1
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Yu S, Li Q, Xiang K, Hua Y, Zhao X. Prevalence and severity of thrombocytopenia in patients with hyperferritinemia. Hematology 2023; 28:2186047. [PMID: 36971518 DOI: 10.1080/16078454.2023.2186047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/29/2023] Open
Abstract
BACKGROUND In patients with tumors, inflammation, and blood disorders, hyperferritinemia has been associated with the severity of the underlying disease and is frequently accompanied by a co-occurring low platelet count or thrombocytopenia. Despite this, no established correlation has been identified between hyperferritinemia and platelet count. In this retrospective, double-center study, we sought to describe the prevalence and severity of thrombocytopenia in patients with hyperferritinemia. STUDY AND DESIGN A total of 901 samples were enrolled in this study, all of which had significantly high ferritin levels (>2000 μg/L) between January 2019 and June 2021. We analyzed the general distribution, incidence of thrombocytopenia in patients with hyperferritinemia, and the relationship between ferritin level and platelet count. p-values < 0.05 were considered statistically significant. RESULTS The total incidence of thrombocytopenia in patients with hyperferritinemia was 64.7%. Hematological diseases were the most frequent cause of hyperferritinemia (43.1%), followed by solid tumors (29.5%) and infectious diseases (11.7%). Patients with thrombocytopenia (<150 × 109/L) had significantly higher ferritin levels than those with platelet counts exceeding 150 × 109/L, with median ferritin levels of 4011 and 3221 μg/L, respectively (P < 0.001). Additionally, the results showed that the incidence of thrombocytopenia was higher in hematological patients with chronic transfusion than in those without chronic blood transfusions (93% vs 69%). CONCLUSIONS In conclusion, our results suggest that hematological diseases are the most common cause of hyperferritinemia and that patients with chronic blood transfusions are more susceptible to thrombocytopenia. Elevated ferritin levels may act as a trigger for thrombocytopenia.
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Affiliation(s)
- Shifang Yu
- Department of Transfusion Medicine, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, People's Republic of China
| | - Qiang Li
- Department of Laboratory Medicine, The First Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, People's Republic of China
| | - Kaihua Xiang
- Department of Transfusion Medicine, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, People's Republic of China
| | - Yanjie Hua
- Department of Laboratory Medicine, Zhejiang Chinese Medical University, Hangzhou, People's Republic of China
| | - Xiaoying Zhao
- Department of Hematology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, People's Republic of China
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2
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Lau G, Dougherty SC, Friedman L, Wispelwey B. Extreme hyperferritinemia without associated
HLH
in a patient with T‐cell lymphoma. Clin Case Rep 2022; 10:e6562. [DOI: 10.1002/ccr3.6562] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 09/28/2022] [Accepted: 10/19/2022] [Indexed: 11/18/2022] Open
Affiliation(s)
- Grace Lau
- Department of Internal Medicine University of Virginia Charlottesville Virginia USA
| | - Sean C. Dougherty
- Department of Internal Medicine University of Virginia Charlottesville Virginia USA
| | - Lisa Friedman
- Department of Pathology University of Virginia Charlottesville Virginia USA
| | - Brian Wispelwey
- Department of Internal Medicine University of Virginia Charlottesville Virginia USA
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3
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Brands X, van Engelen TSR, de Vries FMC, Haak BW, Klarenbeek AM, Kanglie MMNP, van den Berk IAH, Schuurman AR, Peters-Sengers H, Otto NA, Faber DR, Lutter R, Scicluna BP, Stoker J, Prins JM, Joost Wiersinga W, van der Poll T. OUP accepted manuscript. J Infect Dis 2022; 225:2023-2032. [PMID: 35100411 PMCID: PMC9312861 DOI: 10.1093/infdis/jiac013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Accepted: 01/27/2022] [Indexed: 11/21/2022] Open
Abstract
Background Strongly elevated ferritin levels have been proposed to reflect systemic hyperinflammation in patients admitted to the intensive care unit. Knowledge of the incidence and pathophysiological implications of hyperferritinemia in patients with acute infection admitted to a non–intensive care setting is limited. Methods We determined the association between hyperferritinemia, defined by 2 cutoff values (500 and 250 ng/mL), and aberrations in key host response mechanisms among patients with community-acquired pneumonia (CAP) on admission to a general hospital ward (clinicaltrials.gov NCT02928367; trialregister.nl NTR6163). Results Plasma ferritin levels were higher in patients with CAP (n = 174; median [interquartile ranges], 259.5 [123.1–518.3] ng/mL) than in age- and sex-matched controls without infection (n = 50; 102.8 [53.5–185.7] ng/mL); P < .001); they were ≥500 ng/mL in 46 patients (26%) and ≥250 ng/mL in 90 (52%). Measurements of 26 biomarkers reflective of distinct pathophysiological domains showed that hyperferritinemia was associated with enhanced systemic inflammation, neutrophil activation, cytokine release, endothelial cell activation and dysfunction, and activation of the coagulation system. Results were robust across different cutoff values. Conclusions Hyperferritinemia identifies patients with CAP with a broad deregulation of various host response mechanisms implicated in the pathogenesis of sepsis. This could inform future therapeutic strategies targeting subgroups within the CAP population.
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Affiliation(s)
| | - Tjitske S R van Engelen
- Correspondence: Tjitske S. R. van Engelen, Center for Experimental and Molecular Medicine, Amsterdam University Medical Centers, Location AMC, Room G2-105, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands ()
| | - Floris M C de Vries
- Center for Experimental and Molecular Medicine, Amsterdam University Medical Centers, Location AMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Bastiaan W Haak
- Center for Experimental and Molecular Medicine, Amsterdam University Medical Centers, Location AMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Augustijn M Klarenbeek
- Center for Experimental and Molecular Medicine, Amsterdam University Medical Centers, Location AMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Maadrika M N P Kanglie
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, Location AMC, University of Amsterdam, the Netherlands
| | - Inge A H van den Berk
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, Location AMC, University of Amsterdam, the Netherlands
| | - Alex R Schuurman
- Center for Experimental and Molecular Medicine, Amsterdam University Medical Centers, Location AMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Hessel Peters-Sengers
- Center for Experimental and Molecular Medicine, Amsterdam University Medical Centers, Location AMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Natasja A Otto
- Center for Experimental and Molecular Medicine, Amsterdam University Medical Centers, Location AMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Daniël R Faber
- Department of Internal Medicine, BovenIJ Hospital, Amsterdam, the Netherlands
| | - René Lutter
- Respiratory Medicine and Experimental Immunology, Amsterdam University Medical Centers, Location AMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Brendon P Scicluna
- Center for Experimental and Molecular Medicine, Amsterdam University Medical Centers, Location AMC, University of Amsterdam, Amsterdam, the Netherlands
- Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Amsterdam University Medical Centers, Location AMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Jaap Stoker
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, Location AMC, University of Amsterdam, the Netherlands
| | - Jan M Prins
- Department of Internal Medicine, Division of Infectious Diseases, Amsterdam University Medical Centers, Location AMC, University of Amsterdam, Amsterdam, the Netherlands
| | - W Joost Wiersinga
- Center for Experimental and Molecular Medicine, Amsterdam University Medical Centers, Location AMC, University of Amsterdam, Amsterdam, the Netherlands
- Department of Internal Medicine, Division of Infectious Diseases, Amsterdam University Medical Centers, Location AMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Tom van der Poll
- Center for Experimental and Molecular Medicine, Amsterdam University Medical Centers, Location AMC, University of Amsterdam, Amsterdam, the Netherlands
- Department of Internal Medicine, Division of Infectious Diseases, Amsterdam University Medical Centers, Location AMC, University of Amsterdam, Amsterdam, the Netherlands
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4
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Marín-García G, María-Rios J, Rodriguez-Cintrón W. Hemophagocytic Lymphohistiocytosis: Early Treatment Leading to an Excellent Outcome. Fed Pract 2021; 38:e64-e66. [PMID: 34733099 DOI: 10.12788/fp.0162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
HLH is a rare and deadly disease increasingly more present in adults, but following treatment protocol may yield favorable results.
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Affiliation(s)
- Gerald Marín-García
- is an Emergency Medicine-Critical Care Attending Physician, and is Chairperson Pulmonary-Critical Care Department, Pulmonary-Critical Care Fellowship Program Director, both at Veterans Affairs Caribbean Healthcare System in San Juan, Puerto Rico. is Critical Care Fellow at AdventHealth in Orlando, Florida
| | - José María-Rios
- is an Emergency Medicine-Critical Care Attending Physician, and is Chairperson Pulmonary-Critical Care Department, Pulmonary-Critical Care Fellowship Program Director, both at Veterans Affairs Caribbean Healthcare System in San Juan, Puerto Rico. is Critical Care Fellow at AdventHealth in Orlando, Florida
| | - William Rodriguez-Cintrón
- is an Emergency Medicine-Critical Care Attending Physician, and is Chairperson Pulmonary-Critical Care Department, Pulmonary-Critical Care Fellowship Program Director, both at Veterans Affairs Caribbean Healthcare System in San Juan, Puerto Rico. is Critical Care Fellow at AdventHealth in Orlando, Florida
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5
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Zhang Z, Liu J, Wang J, Wang Y. Hemophagocytic Lymphohistiocytosis Associated to Klebsiella pneumoniae Infection: A Case Report. Front Immunol 2021; 12:684805. [PMID: 34335586 PMCID: PMC8318975 DOI: 10.3389/fimmu.2021.684805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 06/09/2021] [Indexed: 12/02/2022] Open
Abstract
This is a case analysis of a 73-year-old Chinese man admitted to the cardiac intensive care unit (ICU) with fever and general pain. Based on the patient’s initial condition of multi-organ function impairment and increased serum ferritin, and after a series of examinations, the patient was diagnosed with Klebsiella pneumonia-induced hemophagocytic lymphohistiocytosis (HLH). Meropenem and dexamethasone were used in combination to treat the patient, and the results were very successful. In this case report, it is further suggested that Klebsiella pneumoniae is a possible trigger of HLH, and a combination of antibiotics and corticosteroids can be effective in treating HLH. It is also recommended that doctors in the ICU of each department should pay attention to the role of hyperferritinemia in the diagnosis of HLH, and ICU admission teams should include ferritin in their monitoring.
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Affiliation(s)
- Zhiyu Zhang
- Department of Cardiology, The First Hospital of Jilin University, Changchun, China
| | - Junqian Liu
- Department of Cardiology, The First Hospital of Jilin University, Changchun, China
| | - Jingyue Wang
- Department of Cardiology, The First Hospital of Jilin University, Changchun, China
| | - Yushi Wang
- Department of Cardiology, The First Hospital of Jilin University, Changchun, China
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6
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Israel A, Bornstein G, Gilad L, Shechtman L, Furie N, Ben-Zvi I, Grossman C. Clinical and prognostic significance of elevated ferritin levels in hospitalised adults. Postgrad Med J 2021; 98:622-625. [PMID: 33846221 DOI: 10.1136/postgradmedj-2021-139832] [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: 01/28/2021] [Revised: 03/21/2021] [Accepted: 03/25/2021] [Indexed: 11/03/2022]
Abstract
PURPOSE OF THE STUDY Elevated ferritin levels are associated with a variety of infectious, malignant and inflammatory diseases. We aimed to investigate the prognostic value of markedly elevated ferritin levels in hospitalised patients with various medical conditions. STUDY DESIGN Retrospective analysis of patients with a ferritin level higher than 2000 ng/mL hospitalised in Sheba Medical Center between 1 January 2007 and 31 December 2015. Medical conditions of these patients were recorded. In-hospital, 30-day and 1-year mortality rates were evaluated according to ferritin ranges and clinical categories. RESULTS The study included 722 patients (63.4% men) with a mean age of 63.9±16.7 years. The most common clinical conditions associated with markedly elevated ferritin were infectious diseases and malignancies. The highest mean ferritin levels were associated with rheumatological/inflammatory conditions (16 241.3 ng/dL), particularly in patients with macrophage activation syndrome (MAS) (96 615.5 ng/dL). In-hospital, 30-day and 1-year mortality rates were 32.3%, 46.7% and 70.8%, respectively. The highest in-hospital, 30-day and 1-year mortality rates were observed among patients with solid malignancies (40.1%, 64.7% and 90.3%, respectively), whereas the lowest rates were found among patients with rheumatological/inflammatory conditions, including MAS (21.4%, 38.1% and 45.2%, respectively). Ferritin levels were not associated with mortality. CONCLUSIONS In hospitalised patients, ferritin levels higher than 2000 ng/mL are mainly associated with infectious and malignant diseases but do not predict mortality.
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Affiliation(s)
- Ariel Israel
- Department of Family Medicine, Clalit Health Services, Tel Aviv, Israel
| | - Gil Bornstein
- Department of Internal Medicine B, Tel Aviv Sourasky Medical Center, affiliated to Sackler Faculty of Medicine, Tel Aviv, Israel
| | - Lee Gilad
- Department of Internal Medicine F, Sheba Medical Center at Tel Hashomer, affilated to Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Liran Shechtman
- Department of Internal Medicine F, Sheba Medical Center at Tel Hashomer, affilated to Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Nadav Furie
- Department of Internal Medicine F, Sheba Medical Center at Tel Hashomer, affilated to Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Ilan Ben-Zvi
- Department of Internal Medicine F, Sheba Medical Center at Tel Hashomer, affilated to Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Chagai Grossman
- Department of Internal Medicine F, Sheba Medical Center at Tel Hashomer, affilated to Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
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7
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Sarangi R, Pathak M, Padhi S, Mahapatra S. Ferritin in hemophagocytic lymphohistiocytosis (HLH): current concepts and controversies. Clin Chim Acta 2020; 510:408-415. [PMID: 32745577 DOI: 10.1016/j.cca.2020.07.053] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2020] [Revised: 07/26/2020] [Accepted: 07/27/2020] [Indexed: 12/11/2022]
Affiliation(s)
- RajLaxmi Sarangi
- Department of Biochemistry, Kalinga Institute of Medical Sciences, KIIT University, Bhubaneswar, Odisha, India
| | - Mona Pathak
- Department of Biostatistics, Kalinga Institute of Medical Sciences, KIIT University, Bhubaneswar, Odisha, India
| | - Somanath Padhi
- Department of Pathology and Laboratory Medicine, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India.
| | - Srikrushna Mahapatra
- Department of Biochemistry, Kalinga Institute of Medical Sciences, KIIT University, Bhubaneswar, Odisha, India
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8
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Perricone C, Bartoloni E, Bursi R, Cafaro G, Guidelli GM, Shoenfeld Y, Gerli R. COVID-19 as part of the hyperferritinemic syndromes: the role of iron depletion therapy. Immunol Res 2020; 68:213-224. [PMID: 32681497 PMCID: PMC7366458 DOI: 10.1007/s12026-020-09145-5] [Citation(s) in RCA: 122] [Impact Index Per Article: 30.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
SARS-CoV-2 infection is characterized by a protean clinical picture that can range from asymptomatic patients to life-threatening conditions. Severe COVID-19 patients often display a severe pulmonary involvement and develop neutrophilia, lymphopenia, and strikingly elevated levels of IL-6. There is an over-exuberant cytokine release with hyperferritinemia leading to the idea that COVID-19 is part of the hyperferritinemic syndrome spectrum. Indeed, very high levels of ferritin can occur in other diseases including hemophagocytic lymphohistiocytosis, macrophage activation syndrome, adult-onset Still's disease, catastrophic antiphospholipid syndrome and septic shock. Numerous studies have demonstrated the immunomodulatory effects of ferritin and its association with mortality and sustained inflammatory process. High levels of free iron are harmful in tissues, especially through the redox damage that can lead to fibrosis. Iron chelation represents a pillar in the treatment of iron overload. In addition, it was proven to have an anti-viral and anti-fibrotic activity. Herein, we analyse the pathogenic role of ferritin and iron during SARS-CoV-2 infection and propose iron depletion therapy as a novel therapeutic approach in the COVID-19 pandemic.
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Affiliation(s)
- Carlo Perricone
- Rheumatology, Department of Medicine, University of Perugia, Piazzale Giorgio Menghini, 1, 06129, Perugia, Italy
| | - Elena Bartoloni
- Rheumatology, Department of Medicine, University of Perugia, Piazzale Giorgio Menghini, 1, 06129, Perugia, Italy
| | - Roberto Bursi
- Rheumatology, Department of Medicine, University of Perugia, Piazzale Giorgio Menghini, 1, 06129, Perugia, Italy
| | - Giacomo Cafaro
- Rheumatology, Department of Medicine, University of Perugia, Piazzale Giorgio Menghini, 1, 06129, Perugia, Italy
| | | | - Yehuda Shoenfeld
- Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel-Aviv University, 5265601, Tel-Hashomer, Israel
- The Mosaic of Autoimmunity Project, Saint Petersburg University, Saint Petersburg, Russia
- Ministry of Health of the Russian Federation, Sechenov First Moscow State Medical University, Moscow, Russia
| | - Roberto Gerli
- Rheumatology, Department of Medicine, University of Perugia, Piazzale Giorgio Menghini, 1, 06129, Perugia, Italy.
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9
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Giemza-Stokłosa J, Islam MA, Kotyla PJ. Hyperferritinaemia: An Iron Sword of Autoimmunity. Curr Pharm Des 2020; 25:2909-2918. [PMID: 31686632 DOI: 10.2174/1381612825666190709202804] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2019] [Accepted: 06/30/2019] [Indexed: 01/01/2023]
Abstract
BACKGROUND Ferritin is a molecule that plays many roles being the storage for iron, signalling molecule, and modulator of the immune response. METHODS Different electronic databases were searched in a non-systematic way to find out the literature of interest. RESULTS The level of ferritin rises in many inflammatory conditions including autoimmune disorders. However, in four inflammatory diseases (i.e., adult-onset Still's diseases, macrophage activation syndrome, catastrophic antiphospholipid syndrome, and sepsis), high levels of ferritin are observed suggesting it as a remarkable biomarker and pathological involvement in these diseases. Acting as an acute phase reactant, ferritin is also involved in the cytokine-associated modulator of the immune response as well as a regulator of cytokine synthesis and release which are responsible for the inflammatory storm. CONCLUSION This review article presents updated information on the role of ferritin in inflammatory and autoimmune diseases with an emphasis on hyperferritinaemic syndrome.
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Affiliation(s)
| | - Md Asiful Islam
- Department of Haematology, School of Medical Sciences, Universiti Sains Malaysia, 16150 Kubang Kerian, Kelantan, Malaysia
| | - Przemysław J Kotyla
- Department of Internal Medicine, Rheumatology and Clinical Immunology, Faculty in Katowice, Medical University of Silesia, 40-635 Katowice, Poland
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10
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Affiliation(s)
- Stefano Skurzak
- Division of Anesthesia and Resuscitation 2, Città della Salute e della Scienza, Turin, Italy -
| | - Elena Sieni
- Department of Pediatric Oncologic Hematology, A. Meyer University Hospital, Florence, Italy
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11
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Hyzy RC, McSparron J. Hemophagocytic Lymphohistiocytosis and Other Culture Negative Sepsis-Like Syndromes in the ICU. EVIDENCE-BASED CRITICAL CARE 2020. [PMCID: PMC7120049 DOI: 10.1007/978-3-030-26710-0_79] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
There are many sepsis-like inflammatory syndromes that may be encountered by critical care practitioners. Clinically, these syndromes may imitate sepsis and are often identified after an extensive, but unrevealing evaluation for infection. In some instances, these syndromes are anticipated complications of advanced therapies for malignancy. It is vitally important to identify these disorders and treat them with specific chemotherapeutic or immunomodulating therapies. This chapter will focus on hemophagocytic lympho-histiocytosis (HLH), a rare disorder of pathologic immune system activation that presents as a sepsis-like illness in the critically ill. While treatment of HLH with chemotherapy and immunosuppression should be guided by an expert hematologist, the diagnosis is often made by the critical care medicine practitioner. We present a case illustrating the challenges of defining this syndrome in a patient with recurrent critical illness, and review the evidence underlying diagnostic and prognostic criteria for this protean syndrome. We also review several of the more common sepsis-like inflammatory syndromes that are encountered in the critical care unit along with their specific treatments.
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Affiliation(s)
- Robert C. Hyzy
- Division of Pulmonary and Critical Care, University of Michigan, Ann Arbor, MI USA
| | - Jakob McSparron
- Division of Pulmonary and Critical Care, University of Michigan, Ann Arbor, MI USA
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12
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Wurschi GW, Mentzel HJ, Herrmann KH, Krumbein I, Beck JF, Reichenbach JR, Kentouche K. MRI as an alternative to serum ferritin for diagnosis of iron overload in children in the context of immune response after stem cell transplantation. Pediatr Transplant 2019; 23:e13583. [PMID: 31535426 DOI: 10.1111/petr.13583] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Revised: 06/18/2019] [Accepted: 08/07/2019] [Indexed: 12/30/2022]
Abstract
Multiple blood cell transfusions may cause iron overload or even liver fibrosis, requiring early diagnosis and intervention. SF is the standard for estimating iron levels in the body, but it also increases with inflammation. We hypothesized that T2 * magnetic resonance (MR) relaxometry is a more accurate alternative for follow-up in pediatric patients before and after allogenic SCT. Twenty-three children (mean age 10.2 years, 10 female, 13 male) were evaluated prospectively before SCT as well as at least 1 year after SCT with T2 * relaxometry on a 1.5 T MR-scanner to estimate liver iron concentrations from the T2 * values ("MR-Fe"). The results were compared with SF, while also considering CRP, and correlated with the number of transfusions. Overall, 24.3 transfusions were administered in average, mainly within 100 days of SCT (mean 10.5 units). Both MR-Fe and SF increased after SCT and decreased in the absence of new transfusions 1 year later without chelate therapy. This suggests regeneration of LP and iron loss, although the original states were not reached. Additionally, simultaneous peaks of CRP and SF were observed directly after SCT. MR-Fe did neither reveal these peaks nor was it associated with CRP (P = .39). We postulate that these early CRP and SF peaks after SCT are probably related to inflammatory reactions and not to iron overload. Thus, SF is not reliable for iron overload diagnosis after SCT in every condition. Beside this interaction, SF and MR-Fe revealed similar accuracy. MRI, however, has practical and economical disadvantages in routine estimation of iron.
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Affiliation(s)
- Georg W Wurschi
- Section of Pediatric Radiology, Institute of Diagnostic and Interventional Radiology, University Hospital Jena, Friedrich Schiller University, Jena, Germany
| | - Hans-Joachim Mentzel
- Section of Pediatric Radiology, Institute of Diagnostic and Interventional Radiology, University Hospital Jena, Friedrich Schiller University, Jena, Germany
| | - Karl-Heinz Herrmann
- Medical Physics Group, Institute of Diagnostic and Interventional Radiology, University Hospital Jena, Friedrich Schiller University, Jena, Germany
| | - Ines Krumbein
- Medical Physics Group, Institute of Diagnostic and Interventional Radiology, University Hospital Jena, Friedrich Schiller University, Jena, Germany
| | - James F Beck
- Section of Pediatric Hematology and Oncology, Department of Pediatrics, University Hospital Jena, Friedrich Schiller University, Jena, Germany
| | - Juergen R Reichenbach
- Medical Physics Group, Institute of Diagnostic and Interventional Radiology, University Hospital Jena, Friedrich Schiller University, Jena, Germany
| | - Karim Kentouche
- Section of Pediatric Hematology and Oncology, Department of Pediatrics, University Hospital Jena, Friedrich Schiller University, Jena, Germany
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13
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Macrophage activation syndrome complicating rheumatic diseases in adults: case-based review. Rheumatol Int 2019; 40:663-669. [PMID: 31367795 DOI: 10.1007/s00296-019-04393-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Accepted: 07/22/2019] [Indexed: 12/17/2022]
Abstract
Macrophage activation syndrome (MAS) is a life-threatening complication of rheumatologic diseases. Data regarding the clinical course, management and outcome of adults with MAS is limited. Therefore, we aimed to describe the clinical features, treatment and outcome of adult patients with MAS, and review the literature for previous cohorts. We retrospectively reviewed patients with MAS complicating rheumatologic diseases between the years 2007 and 2017. Through Pubmed, Medline and Scopus literature search we identified previous cases of adult patients with MAS. We identified 7 patients with MAS complicating rheumatologic diseases (5 females and 2 males). The median age of diagnosis was 32 (range 26-57) years. The median follow-up was 30 months (range 6.95-36.5) months. The underlying rheumatologic disease was adult onset Still's disease (AOSD) in 3 patients, systemic juvenile idiopathic arthritis (sJIA) in 2 patients, systemic lupus erythematosus (SLE) in 1 patient, and systemic vasculitis in 1 patient. Four patients developed MAS concurrently with the clinical development of the rheumatologic disease. All the patients were treated with systemic corticosteroids. Five patients were treated with cyclosporine A, one of which received combination therapy with anakinra, and one received tocilizumab. Two patients deceased during the hospitalization. We identified 92 patients from literature cohorts, 73 (79%) of them with AOSD. MAS developed concurrently with the underlying rheumatologic disease in 25 (27%) patients, and 30 (33%) patients deceased. Our cohort and previous cohorts demostrate that MAS often presents concurrently with the underlying rheumatologic disease and is associated with a high mortality rate. Further larger prospective studies are needed to determine the optimal management of MAS.
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14
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Evaluation of liver tissue by ultrasound elastography and clinical parameters in children with multiple blood cell transfusions. Pediatr Radiol 2019; 49:897-905. [PMID: 30927037 DOI: 10.1007/s00247-019-04382-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Revised: 01/23/2019] [Accepted: 03/08/2019] [Indexed: 10/27/2022]
Abstract
BACKGROUND Children receiving multiple blood cell transfusions are prone to iron overload and successive tissue damage in liver parenchyma, making noninvasive screening options desirable. Ultrasound (US) elastography using acoustic radiation force impulse (ARFI) imaging enables evaluation of liver parenchyma stiffness, and MRI allows for quantification of liver iron concentration. OBJECTIVE The objective was to correlate US elastography with MRI in children who had undergone bone marrow transplantation and to evaluate the modification of liver tissue with US in combination with clinical parameters at follow-up. MATERIALS AND METHODS ARFI, T2*-weighted MRI and a clinical score (HepScore, based on parameters of liver function) were performed in 45 patients (24 male; mean age 9.7 years) before and 100 days and 365 days after transplantation. All received multiple blood transfusions (mean number 22.2 up until 1 year after transplantation). We correlated US findings and HepScore with MRI findings. RESULTS We observed signs of iron accumulation in 29/45 (64.4%) patients on MRI (T2*<10 ms) and 15/45 (33.3%) showed increased tissue stiffness (ARFI>5.5 kPa). Correlation of elastography and MRI was not significant (P=0.57; n=51 matched measurements). Comparing US elastography with HepScore in receiver operating characteristic (ROC) curve analysis indicated a cut-off for affected parenchyma if HepScore was >5 points (sensitivity 67%, specificity 68%). Simultaneous increases of both indicated tissue alteration. CONCLUSION Combining US and HepScore enabled detection of liver tissue alteration through iron overload, but we found no direct significant effect of estimated iron from MRI on ARFI imaging.
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Kapoor S, Morgan CK, Siddique MA, Guntupalli KK. Intensive care unit complications and outcomes of adult patients with hemophagocytic lymphohistiocytosis: A retrospective study of 16 cases. World J Crit Care Med 2018; 7:73-83. [PMID: 30596029 PMCID: PMC6305525 DOI: 10.5492/wjccm.v7.i6.73] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2018] [Revised: 10/21/2018] [Accepted: 11/07/2018] [Indexed: 02/06/2023] Open
Abstract
AIM To study the management, complications and outcomes of adult patients admitted with hemophagocytic lymphohistiocytosis (HLH) in the intensive care unit (ICU).
METHODS We performed a retrospective observational study of adult patients with the diagnosis of “HLH” admitted to the two academic medical ICUs of Baylor College of Medicine between 01/01/2013 to 06/30/2017. HLH was diagnosed using the HLH-2004 criteria proposed by the Histiocyte Society.
RESULTS Sixteen adult cases of HLH were admitted to the medical ICUs over 4 years. Median age of presentation was 49 years and 10 (63%) were males. Median Sequential Organ Failure Assessment (SOFA) score at the time of ICU admission was 10. Median ICU length of stay (LOS) was 11.5 d and median hospital LOS was 29 d. Septic shock and acute respiratory failure accounted for majority of diagnoses necessitating ICU admission. Septic shock was the most common ICU complication seen in (88%) patients, followed by acute kidney injury (81%) and acute respiratory failure requiring mechanical ventilation (75%). Nine patients (56%) developed disseminated intravascular coagulation and eight (50%) had acute liver failure. 10 episodes of clinically significant bleeding were observed. Multi system organ failure was the most common cause of death seen in 12 (75%) patients. The 30 d mortality was 37% (6 cases) and 90 d mortality was 81% (13 cases). There was no difference in mortality based on age (above or less than 50 years), SOFA score on ICU admission (more than or less than 10), immunosuppression, time to diagnose HLH or direct ICU admission versus floor transfer.
CONCLUSION HLH is a devastating disease associated with poor outcomes in ICU. Intensivists need to have a high degree of clinical suspicion for HLH in patients with septic shock/multi system organ failure and progressive bi/pancytopenia who are not responding to standard management in ICU.
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Affiliation(s)
- Sumit Kapoor
- Department of Critical Care Medicine, Montefiore Medical Center, Bronx, NY 10467, United States
| | - Christopher K Morgan
- Department of Pulmonary, Critical Care and Sleep, Baylor College of Medicine, Houston, TX 77030, United States
| | - Muhammad Asim Siddique
- Department of Pulmonary, Critical Care and Sleep, Baylor College of Medicine, Houston, TX 77030, United States
| | - Kalpalatha K Guntupalli
- Department of Pulmonary, Critical Care and Sleep, Baylor College of Medicine, Houston, TX 77030, United States
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Lange AV, Kazi S, Chen W, Barnes A. Fatal case of macrophage activation syndrome (MAS) in a patient with dermatomyositis and cytomegalovirus (CMV) viraemia. BMJ Case Rep 2018; 2018:bcr-2018-225231. [PMID: 30061130 PMCID: PMC6067131 DOI: 10.1136/bcr-2018-225231] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/09/2018] [Indexed: 12/17/2022] Open
Abstract
We describe a case of an adult with dermatomyositis (DM) who presents with a rash, high fevers, tachycardia and hypotension, initially concerning for an infectious aetiology or a DM flare. She was found to have cytomegalovirus viraemia which improved after starting valganciclovir. After extensive workup and lack of improvement with broad-spectrum antimicrobial therapy, intravenous immunoglobulin and steroids, the patient was diagnosed with macrophage activation syndrome after bone marrow biopsy and levels of soluble CD25 (soluble interleukin (IL)-2 receptor) and IL2 were obtained. Unfortunately, despite therapy with dexamethasone, anakinra and etoposide, the patient decompensated and the patient's family opted for comfort care. The patient subsequently expired in the intensive care unit.
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Affiliation(s)
| | - Salahuddin Kazi
- Internal Medicine, University of Texas Southwestern, Dallas, Texas, USA
| | - Weina Chen
- Pathology, Univ Texas SW Med Ctr Dallas, Dallas, Texas, USA
| | - Arti Barnes
- Infectious Diseases, University of Texas Southwestern, Dallas, Texas, USA
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