed with HLH constituted the case group. A 1:4 case-control study was performed to identify risk factors for HLH in patients with DM, PM, or CADM through comparison, univariate, and multivariate logistic regression analysis. Intragroup comparison was made among patients with HLH to identify factors influencing unfavorable short-term outcome. RESULTS HLH was a rare (4.2%) but fatal (77.8%) complication in patients with DM, PM, or CADM. The retrospective case-control study revealed that higher on-admission disease activity (p = 0.008), acute exacerbation of interstitial lung disease (AE-ILD, p = 0.002), and infection (p = 0.002) were risk factors for complication of HLH in patients with DM, PM, or CADM. The following intragroup comparison showed that higher on-admission disease activity (p = 0.035) and diagnosis of CADM (p = 0.039) might influence the short-term outcome of patients with HLH. However, no risk factor was identified after false discovery rate correction. CONCLUSION In this study, secondary HLH was a fatal complication, with higher on-admission disease activity, AE-ILD, and infection working as risk factors. The underlying role of infection and autoimmune abnormality in HLH in connective tissue disease was subsequently noted. Clinical factors influencing the short-term outcome of patients with secondary HLH require further study.
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Affiliation(s)
- Junyu Liang
- J.Y. Liang, MD, D.Y. Xu, Attending Doctor, Master of Medicine, C. Sun, Attending Doctor, Master of Medicine, W. Chen, Attending Doctor, MD, H. Cao, Associate Chief Physician, Master of Medicine, J. Lin, Chief Physician, MD, Department of Rheumatology, the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou-Zhejiang, China
| | - Danyi Xu
- J.Y. Liang, MD, D.Y. Xu, Attending Doctor, Master of Medicine, C. Sun, Attending Doctor, Master of Medicine, W. Chen, Attending Doctor, MD, H. Cao, Associate Chief Physician, Master of Medicine, J. Lin, Chief Physician, MD, Department of Rheumatology, the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou-Zhejiang, China
| | - Chuanyin Sun
- J.Y. Liang, MD, D.Y. Xu, Attending Doctor, Master of Medicine, C. Sun, Attending Doctor, Master of Medicine, W. Chen, Attending Doctor, MD, H. Cao, Associate Chief Physician, Master of Medicine, J. Lin, Chief Physician, MD, Department of Rheumatology, the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou-Zhejiang, China
| | - Weiqian Chen
- J.Y. Liang, MD, D.Y. Xu, Attending Doctor, Master of Medicine, C. Sun, Attending Doctor, Master of Medicine, W. Chen, Attending Doctor, MD, H. Cao, Associate Chief Physician, Master of Medicine, J. Lin, Chief Physician, MD, Department of Rheumatology, the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou-Zhejiang, China
| | - Heng Cao
- J.Y. Liang, MD, D.Y. Xu, Attending Doctor, Master of Medicine, C. Sun, Attending Doctor, Master of Medicine, W. Chen, Attending Doctor, MD, H. Cao, Associate Chief Physician, Master of Medicine, J. Lin, Chief Physician, MD, Department of Rheumatology, the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou-Zhejiang, China
| | - Jin Lin
- J.Y. Liang, MD, D.Y. Xu, Attending Doctor, Master of Medicine, C. Sun, Attending Doctor, Master of Medicine, W. Chen, Attending Doctor, MD, H. Cao, Associate Chief Physician, Master of Medicine, J. Lin, Chief Physician, MD, Department of Rheumatology, the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou-Zhejiang, China.
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[Hemophagocytic lymphohistiocytosis in unspecific virus infection]. Anaesthesist 2019; 68:626-632. [PMID: 31396675 PMCID: PMC7079861 DOI: 10.1007/s00101-019-00634-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Revised: 06/17/2019] [Accepted: 07/14/2019] [Indexed: 12/28/2022]
Abstract
Die Hämophagozytische Lymphohistiozytose (HLH), in der Literatur auch Hämophagozytosesyndrom oder Makrophagenaktivierungssyndrom im Rahmen einer rheumatologischen Vorerkrankung, wird auf Intensivstationen aufgrund des sepsisähnlichen Krankheitsbildes in über 70 % der Fälle nicht erkannt. Es wird von einem 30-jährigen, zuvor gesunden Patienten berichtet, der nach einer 3‑monatigen Asien- und Südamerikareise mit unklarem Fieber zunächst auf die infektiologische Normalstation der Charité – Universitätsmedizin Berlin aufgenommen und nach 3 Tagen bei respiratorischer Insuffizienz auf die Intensivstation verlegt wurde. Durch die sofortige HLH-Diagnostik mit Initiierung der spezifischen immunsupprimierenden Therapie mittels Dexamethason, Immunglobulinen und Anakinra konnte der Patient nach insgesamt 14-tägigem Krankenhausaufenthalt vollständig genesen in die Häuslichkeit entlassen werden. Es werden weiterhin aktuelle diagnostische und therapeutische Möglichkeiten diskutiert. Ferritin als entscheidender diagnostischer Marker sollte bei jedem Patienten mit unklarem Organversagen bestimmt werden.
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Recommendations for the management of hemophagocytic lymphohistiocytosis in adults. Blood 2019; 133:2465-2477. [PMID: 30992265 DOI: 10.1182/blood.2018894618] [Citation(s) in RCA: 540] [Impact Index Per Article: 108.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Accepted: 04/12/2019] [Indexed: 12/11/2022] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a severe hyperinflammatory syndrome induced by aberrantly activated macrophages and cytotoxic T cells. The primary (genetic) form, caused by mutations affecting lymphocyte cytotoxicity and immune regulation, is most common in children, whereas the secondary (acquired) form is most frequent in adults. Secondary HLH is commonly triggered by infections or malignancies but may also be induced by autoinflammatory/autoimmune disorders, in which case it is called macrophage activation syndrome (MAS; or MAS-HLH). Most information on the diagnosis and treatment of HLH comes from the pediatric literature. Although helpful in some adult cases, this raises several challenges. For example, the HLH-2004 diagnostic criteria developed for children are commonly applied but are not validated for adults. Another challenge in HLH diagnosis is that patients may present with a phenotype indistinguishable from sepsis or multiple organ dysfunction syndrome. Treatment algorithms targeting hyperinflammation are frequently based on pediatric protocols, such as HLH-94 and HLH-2004, which may result in overtreatment and unnecessary toxicity in adults. Therefore, dose reductions, individualized tailoring of treatment duration, and an age-dependent modified diagnostic approach are to be considered. Here, we present expert opinions derived from an interdisciplinary working group on adult HLH, sponsored by the Histiocyte Society, to facilitate knowledge transfer between physicians caring for pediatric and adult patients with HLH, with the aim to improve the outcome for adult patients affected by HLH.
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Halyabar O, Chang MH, Schoettler ML, Schwartz MA, Baris EH, Benson LA, Biggs CM, Gorman M, Lehmann L, Lo MS, Nigrovic PA, Platt CD, Priebe GP, Rowe J, Sundel RP, Surana NK, Weinacht KG, Mann A, Yuen JC, Meleedy-Rey P, Starmer A, Banerjee T, Dedeoglu F, Degar BA, Hazen MM, Henderson LA. Calm in the midst of cytokine storm: a collaborative approach to the diagnosis and treatment of hemophagocytic lymphohistiocytosis and macrophage activation syndrome. Pediatr Rheumatol Online J 2019; 17:7. [PMID: 30764840 PMCID: PMC6376762 DOI: 10.1186/s12969-019-0309-6] [Citation(s) in RCA: 62] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2018] [Accepted: 02/04/2019] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Hemophagocytic lymphohistiocytosis (HLH) and macrophage activation syndrome (MAS) were historically thought to be distinct entities, often managed in isolation. In fact, these conditions are closely related. A collaborative approach, which incorporates expertise from subspecialties that previously treated HLH/MAS independently, is needed. We leveraged quality improvement (QI) techniques in the form of an Evidence-Based Guideline (EBG) to build consensus across disciplines on the diagnosis and treatment of HLH/MAS. METHODS A multidisciplinary work group was convened that met monthly to develop the HLH/MAS EBG. Literature review and expert opinion were used to develop a management strategy for HLH/MAS. The EBG was implemented, and quality metrics were selected to monitor outcomes. RESULTS An HLH/MAS clinical team was formed with representatives from subspecialties involved in the care of patients with HLH/MAS. Broad entry criteria for the HLH/MAS EBG were established and included fever and ferritin ≥500 ng/mL. The rheumatology team was identified as the "gate-keeper," charged with overseeing the diagnostic evaluation recommended in the EBG. First-line medications were recommended based on the acuity of illness and risk of concurrent infection. Quality metrics to be tracked prospectively based on time to initiation of treatment and clinical response were selected. CONCLUSION HLH/MAS are increasingly considered to be a spectrum of related conditions, and joint management across subspecialties could improve patient outcomes. Our experience in creating a multidisciplinary approach to HLH/MAS management can serve as a model for care at other institutions.
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Affiliation(s)
- Olha Halyabar
- 0000 0004 0378 8438grid.2515.3Division of Immunolgy, Boston Children’s Hospital, Boston, MA USA
| | - Margaret H. Chang
- 0000 0004 0378 8438grid.2515.3Division of Immunolgy, Boston Children’s Hospital, Boston, MA USA ,0000 0004 0378 8294grid.62560.37Division of Rheumatology, Immunology, and Allergy, Brigham and Women’s Hospital, Boston, MA USA
| | - Michelle L. Schoettler
- 0000 0004 0378 8438grid.2515.3Division of Hematology-Oncology, Boston Children’s Hospital, Boston, MA USA ,0000 0001 2106 9910grid.65499.37Department of Pediatric Oncology, Dana Farber Cancer Institute, Boston, MA USA
| | - Marc A. Schwartz
- 0000 0004 0378 8438grid.2515.3Division of Hematology-Oncology, Boston Children’s Hospital, Boston, MA USA ,0000 0001 2106 9910grid.65499.37Department of Pediatric Oncology, Dana Farber Cancer Institute, Boston, MA USA
| | - Ezgi H. Baris
- 0000 0004 0378 8438grid.2515.3Division of Immunolgy, Boston Children’s Hospital, Boston, MA USA ,0000 0001 0668 8422grid.16477.33Department of Pediatrics, Marmara University Pendik Research and Training Hospital, Istanbul, Turkey
| | - Leslie A. Benson
- 0000 0004 0378 8438grid.2515.3Department of Neurology, Boston Children’s Hospital, Boston, MA USA
| | - Catherine M. Biggs
- 0000 0004 0378 8438grid.2515.3Division of Immunolgy, Boston Children’s Hospital, Boston, MA USA ,0000 0001 2288 9830grid.17091.3eDepartment of Pediatrics, British Columbia Children’s Hospital, University of British Columbia, Vancouver, BC Canada
| | - Mark Gorman
- 0000 0004 0378 8438grid.2515.3Department of Neurology, Boston Children’s Hospital, Boston, MA USA
| | - Leslie Lehmann
- 0000 0004 0378 8438grid.2515.3Division of Hematology-Oncology, Boston Children’s Hospital, Boston, MA USA ,0000 0001 2106 9910grid.65499.37Department of Pediatric Oncology, Dana Farber Cancer Institute, Boston, MA USA
| | - Mindy S. Lo
- 0000 0004 0378 8438grid.2515.3Division of Immunolgy, Boston Children’s Hospital, Boston, MA USA
| | - Peter A. Nigrovic
- 0000 0004 0378 8438grid.2515.3Division of Immunolgy, Boston Children’s Hospital, Boston, MA USA ,0000 0004 0378 8294grid.62560.37Division of Rheumatology, Immunology, and Allergy, Brigham and Women’s Hospital, Boston, MA USA
| | - Craig D. Platt
- 0000 0004 0378 8438grid.2515.3Division of Immunolgy, Boston Children’s Hospital, Boston, MA USA
| | - Gregory P. Priebe
- 0000 0004 0378 8438grid.2515.3Division of Critical Care Medicine, Boston Children’s Hospital, Boston, MA USA
| | - Jared Rowe
- 0000 0004 0378 8438grid.2515.3Division of Hematology-Oncology, Boston Children’s Hospital, Boston, MA USA ,0000 0001 2106 9910grid.65499.37Department of Pediatric Oncology, Dana Farber Cancer Institute, Boston, MA USA
| | - Robert P. Sundel
- 0000 0004 0378 8438grid.2515.3Division of Immunolgy, Boston Children’s Hospital, Boston, MA USA
| | - Neeraj K. Surana
- 0000 0004 0378 8438grid.2515.3Division of Infectious Diseases, Boston Children’s Hospital, Boston, MA USA ,0000 0004 1936 7961grid.26009.3dDepartment of Pediatrics, Duke University, Durham, NC USA
| | - Katja G. Weinacht
- 0000 0004 0378 8438grid.2515.3Division of Hematology-Oncology, Boston Children’s Hospital, Boston, MA USA ,0000 0001 2106 9910grid.65499.37Department of Pediatric Oncology, Dana Farber Cancer Institute, Boston, MA USA ,0000 0004 0450 875Xgrid.414123.1Division of Stem Cell Transplantation and Regenerative Medicine, Lucile Packard Children’s Hospital Stanford, Stanford, CA USA
| | - Alison Mann
- 0000 0004 0378 8438grid.2515.3Department of Pediatrics, Boston Children’s Hospital, Boston, MA USA
| | - Jenny Chan Yuen
- 0000 0004 0378 8438grid.2515.3Department of Pediatrics, Boston Children’s Hospital, Boston, MA USA
| | - Patricia Meleedy-Rey
- 0000 0004 0378 8438grid.2515.3Department of Pediatrics, Boston Children’s Hospital, Boston, MA USA
| | - Amy Starmer
- 0000 0004 0378 8438grid.2515.3Department of Pediatrics, Boston Children’s Hospital, Boston, MA USA
| | - Taruna Banerjee
- 0000 0004 0378 8438grid.2515.3Department of Pediatrics, Boston Children’s Hospital, Boston, MA USA
| | - Fatma Dedeoglu
- 0000 0004 0378 8438grid.2515.3Division of Immunolgy, Boston Children’s Hospital, Boston, MA USA
| | - Barbara A. Degar
- 0000 0004 0378 8438grid.2515.3Division of Hematology-Oncology, Boston Children’s Hospital, Boston, MA USA ,0000 0001 2106 9910grid.65499.37Department of Pediatric Oncology, Dana Farber Cancer Institute, Boston, MA USA
| | - Melissa M. Hazen
- 0000 0004 0378 8438grid.2515.3Division of Immunolgy, Boston Children’s Hospital, Boston, MA USA ,0000 0004 0378 8438grid.2515.3Department of Pediatrics, Boston Children’s Hospital, Boston, MA USA
| | - Lauren A. Henderson
- 0000 0004 0378 8438grid.2515.3Division of Immunolgy, Boston Children’s Hospital, Boston, MA USA
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Thornton CS, Minoo P, Schneider M, Fifi-Mah A. Severe skin disease in lupus associated with hemophagocytic lymphohistiocytosis: case reports and review of the literature. BMC Rheumatol 2019; 3:7. [PMID: 30886995 PMCID: PMC6390523 DOI: 10.1186/s41927-019-0055-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Accepted: 01/25/2019] [Indexed: 01/30/2023] Open
Abstract
Background Hemophagocytic lymphohistiocytosis (HLH) is a severe clinical entity associated with high mortality in the adult population. HLH has been associated with infections, malignancy and autoimmune conditions such as Systemic Lupus Erythematosus (SLE), however this is often in the context of a disease flare. Currently, there are limited reports of inaugural SLE manifesting as HLH with a lack of consensus on treatment and management of these patients. Case presentation Here, we present two rare case reports of severe cutaneous manifestation of lupus associated with HLH. Both patients presented with sinister clinical courses with primarily rheumatologic complaints including malaise, arthralgia, and myalgia with biochemical abnormalities. Both patients were diagnosed with HLH as a result of first presentation from cutaneous lupus. A comprehensive literature review using the PubMed database with cases comprising keywords of HLH and SLE up to September 2017 was conducted, with an emphasis on inaugural cutaneous SLE cases. Conclusions Ultimately, we highlight that a keen clinical acumen is required as misdiagnosis may lead to insufficient treatment with adverse clinical outcomes with the unique presentation of HLH from inaugural cases of SLE.
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Affiliation(s)
| | - Parham Minoo
- 2Department of Pathology and Laboratory Medicine, University of Calgary, Calgary, Alberta Canada
| | - Michelle Schneider
- 2Department of Pathology and Laboratory Medicine, University of Calgary, Calgary, Alberta Canada
| | - Aurore Fifi-Mah
- 3Division of Rheumatology, Department of Medicine, University of Calgary, Calgary, Alberta Canada.,4Rheumatology Outpatient Clinic, South Health Campus, 4448 Front Street SE, Calgary, Alberta T2M 1M4 Canada
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Karakike E, Giamarellos-Bourboulis EJ. Macrophage Activation-Like Syndrome: A Distinct Entity Leading to Early Death in Sepsis. Front Immunol 2019; 10:55. [PMID: 30766533 PMCID: PMC6365431 DOI: 10.3389/fimmu.2019.00055] [Citation(s) in RCA: 182] [Impact Index Per Article: 36.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Accepted: 01/10/2019] [Indexed: 12/13/2022] Open
Abstract
Hemophagocytic lymphohistocytosis (HLH) is characterized by fulminant cytokine storm leading to multiple organ dysfunction and high mortality. HLH is classified into familial (fHLH) and into secondary (sHLH). fHLH is rare and it is due to mutations of genes encoding for perforin or excretory granules of natural killer (NK) cells of CD8-lymphocytes. sHLH is also known as macrophage activation syndrome (MAS). Macrophage activation syndrome (MAS) in adults is poorly studied. Main features are fever, hepatosplenomegaly, hepatobiliary dysfunction (HBD), coagulopathy, cytopenia of two to three cell lineages, increased triglycerides and hemophagocytosis in the bone marrow. sHLH/MAS complicates hematologic malignancies, autoimmune disorders and infections mainly of viral origin. Pathogenesis is poorly understood and it is associated with increased activation of macrophages and NK cells. An autocrine loop of interleukin (IL)-1β over-secretion leads to cytokine storm of IL-6, IL-18, ferritin, and interferon-gamma; soluble CD163 is highly increased from macrophages. The true incidence of sHLH/MAS among patients with sepsis has only been studied in the cohort of the Hellenic Sepsis Study Group. Patients meeting the Sepsis-3 criteria and who had positive HSscore or co-presence of HBD and disseminated intravascular coagulation (DIC) were classified as patients with macrophage activation-like syndrome (MALS). The frequency of MALS ranged between 3 and 4% and it was an independent entity associated with early mortality after 10 days. Ferritin was proposed as a diagnostic and surrogate biomarker. Concentrations >4,420 ng/ml were associated with diagnosis of MALS with 97.1% specificity and 98% negative predictive value. Increased ferritin was also associated with increased IL-6, IL-18, IFNγ, and sCD163 and by decreased IL-10/TNFα ratio. A drop of ferritin by 15% the first 48 h was a surrogate finding of favorable outcome. There are 10 on-going trials in adults with sHLH; two for the development of biomarkers and eight for management. Only one of them is focusing in sepsis. The acronym of the trial is PROVIDE (ClinicalTrials.gov NCT03332225) and it is a double-blind randomized clinical trial aiming to deliver to patients with septic shock treatment targeting their precise immune state. Patients diagnosed with MALS are receiving randomized treatment with placebo or the IL-1β blocker anakinra.
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Affiliation(s)
- Eleni Karakike
- Fourth Department of Internal Medicine, Medical School, National and Kapodistrian University of Athens, Athens, Greece
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Prokesch BC, Nagalla S, Ezzati F, Tujios SR, Dominguez A, Chen W, Kershaw C, Patel P, de la Flor C, Foster J, Martin AA, de la Morena MT, Wysocki CA. What's in a name? The heterogeneous clinical spectrum and prognostic factors in a cohort of adults with hemophagocytic lymphohistiocytosis. Transfus Apher Sci 2018; 57:779-784. [PMID: 30327177 DOI: 10.1016/j.transci.2018.10.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2018] [Revised: 09/05/2018] [Accepted: 10/01/2018] [Indexed: 01/21/2023]
Abstract
PURPOSE Hemophagocytic lymphohistiocytosis (HLH) in adults is rare but frequently fatal. Diagnosis is often delayed and treatment approaches vary significantly in contrast to the protocol-driven approach typically used in pediatric HLH. To improve care of these complex patients, this study retrospectively examined the prevalence, clinical characteristics, therapies and outcomes of adult HLH patients at two large tertiary care centers. METHODS Adult patients with HLH confirmed by retrospective review of electronic medical records using HLH2004 criteria during admissions to the University of Texas Southwestern and Parkland Memorial Hospitals between June 2007 and June 2017 were studied. RESULTS Of 31 patients included, 67.7% were male with mean age of 46 years. Average time from admission to diagnosis was 10.5 days. 48% of patients had malignancy, with T-cell lymphoma being most common. Infections were seen in 70%. Autoimmune disorders were found in 9.6%. In total, 13 patients survived (44.8%). Median survival was 8 months with increased mortality in malignancy-associated HLH (median 0.56 months versus 36.5 months, p < 0.001). T-cell lymphoma carried a worse prognosis than other malignancies. Central nervous system disease, hypoalbuminemia, elevated bilirubin, elevated soluble interleukin 2 receptor, and elevated lactate dehydrogenase, were also associated with poor survival. Treatment varied significantly. No individual treatment improved survival. CONCLUSION This study corroborates prior limited data in adult HLH patients regarding poor survival, particularly in malignancy-associated HLH. Earlier recognition of this disease and a multidisciplinary approach to streamline diagnosis and optimize treatment are needed to improve outcomes in adult HLH patients.
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Affiliation(s)
- Bonnie C Prokesch
- Division of Infectious Disease, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX, USA
| | - Srikanth Nagalla
- Division of Hematology and Oncology, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX, USA
| | - Fatemeh Ezzati
- Division of Rheumatic Diseases, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX, USA
| | - Shannan R Tujios
- Division of Digestive and Liver Diseases, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX, USA
| | - Arturo Dominguez
- Departments of Dermatology and Internal Medicine, UT Southwestern Medical Center, Dallas, TX, USA
| | - Weina Chen
- Department of Pathology, UT Southwestern Medical Center, Dallas, TX, USA
| | - Corey Kershaw
- Division of Pulmonary and Critical Care Medicine, UT Southwestern Medical Center, Dallas, TX, USA
| | - Prapti Patel
- Division of Hematology and Oncology, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX, USA
| | - Carolina de la Flor
- Division of Infectious Disease, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX, USA
| | | | - Andrew A Martin
- Division of Hematology and Oncology, Department of Pediatrics, UT Southwestern Medical Center, Dallas, TX, USA
| | - Maria Teresa de la Morena
- Division of Allergy and Immunology, Departments of Internal Medicine and Pediatrics, UT Southwestern Medical Center, Dallas, TX, USA
| | - Christian A Wysocki
- Division of Allergy and Immunology, Departments of Internal Medicine and Pediatrics, UT Southwestern Medical Center, Dallas, TX, USA.
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Tamura D, Inoue S, Kawahara Y, Mori M, Yamagata T. Hypercytokinemia with hemophagocytic syndrome due to human metapneumovirus. Pediatr Int 2018; 60:974-976. [PMID: 30345702 DOI: 10.1111/ped.13665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Revised: 06/27/2018] [Accepted: 07/13/2018] [Indexed: 11/27/2022]
Affiliation(s)
- Daisuke Tamura
- Department of Pediatrics, Jichi Medical University, Shimotsuke, Tochigi, Japan
| | - Shun Inoue
- Department of Pediatrics, Jichi Medical University, Shimotsuke, Tochigi, Japan
| | - Yuta Kawahara
- Department of Pediatrics, Jichi Medical University, Shimotsuke, Tochigi, Japan
| | - Masaaki Mori
- Department of Life Clinical Immunology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Takanori Yamagata
- Department of Pediatrics, Jichi Medical University, Shimotsuke, Tochigi, Japan
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