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Yang M, Liu ZQ, Wang Y, Luo LL, Qiao LN. Successful treatment of diffuse alveolar hemorrhage secondary to Mycoplasma pneumoniae complicated with hemophagocytic lymphohistiocytosis in children: a case report and non-systematic literature review. Front Pediatr 2024; 12:1404872. [PMID: 39049845 PMCID: PMC11266077 DOI: 10.3389/fped.2024.1404872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Accepted: 06/06/2024] [Indexed: 07/27/2024] Open
Abstract
Background After quarantine-related measures were completely lifted in China, the respiratory infection rate of children caused by Mycoplasma pneumoniae (MP) increased significantly, and MP infection may lead to rare severe intra- and extrapulmonary manifestation. Hemophagocytic lymphohistiocytosis (HLH) and diffuse alveolar hemorrhage (DAH) are life-threatening clinical syndromes. Timely recognition may contribute to timely treatment and an improved prognosis. Currently there are no reports of children with DAH secondary to MP infection complicated with HLH. Case presentation We successfully treated a previously healthy school-aged child who was admitted to the pediatric intensive care unit with fever, cough, drowsiness, and progressive dyspnea. HLH was confirmed by clinical and testing criteria, DAH was indicated by computed tomography scan of the chest, and Mycoplasma antibody detection and endotracheal aspirates pathogen metagenomic next-generation sequencing (mNGS) confirmed MP infection. After invasive mechanical ventilation, antibiotics, and glucocorticoid treatment, the patient recovered well and was discharged. At follow-up, she did not experience any more initial symptoms. For the fourth consecutive month, all indexes remained normal. Conclusion mNGS can be considered for identifying the causative agent of infection in patients with DAH and/or HLH. The clinical manifestations of DAH in children may only present as acute hypoxic respiratory failure, significantly decreased hemoglobin without bleeding elsewhere, and chest imaging findings may assist in the diagnosis of DAH. When MP infection is associated with hemocytopenia, HLH should be considered.
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Affiliation(s)
- Min Yang
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children of Sichuan University, Ministry of Education, Chengdu, Sichuan, China
- NHC Key Laboratory of Chronobiology, Sichuan University, Chengdu, China
| | - Zhong-Qiang Liu
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children of Sichuan University, Ministry of Education, Chengdu, Sichuan, China
- NHC Key Laboratory of Chronobiology, Sichuan University, Chengdu, China
| | - Yang Wang
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children of Sichuan University, Ministry of Education, Chengdu, Sichuan, China
- NHC Key Laboratory of Chronobiology, Sichuan University, Chengdu, China
| | - Li-Li Luo
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children of Sichuan University, Ministry of Education, Chengdu, Sichuan, China
- NHC Key Laboratory of Chronobiology, Sichuan University, Chengdu, China
| | - Li-Na Qiao
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children of Sichuan University, Ministry of Education, Chengdu, Sichuan, China
- NHC Key Laboratory of Chronobiology, Sichuan University, Chengdu, China
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Löfstedt A, Jädersten M, Meeths M, Henter JI. Malignancy-associated hemophagocytic lymphohistiocytosis in Sweden: incidence, clinical characteristics, and survival. Blood 2024; 143:233-242. [PMID: 37595287 PMCID: PMC10808245 DOI: 10.1182/blood.2023020715] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 07/31/2023] [Accepted: 07/31/2023] [Indexed: 08/20/2023] Open
Abstract
ABSTRACT We evaluated malignancy-associated hemophagocytic lymphohistiocytosis (mal-HLH) in Sweden regarding population-based incidence, clinical features, and survival. From 1997 to 2018, we identified 307 adults (≥18 years old) and 9 children (209 males, 107 females; P < .001) with both an HLH-related diagnosis and malignant disease, corresponding to 0.19 per 100 000 adults annually (0.15/100 000 for the entire population), increasing from 0.026 (1997-2007) to 0.34 (2008-2018) (P < .001). In the latest 7-year period (2012-2018), the annual incidence was 0.45 per 100 000 adults (n = 246). This incidence varied between the 6 health care regions in Sweden, from 0.18 to 0.71 (Region Stockholm) per 100 000 adults annually (P < .001), likely due to variable awareness. Mal-HLH was reported in 0.6% of all hematological malignancies, with the highest proportion (2.5%) in young males. Among the 316 patients, the 1-month probability of survival, likely representing the HLH episode, increased significantly from 52% (95% confidence interval [CI], 40-63) (1997-2007) to 71% (95% CI, 65-76) (2008-2018), whereas 2-year survival remained poor (25%; 95% CI, 20-30). Altogether, 52% were lymphomas, 29% leukemias, 8% other hematological malignancies, and 11% solid tumors. Males were more affected than females by mal-HLH, also taking the over-representation of males with hematological malignancies into account (P = .0012). Validation by medical-file reviews revealed 13% over-reporting of HLH. We conclude that the annual mal-HLH incidence has increased 10-fold and was at least 0.71 per 100 000 adults from 2012 to 2018, that is, 0.62 per 100 000 adults considering 13% estimated HLH over-reporting, and that early survival improved significantly, likely due to increased awareness and more HLH-directed therapy.
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Affiliation(s)
- Alexandra Löfstedt
- Department of Women’s and Children’s Health, Childhood Cancer Research Unit, Karolinska Institutet, Stockholm, Sweden
- Astrid Lindgrens Children’s Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Martin Jädersten
- Department of Hematology, Karolinska University Hospital, Stockholm, Sweden
- Department of Medicine, Center for Hematology and Regenerative Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Marie Meeths
- Department of Women’s and Children’s Health, Childhood Cancer Research Unit, Karolinska Institutet, Stockholm, Sweden
- Astrid Lindgrens Children’s Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Jan-Inge Henter
- Department of Women’s and Children’s Health, Childhood Cancer Research Unit, Karolinska Institutet, Stockholm, Sweden
- Astrid Lindgrens Children’s Hospital, Karolinska University Hospital, Stockholm, Sweden
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Benevenuta C, Mussinatto I, Orsi C, Timeus FS. Secondary hemophagocytic lymphohistiocytosis in children (Review). Exp Ther Med 2023; 26:423. [PMID: 37602304 PMCID: PMC10433411 DOI: 10.3892/etm.2023.12122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Accepted: 06/16/2023] [Indexed: 08/22/2023] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a rare, life-threatening condition characterized by hyperinflammation in an uncontrolled and ineffective immune response. Despite great improvement in diagnosis and treatment, it still represents a challenge in clinical management, with poor prognosis in the absence of an aggressive therapeutic approach. The present literature review focuses on secondary HLH at pediatric age, which represents a heterogeneous group in terms of etiology and therapeutic approach. It summarizes the most recent evidence on epidemiology, pathophysiology, diagnosis, treatment and prognosis, and provides a detailed description and comparison of the major subtypes of secondary HLH. Finally, it addresses the open questions with a focus on diagnosis and new treatment insights.
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Affiliation(s)
- Chiara Benevenuta
- Department of Pediatrics, Azienda Sanitaria Locale Torino 4, Chivasso Hospital, I-10034 Turin, Italy
| | - Ilaria Mussinatto
- Department of Pediatrics, Azienda Sanitaria Locale Torino 4, Chivasso Hospital, I-10034 Turin, Italy
| | - Cecilia Orsi
- Department of Pediatrics, Azienda Sanitaria Locale Torino 4, Chivasso Hospital, I-10034 Turin, Italy
| | - Fabio S. Timeus
- Department of Pediatrics, Azienda Sanitaria Locale Torino 4, Chivasso Hospital, I-10034 Turin, Italy
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Bailly C. Etoposide: A rider on the cytokine storm. Cytokine 2023; 168:156234. [PMID: 37269699 DOI: 10.1016/j.cyto.2023.156234] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 05/03/2023] [Accepted: 05/04/2023] [Indexed: 06/05/2023]
Abstract
For more than 40 years, the epipodophyllotoxin drug etoposide is prescribed to treat cancer. This semi-synthetic compound remains extensively used to treat advanced small-cell lung cancer and in various chemotherapy regimen for autologous stem cell transplantation, and other anticancer protocols. Etoposide is a potent topoisomerase II poison, causing double-stranded DNA breaks which lead to cell death if they are not repaired. It is also a genotoxic compound, responsible for severe side effects and secondary leukemia occasionally. Beyond its well-recognized function as an inducer of cancer cell death (a "killer on the road"), etoposide is also useful to treat immune-mediated inflammatory diseases associated with a cytokine storm syndrome. The drug is essential to the treatment of hemophagocytic lymphohistiocytosis (HLH) and the macrophage activation syndrome (MAS), in combination with a corticosteroid and other drugs. The use of etoposide to treat HLH, either familial or secondary to a viral or parasitic infection, or treatment-induced HLH and MAS is reviewed here. Etoposide dampens inflammation in HLH patients via an inhibition of the production of pro-inflammatory mediators, such as IL-6, IL-10, IL-18, IFN-γ and TNF-α, and reduction of the secretion of the alarmin HMGB1. The modulation of cytokines production by etoposide contributes to deactivate T cells and to dampen the immune stimulation associated to the cytokine storm. This review discussed the clinical benefits and mechanism of action of etoposide (a "rider on the storm") in the context of immune-mediated inflammatory diseases, notably life-threatening HLH and MAS. The question arises as to whether the two faces of etoposide action can apply to other topoisomerase II inhibitors.
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Affiliation(s)
- Christian Bailly
- OncoWitan, Consulting Scientific Office, Lille (Wasquehal) 59290, France; University of Lille, Faculty of Pharmacy, Institut de Chimie Pharmaceutique Albert Lespagnol (ICPAL), 3 rue du Professeur Laguesse, 59000 Lille, France; University of Lille, CNRS, Inserm, CHU Lille, UMR9020 - UMR1277 - Canther - Cancer Heterogeneity, Plasticity and Resistance to Therapies, 59000 Lille, France.
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Gao WB, Hu LJ, Ma XL, Shi MJ, Wang CY, Ma Y, Song XJ, Zhu JH, Wang TB. A predictive model for identifying secondary underlying diseases of hemophagocytic lymphohistiocytosis. Front Immunol 2023; 14:1143181. [PMID: 37187741 PMCID: PMC10175773 DOI: 10.3389/fimmu.2023.1143181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Accepted: 04/14/2023] [Indexed: 05/17/2023] Open
Abstract
Background Secondary hemophagocytic lymphohistiocytosis (HLH) is a rare, life-threatening disease of immune hyperactivation that arises in the context of infectious, inflammatory, or neoplastic triggers. The aim of this study was to establish a predictive model for the timely differential diagnosis of the original disease resulting in HLH by validating clinical and laboratory findings to further improve the efficacy of therapeutics for HLH. Methods We retrospectively enrolled 175 secondary HLH patients in this study, including 92 patients with hematologic disease and 83 patients with rheumatic disease. The medical records of all identified patients were retrospectively reviewed and used to generate the predictive model. We also developed an early risk score using multivariate analysis weighted points proportional to the β regression coefficient values and calculated its sensitivity and specificity for the diagnosis of the original disease resulting in HLH. Results The multivariate logistic analysis revealed that lower levels of hemoglobin and platelets (PLT), lower levels of ferritin, splenomegaly and Epstein-Barr virus (EBV) positivity were associated with hematologic disease, but young age and female sex were associated with rheumatic disease. The risk factors for HLH secondary to rheumatic diseases were female sex [OR 4.434 (95% CI, 1.889-10.407), P =0.001], younger age [OR 6.773 (95% CI, 2.706-16.952), P<0.001], higher PLT level [OR 6.674 (95% CI, 2.838-15.694), P<0.001], higher ferritin level [OR 5.269 (95% CI, 1.995-13.920), P =0.001], and EBV negativity [OR 27.656 (95% CI, 4.499-169.996), P<0.001]. The risk score included assessments of female sex, age, PLT count, ferritin level and EBV negativity, which can be used to predict HLH secondary to rheumatic diseases with an AUC of 0.844 (95% CI, 0.836~0.932). Conclusion The established predictive model was designed to help clinicians diagnose the original disease resulting in secondary HLH during routine practice, which might be improve prognosis by enabling the timely treatment of the underlying disease.
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Affiliation(s)
- Wei-bo Gao
- Department of Emergency, Peking University People’s Hospital, Beijing, China
| | - Li-juan Hu
- Peking University People’s Hospital, Peking University Institute of Haematology, Beijing, China
- National Clinical Research Center for Haematologic Disease, Beijing, China
- *Correspondence: Li-juan Hu, ; Ji-hong Zhu, ; Tian-bing Wang,
| | - Xiao-lu Ma
- Department of Emergency, Peking University People’s Hospital, Beijing, China
| | - Mao-jing Shi
- Department of Emergency, Peking University People’s Hospital, Beijing, China
| | - Chun-yu Wang
- Department of Emergency, Peking University People’s Hospital, Beijing, China
| | - Yong Ma
- Department of Emergency, Peking University People’s Hospital, Beijing, China
| | - Xiao-jing Song
- Department of Emergency, Peking University People’s Hospital, Beijing, China
| | - Ji-hong Zhu
- Department of Emergency, Peking University People’s Hospital, Beijing, China
- *Correspondence: Li-juan Hu, ; Ji-hong Zhu, ; Tian-bing Wang,
| | - Tian-bing Wang
- Trauma Center, Peking University People’s Hospital, Beijing, China
- *Correspondence: Li-juan Hu, ; Ji-hong Zhu, ; Tian-bing Wang,
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Expression of Peripheral Blood DCs CD86, CD80, and Th1/Th2 in Sepsis Patients and Their Value on Survival Prediction. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2022; 2022:4672535. [PMID: 35309834 PMCID: PMC8926526 DOI: 10.1155/2022/4672535] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 02/08/2022] [Accepted: 02/16/2022] [Indexed: 11/17/2022]
Abstract
Objective. To explore the expression of peripheral blood dendritic cells (DCs) CD86, CD80, and Th1/Th2 in patients with sepsis and their value on survival prediction. Methods. 118 patients with sepsis from January 2019 to December 2020 were selected, According to the prognosis, the patients were divided into the death group (
) and survival group (
). The general data and pathogen division of the two groups were collected, and the levels of peripheral blood DCs CD86, CD80, and Th1/Th2; APACHE II score; inflammatory factor (procalcitonin (PCT)); and cell growth chemokine (GRO) were compared between the two groups heparin-binding protein (HBP) and myocardial enzyme indexes (creatine kinase (CK), creatine kinase isozyme (CK-MB), and lactate dehydrogenase (LDH)) to explore the relationship between CD86, CD80, Th1/Th2, and various serological indexes and the evaluation value of prognosis. Results. 124 strains of pathogenic bacteria were isolated from 118 patients, including 78 strains of gram-negative bacteria (62.90%), 31 strains of Gram-positive bacteria (25.00%), and 15 strains of fungi (12.10%). The scores of CD86, CD80, Th1, Th2, Th1/Th2, and APACHE II in the dead group were higher than those in the surviving group, and the difference was statistically significant (
). PCT, GRO-α, HBP, LDH, CK-MB, and CK levels of patients in death group were higher than those in survival group, and the difference was statistically significant (
). The levels of peripheral blood DCs CD86, CD80, and Th1/Th2 were positively correlated with PCT, GRO-α, HBP, LDH, CK-MB, and CK (
). ROC curve analysis showed that the AUC of the combined detection of DCs CD86, CD80, and Th1/Th2 in peripheral blood was 0.951, which was higher than 0.882, 0.883, and 0.734 of single index (
). Conclusion. All patients with sepsis have immune imbalance, and the peripheral blood CD86, CD80, and Th1/Th2 of the dead patients are higher than those of the survivors. The combined detection of these three indicators has the highest predictive value for the prognosis of patients.
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Xu XJ, Luo ZB, Song H, Xu WQ, Henter JI, Zhao N, Wu MH, Tang YM. Simple Evaluation of Clinical Situation and Subtypes of Pediatric Hemophagocytic Lymphohistiocytosis by Cytokine Patterns. Front Immunol 2022; 13:850443. [PMID: 35296096 PMCID: PMC8918565 DOI: 10.3389/fimmu.2022.850443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Accepted: 02/04/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundHemophagocytic lymphohistiocytosis (HLH) is a rapidly fatal disease caused by immune dysregulation. Early initiation of treatment is imperative for saving lives. However, a laboratory approach that could be used to quickly evaluate the HLH subtype and clinical situation is lacking. Our previous studies indicated that cytokines such as interferon (IFN)-γ and interleukin (IL)-10 were helpful for the early diagnosis of HLH and were associated with disease severity. The purpose of this study is to clarify the different cytokine patterns of various subtypes of pediatric HLH and to investigate the role of cytokines in a simple evaluation of disease feature.Patients and MethodsWe enrolled 256 pediatric patients with newly diagnosed HLH. The clinical features and laboratory findings were collected and compared among different subtypes of HLH. A model integrating cytokines was established to stratify HLH patients into different clinical groups.ResultsTwenty-seven patients were diagnosed with primary HLH (pHLH), 179 with EBV-HLH, and 50 with other causes. The IL-6, IL-10, and IFN-γ levels and the ratios of IL-10 to IFN-γ were different among EBV-HLH, other infection-associated HLH, malignancy-associated HLH, familial HLH, and X-linked lymphoproliferative disease. Patients with the ratio of IL-10 to IFN-γ >1.33 and the concentration of IFN-γ ≤225 pg/ml were considered to have pHLH, with a sensitivity of 73% and a specificity of 84%. A four-quadrant model based on the two cutoff values was established to stratify the patients into different clinical situations. The HLH subtypes, cytokine levels, treatment regimens, treatment response, and outcomes were different among the four quadrants, with the 8-week mortality from 2.9 ± 2.9% to 21.4 ± 5.5% and the 5-year overall survival from 93.9 ± 4.2% to 52.6 ± 7.1%.ConclusionsDifferent subtypes of HLH present distinct cytokine patterns. IFN-γ and the ratio of IL-10 to IFN-γ are helpful tools to differentiate HLH subtypes. A four-quadrant model based on these two parameters is a useful tool for a simple evaluation of the HLH situation.
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Affiliation(s)
- Xiao-Jun Xu
- Division/Center of Pediatric Hematology-Oncology, the Children’s Hospital of Zhejiang University School of Medicine, Hangzhou, China
- The Pediatric Leukemia Diagnostic and Therapeutic Technology Research Center of Zhejiang Province, National Clinical Research Center for Child Health, Hangzhou, China
| | - Ze-Bin Luo
- Division/Center of Pediatric Hematology-Oncology, the Children’s Hospital of Zhejiang University School of Medicine, Hangzhou, China
- The Pediatric Leukemia Diagnostic and Therapeutic Technology Research Center of Zhejiang Province, National Clinical Research Center for Child Health, Hangzhou, China
| | - Hua Song
- Division/Center of Pediatric Hematology-Oncology, the Children’s Hospital of Zhejiang University School of Medicine, Hangzhou, China
- The Pediatric Leukemia Diagnostic and Therapeutic Technology Research Center of Zhejiang Province, National Clinical Research Center for Child Health, Hangzhou, China
| | - Wei-Qun Xu
- Division/Center of Pediatric Hematology-Oncology, the Children’s Hospital of Zhejiang University School of Medicine, Hangzhou, China
- The Pediatric Leukemia Diagnostic and Therapeutic Technology Research Center of Zhejiang Province, National Clinical Research Center for Child Health, Hangzhou, China
| | - Jan-Inge Henter
- Childhood Cancer Research Unit, Department of Women’s and Children’s Health, Karolinska Institute, Stockholm, Sweden
- Pediatric Oncology, Theme of Children’s Health, Karolinska University Hospital, Stockholm, Sweden
| | - Ning Zhao
- Division/Center of Pediatric Hematology-Oncology, the Children’s Hospital of Zhejiang University School of Medicine, Hangzhou, China
- The Pediatric Leukemia Diagnostic and Therapeutic Technology Research Center of Zhejiang Province, National Clinical Research Center for Child Health, Hangzhou, China
| | - Meng-Hui Wu
- Division/Center of Pediatric Hematology-Oncology, the Children’s Hospital of Zhejiang University School of Medicine, Hangzhou, China
- The Pediatric Leukemia Diagnostic and Therapeutic Technology Research Center of Zhejiang Province, National Clinical Research Center for Child Health, Hangzhou, China
| | - Yong-Min Tang
- Division/Center of Pediatric Hematology-Oncology, the Children’s Hospital of Zhejiang University School of Medicine, Hangzhou, China
- The Pediatric Leukemia Diagnostic and Therapeutic Technology Research Center of Zhejiang Province, National Clinical Research Center for Child Health, Hangzhou, China
- *Correspondence: Yong-Min Tang,
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Liang J, Cao H, Wu B, Liu Y, He Y, Xu B, Sun Y, Ye B, Lin J. Clinical Value of 18F-FDG PET/CT Scan and Cytokine Profiles in Secondary Hemophagocytic Lymphohistiocytosis in Idiopathic Inflammatory Myopathy Patients: A Pilot Study. Front Immunol 2021; 12:745211. [PMID: 34867971 PMCID: PMC8636988 DOI: 10.3389/fimmu.2021.745211] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Accepted: 11/01/2021] [Indexed: 11/13/2022] Open
Abstract
Background Secondary hemophagocytic lymphohistiocytosis (sHLH) is a rare but fatal complication in idiopathic inflammatory myopathy (IIM) patients. The clinical value of radiological manifestations and serum cytokines remain unknown in this systemic crisis. This study aims to investigate the clinical value of PET/CT scan and cytokine profiles in predicting and understanding sHLH in IIM patients. Methods Adult IIM patients who were admitted to the four divisions of the First Affiliated Hospital, Zhejiang University School of Medicine (FAHZJU) from January 1, 2017 to December 31, 2020 were reviewed. PET/CT scan, cytokine profiles, and other factors of patients who met the inclusion and exclusion criteria were collected and analyzed. Results Sixty-nine out of 352 IIM patients were finally enrolled into the study. Ten patients developed sHLH and 70.0% of them died within 6 months. After false discovery rate (FDR) correction and multivariate logistic regression analysis, increased serum interferon (IFN)-γ level (p = 0.017), higher spleen mean standard uptake value (SUVmean, p = 0.035), and positivity of anti-MDA5 antibody (p = 0.049) were found to be significantly correlated with development of sHLH in IIM patients. The combination of serum IFN-γ, spleen SUVmean, and anti-MDA5 antibody found a balanced and satisfying predictor with a cutoff value of 0.047 and AUC of 0.946. A moderate correlation was identified between ferritin and spleen SUVmean (p = 0.001, r = 0.380) as well as serum IFN-γ(p = 0.001, r = 0.398). Before FDR correction, higher bilateral lung SUVmean (p = 0.034) and higher colon/rectum SUVmean (p = 0.013) were also observed in IIM patients who developed sHLH. By narrowing down to IIM patients with sHLH, anti-MDA5-antibody-positive DM patients tended to suffer from unfavorable outcome (p = 0.004) in Kaplan–Meier survival analysis. Conclusion Increased serum level of IFN-γ, elevated splenic FDG uptake, and positivity of anti-MDA5 antibody were significantly correlated with development of sHLH in IIM patients. Lung and lower digestive tract might also be affected due to systemic immune activation in IIM patients with sHLH. In addition, splenic FDG uptake, in combination with serum IFN-γand anti-MDA5 antibody, was found valuable in predicting development of sHLH in IIM patients. Among IIM patients with sHLH, anti-MDA5-antibody-positive DM patients showed higher tendency for unfavorable outcome.
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Affiliation(s)
- Junyu Liang
- Department of Rheumatology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Heng Cao
- Department of Rheumatology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Bowen Wu
- Department of Hematology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yinuo Liu
- PET Center, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Ye He
- Department of Rheumatology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Bei Xu
- Department of Rheumatology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yiduo Sun
- Department of Rheumatology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Bingjue Ye
- Department of Respiratory Diseases, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Jin Lin
- Department of Rheumatology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
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Imashuku S, Morimoto A, Ishii E. Virus-triggered secondary hemophagocytic lymphohistiocytosis. Acta Paediatr 2021; 110:2729-2736. [PMID: 34096649 DOI: 10.1111/apa.15973] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 05/18/2021] [Accepted: 06/04/2021] [Indexed: 12/16/2022]
Abstract
Primary (familial/hereditary) and secondary (non-familial/hereditary) hemophagocytic lymphohistiocytosis (HLH) are hyperinflammatory and hypercytokinemic syndromes. Secondary HLH includes infection- (eg viral/bacterial/fungal/parasitic) and non-infection- (eg collagen disease or malignancy) related diseases. Viral HLH is the major type among all age groups. Secondary viral HLH and primary HLH must be differentiated carefully because primary HLH can be associated with viral infection(s), and the outcome is dismal without a timely diagnosis and hematopoietic stem cell transplantation (HSCT). Epstein-Barr virus (EBV)-related HLH (EBV-HLH) is the most common type of viral HLH in childhood. For non-EBV-HLH, appropriate treatment of viral infection, followed by immunomodulatory agent(s) such as corticosteroids, intravenous immunoglobulin or cyclosporine A, is usually successful; however, recent SARS-CoV-2-related HLH may become life-threatening. EBV-HLH may occur heterogeneously associated with the primary infection, with chronic active EBV infection or with underlying primary HLH. Although immunomodulatory agent(s) are effective in the majority of EBV-HLH cases, management differs from that of non-EBV-HLH because severe and refractory cases may require etoposide-containing HLH-1994/2004 regimens or other experimental agents. The novel agent, emapalumab (an anti-IFN-γ monoclonal antibody) can be used to treat EBV-HLH cases to avoid the risk of secondary malignancy due to etoposide. Finally, HSCT is required for refractory EBV-HLH cases and can also be curative in some other cases.
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Affiliation(s)
- Shinsaku Imashuku
- Department of Laboratory Medicine Uji‐Tokushukai Medical Center Uji Kyoto Japan
| | - Akira Morimoto
- Department of Pediatrics Jichi Medical University School of Medicine Shimotsuke, Tochigi Japan
| | - Eiichi Ishii
- Director Imabari City Hospital Imabari, Ehime Japan
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Xu XJ, Zhao FY, Tang YM. Fulminant cytokine release syndrome in a paediatric patient with refractory Epstein-Barr virus-associated haemophagocytic lymphohistiocytosis receiving nivolumab treatment. Clin Microbiol Infect 2021; 27:1710-1712. [PMID: 34425245 DOI: 10.1016/j.cmi.2021.08.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 08/09/2021] [Accepted: 08/16/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Xiao-Jun Xu
- Division/Centre of Haematology-Oncology, Children's Hospital of Zhejiang University School of Medicine, The Paediatric Leukaemia Diagnostic and Therapeutic Technology Research Centre of Zhejiang Province, National Clinical Research Centre for Child Health, #57 Zhuganxiang Road, Yan-An Street, Hangzhou 310003, China
| | - Fen-Ying Zhao
- Division/Centre of Haematology-Oncology, Children's Hospital of Zhejiang University School of Medicine, The Paediatric Leukaemia Diagnostic and Therapeutic Technology Research Centre of Zhejiang Province, National Clinical Research Centre for Child Health, #57 Zhuganxiang Road, Yan-An Street, Hangzhou 310003, China
| | - Yong-Min Tang
- Division/Centre of Haematology-Oncology, Children's Hospital of Zhejiang University School of Medicine, The Paediatric Leukaemia Diagnostic and Therapeutic Technology Research Centre of Zhejiang Province, National Clinical Research Centre for Child Health, #57 Zhuganxiang Road, Yan-An Street, Hangzhou 310003, China.
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11
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Bonheur AN, Thomas S, Soshnick SH, McGibbon E, Dupuis AP, Hull R, Slavinski S, Del Rosso PE, Weiss D, Hunt DT, McCabe ME, Dean AB, Folkerth R, Laib AM, Wong SJ. A fatal case report of antibody-dependent enhancement of dengue virus type 1 following remote Zika virus infection. BMC Infect Dis 2021; 21:749. [PMID: 34348665 PMCID: PMC8334327 DOI: 10.1186/s12879-021-06482-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Accepted: 07/27/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Dengue virus (DENV) is endemic in many parts of the world. Antibody dependent enhancement (ADE) in DENV infections occurs when a person with primary immunity is infected by a second, different DENV strain. Antibodies to Zika virus (ZIKV), which emerged in the Western Hemisphere in 2015, are cross reactive with DENV and theoretically could provoke ADE in a DENV naïve individual. CASE PRESENTATION DENV infection was suspected in a child who had recently returned from a one-month stay in the Dominican Republic. The child presented with fever, vomiting, abdominal pain, and in hypovolemic shock. Volume and pressor resuscitation were unsuccessful, and the child died less than 24 h after hospitalization. Laboratory results suggested an early acute first DENV infection since serum, plasma, and spinal fluid had DENV1 detected by polymerase chain reaction (PCR), yet the serum lacked IgG antibodies to DENV nonstructural protein 1 (NS1) of all four DENV serotypes. This acute DENV infection occurred in the presence of a remote ZIKV infection as determined by antibodies to ZIKV NS1 envelope by multiplex microsphere immunoassay and an exceptionally high plaque reduction neutralization titer to ZIKV. ZIKV IgG avidity index was high, confirming a past infection. DENV1 RNA was detected in all ten organs and tissues examined by PCR. The severe and fatal complications reported here suggest that a remote ZIKV infection may provoke an exaggerated immune response leading to hypovolemic shock when primarily infected by DENV1. CONCLUSION We report the first known patient in the United States with a rapidly progressive and fatal case of travel-associated DENV in which prior exposure to ZIKV likely played a role in triggering an ADE phenomenon. This association of prior ZIKV immunity and subsequent new dengue infection is a worrisome phenomenon and an important contribution to the body of knowledge on immunity to flaviviruses.
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Affiliation(s)
- Ashley N Bonheur
- Division of Pediatric Critical Care Medicine, The Children's Hospital at Montefiore/Albert Einstein College of Medicine, Bronx, NY, USA
| | - Sarah Thomas
- Office of the New York City Chief Medical Examiner, New York, NY, USA
| | - Sara H Soshnick
- Division of Pediatric Critical Care Medicine, The Children's Hospital at Montefiore/Albert Einstein College of Medicine, Bronx, NY, USA
| | - Emily McGibbon
- New York City Department of Health and Mental Hygiene, Queens, NY, USA
| | - Alan P Dupuis
- Wadsworth Center, New York State Department of Health, Albany, NY, USA
| | - Rene Hull
- Wadsworth Center, New York State Department of Health, Albany, NY, USA
| | - Sally Slavinski
- New York City Department of Health and Mental Hygiene, Queens, NY, USA
| | - Paula E Del Rosso
- New York City Department of Health and Mental Hygiene, Queens, NY, USA
| | - Don Weiss
- New York City Department of Health and Mental Hygiene, Queens, NY, USA.
| | - Danielle T Hunt
- Wadsworth Center, New York State Department of Health, Albany, NY, USA
| | - Megan E McCabe
- Division of Pediatric Critical Care Medicine, The Children's Hospital at Montefiore/Albert Einstein College of Medicine, Bronx, NY, USA
| | - Amy B Dean
- Wadsworth Center, New York State Department of Health, Albany, NY, USA
| | - Rebecca Folkerth
- Office of the New York City Chief Medical Examiner, New York, NY, USA
| | - Anne M Laib
- Office of the New York City Chief Medical Examiner, New York, NY, USA
| | - Susan J Wong
- Wadsworth Center, New York State Department of Health, Albany, NY, USA
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El-Sayed ZA, El-Owaidy RH, Khamis MA, Rezk AR. Screening of hemophagocytic lymphohistiocytosis in children with severe sepsis in pediatric intensive care. Sci Prog 2021; 104:368504211044042. [PMID: 34519554 PMCID: PMC10402287 DOI: 10.1177/00368504211044042] [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] [Indexed: 11/17/2022]
Abstract
BACKGROUND We sought to screen for clinical and laboratory features of hemophagocytic lymphohistiocytosis among pediatric patients with severe sepsis. METHODS We conducted a retrospective study that analyzed the clinical and laboratory data of 70 pediatric patients who died of severe sepsis. Medical records were revised for the presence of fever, splenomegaly, pancytopenia, hyperferritinemia, hypertriglyceridemia, and hypofibrinogenemia. Soluble CD25 was measured in stored samples. RESULTS Patients' ages ranged between 0.5 and 11 years with median (interquartile range) 2 (1-5). All patients had fever (≥38.5 °C) and pancytopenia, 58 (82.9%) hepatosplenomegaly, 36 (51.4%) lymphadenopathy, 37 (52.9%) had ferritin >500 ng/ml, 20 (28.6%) had fibrinogen <1.5 mg/ml, 14 (20%) had fasting triglycerides >264 mg/dl while 5 (7.1%) had soluble CD25 >2400 U/ml. Twenty-five (35.7%) patients fulfilled at least 5/6 of the hemophagocytic lymphohistiocytosis-2004 diagnostic criteria. Multivariate backward binary logistic regression analysis revealed lymphadenopathy as an independent predictor for hemophagocytic lymphohistiocytosis criteria fulfilment with odds ratio of 23.9. Fibrinogen had the best performance in discriminating hemophagocytic lymphohistiocytosis fulfilling from non-fulfilling groups (cut-off value: <1.8 mg/ml), followed by ferritin/erythrocyte sedimentation rate ratio (cut-off value: >17). CONCLUSION There is a significant clinical and laboratory overlap between hemophagocytic lymphohistiocytosis and severe sepsis, making the syndromes difficult to distinguish. The use of current hemophagocytic lymphohistiocytosis-2004 diagnostic criteria should be applied cautiously in those patients.
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Affiliation(s)
- Zeinab A El-Sayed
- Pediatric Allergy and Immunology Unit, Children’s Hospital, Ain Shams University, Egypt
| | - Rasha H El-Owaidy
- Pediatric Allergy and Immunology Unit, Children’s Hospital, Ain Shams University, Egypt
| | - Mohammed A Khamis
- Pediatric Nephrology Unit, Children’s Hospital, Ain Shams University, Egypt
| | - Ahmed R Rezk
- Pediatric Intensive Care Unit, Children’s Hospital, Ain Shams University, Egypt
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13
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Yan WL, Yang SL, Zhao FY, Xu XJ. Ruxolitinib is an alternative to etoposide for patient with hemophagocytic lymphohistiocytosis complicated by acute renal injury: A case report. J Oncol Pharm Pract 2021; 28:222-227. [PMID: 34074166 DOI: 10.1177/10781552211020821] [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] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening syndrome characterized by excessive production of inflammatory cytokines and multiple organs injury. Ruxolitinib, an oral selective JAK1/2 inhibitor, has recently shown efficacy and safety in the treatment of secondary HLH, which may be an alternative to intensive chemotherapy. CASE REPORT We report a case of a 2-year-old boy who presented to our institution with recurrent fever and acute renal failure. We made the diagnosis of Epstein-Barr virus related HLH based on the HLH-2004 protocol, and gave the treatment of ruxolitinib instead of etoposide. MANAGEMENT AND OUTCOME The patient received dexamethasone and continuous renal replacement therapy due to renal failure, but he still had fever and anuria. Given that the use of etoposide may deteriorate renal function, ruxolitinib was administered instead of etoposide. After 5 days of ruxolitinib treatment, the patient's fever was resolved and renal function also gradually recovered 14 days later. DISCUSSION Currently, dexamethasone, etoposide and cyclosporine A are the main drugs in HLH treatment. However, cytotoxic chemotherapy can temporally deteriorate organ damage and induce serious myelosuppression, which makes clinicians hesitate to implement these regimens. Ruxolitinib has shown efficacy in treating HLH without much toxicity in clinical trials. Thus, we suggest that ruxolitinib constitutes a treatment option for secondary HLH complicated by severe renal damage which may reduce toxic effects compared with intense chemotherapy.
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Affiliation(s)
- Wei-Ling Yan
- Hematology & Oncology Department, The Children's Hospital of Zhejiang University School of Medicine, Hangzhou, PR China
| | - Shi-Long Yang
- Hematology & Oncology Department, The Children's Hospital of Zhejiang University School of Medicine, Hangzhou, PR China
| | - Fen-Ying Zhao
- Hematology & Oncology Department, The Children's Hospital of Zhejiang University School of Medicine, Hangzhou, PR China
| | - Xiao-Jun Xu
- Hematology & Oncology Department, The Children's Hospital of Zhejiang University School of Medicine, Hangzhou, PR China
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