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Vignesh P, Loganathan SK, Sudhakar M, Chaudhary H, Rawat A, Sharma M, Shekar A, Vaiphei K, Kumar N, Singh Sachdeva MU, Jindal AK, Suri D, Gupta A, Ray P, Imai K, Ohara O, Nonoyama S, Lau YL, Singh S. Hemophagocytic Lymphohistiocytosis in Children with Chronic Granulomatous Disease-Single-Center Experience from North India. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 9:771-782.e3. [PMID: 33259975 DOI: 10.1016/j.jaip.2020.11.041] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Revised: 11/07/2020] [Accepted: 11/16/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Chronic granulomatous disease (CGD) is an inherited defect in components of the nicotinamide adenine dinucleotide phosphate oxidase complex that results in potential life-threatening infective and noninfective complications. Hemophagocytic lymphohistiocytosis (HLH) is an unusual but important inflammatory complication of CGD. Optimal management strategies have not yet been identified in children with CGD who develop HLH. OBJECTIVE To analyze clinical and laboratory features of HLH in CGD from a tertiary-care center in North India. METHODS A retrospective review of medical records of children with CGD diagnosed in the last 20 years was performed. Clinical and laboratory features of children with CGD who developed HLH were analyzed. RESULTS Of 80 patients diagnosed with CGD, 5 (6.25%) had evidence of HLH. All 5 were males; 4 had X-linked CGD and 1 had autosomal recessive CGD (NCF2 defect). Two children with CGD had HLH as the predominant presenting manifestation mimicking the clinical presentation of congenital HLH. Infectious triggers identified were bloodstream infections (n = 3) (Candida albicans, Burkholderia cenocepacia, Francisella noatuensis), pneumonia (n = 4), and splenic abscess (n = 1). We document the first human infection with a fish pathogen, F. noatuensis, in a child with X-linked CGD. Although mortality was seen in 3 children who received only intravenous (IV) immunoglobulin therapy, the other 2 who received IV methylprednisolone pulse therapy survived. CONCLUSION HLH can be a presenting manifestation of CGD, and workup for CGD must be considered in children with HLH. Early recognition with optimal management of both infectious trigger and HLH is very important to prevent mortality.
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Affiliation(s)
- Pandiarajan Vignesh
- Pediatric Allergy and Immunology Unit, Advanced Pediatrics Centre, Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Sathish Kumar Loganathan
- Pediatric Allergy and Immunology Unit, Advanced Pediatrics Centre, Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Murugan Sudhakar
- Pediatric Allergy and Immunology Unit, Advanced Pediatrics Centre, Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Himanshi Chaudhary
- Pediatric Allergy and Immunology Unit, Advanced Pediatrics Centre, Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Amit Rawat
- Pediatric Allergy and Immunology Unit, Advanced Pediatrics Centre, Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India.
| | - Megha Sharma
- Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Aravind Shekar
- Department of Histopathology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Kim Vaiphei
- Department of Histopathology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Narender Kumar
- Department of Hematology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Man-Updesh Singh Sachdeva
- Department of Hematology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ankur Kumar Jindal
- Pediatric Allergy and Immunology Unit, Advanced Pediatrics Centre, Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Deepti Suri
- Pediatric Allergy and Immunology Unit, Advanced Pediatrics Centre, Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Anju Gupta
- Pediatric Allergy and Immunology Unit, Advanced Pediatrics Centre, Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Pallab Ray
- Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Kohsuke Imai
- Department of Pediatrics, National Defense Medical College, Tokorozawa, Saitama, Japan
| | - Osamu Ohara
- Department of Applied Genomics, Kazusa DNA Research Institute, Kisarazu, Chiba, Japan
| | - Shigeaki Nonoyama
- Department of Pediatrics, National Defense Medical College, Tokorozawa, Saitama, Japan
| | - Yu Lung Lau
- Department of Pediatrics and Adolescent Medicine, Queen Mary Hospital, LKS Faculty of Medicine, the University of Hong Kong, Hong Kong, Hong Kong Special Administrative Region, China
| | - Surjit Singh
- Pediatric Allergy and Immunology Unit, Advanced Pediatrics Centre, Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Bode SF, Ammann S, Al-Herz W, Bataneant M, Dvorak CC, Gehring S, Gennery A, Gilmour KC, Gonzalez-Granado LI, Groß-Wieltsch U, Ifversen M, Lingman-Framme J, Matthes-Martin S, Mesters R, Meyts I, van Montfrans JM, Pachlopnik Schmid J, Pai SY, Soler-Palacin P, Schuermann U, Schuster V, Seidel MG, Speckmann C, Stepensky P, Sykora KW, Tesi B, Vraetz T, Waruiru C, Bryceson YT, Moshous D, Lehmberg K, Jordan MB, Ehl S. The syndrome of hemophagocytic lymphohistiocytosis in primary immunodeficiencies: implications for differential diagnosis and pathogenesis. Haematologica 2015; 100:978-88. [PMID: 26022711 DOI: 10.3324/haematol.2014.121608] [Citation(s) in RCA: 119] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2015] [Accepted: 05/06/2015] [Indexed: 12/21/2022] Open
Abstract
Hemophagocytic lymphohistiocytosis is a hyperinflammatory syndrome defined by clinical and laboratory criteria. Current criteria were created to identify patients with familial hemophagocytic lmyphohistiocytosis in immediate need of immunosuppressive therapy. However, these criteria also identify patients with infection-associated hemophagocytic inflammatory states lacking genetic defects typically predisposing to hemophagocytic lymphohistiocytosis. These patients include those with primary immunodeficiencies, in whom the pathogenesis of the inflammatory syndrome may be distinctive and aggressive immunosuppression is contraindicated. To better characterize hemophagocytic inflammation associated with immunodeficiencies, we combined an international survey with a literature search and identified 63 patients with primary immunodeficiencies other than cytotoxicity defects or X-linked lymphoproliferative disorders, presenting with conditions fulfilling current criteria for hemophagocytic lymphohistiocytosis. Twelve patients had severe combined immunodeficiency with <100/μL T cells, 18 had partial T-cell deficiencies; episodes of hemophagocytic lymphohistiocytosis were mostly associated with viral infections. Twenty-two patients had chronic granulomatous disease with hemophagocytic episodes mainly associated with bacterial infections. Compared to patients with cytotoxicity defects, patients with T-cell deficiencies had lower levels of soluble CD25 and higher ferritin concentrations. Other criteria for hemophagocytoc lymphohistiocytosis were not discriminative. Thus: (i) a hemophagocytic inflammatory syndrome fulfilling criteria for hemophagocytic lymphohistiocytosis can be the initial manifestation of primary immunodeficiencies; (ii) this syndrome can develop despite severe deficiency of T and NK cells, implying that the pathophysiology is distinct and not appropriately described as "lympho"-histiocytosis in these patients; and (iii) current criteria for hemophagocytoc lymphohistiocytosis are insufficient to differentiate hemophagocytic inflammatory syndromes with different pathogeneses. This is important because of implications for therapy, in particular for protocols targeting T cells.
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Affiliation(s)
- Sebastian Fn Bode
- Center of Chronic Immunodeficiency, University Medical Center Freiburg, Germany Center for Pediatrics and Adolescent Medicine, University Medical Center Freiburg, Germany
| | - Sandra Ammann
- Center of Chronic Immunodeficiency, University Medical Center Freiburg, Germany Faculty of Biology, University of Freiburg, Germany
| | - Waleed Al-Herz
- Department of Pediatrics, Faculty of Medicine, Kuwait University, Safat, Kuwait
| | - Mihaela Bataneant
- Discipline of Pediatrics III, Victor Babes University of Medicine and Pharmacy Timisoara, Romania
| | - Christopher C Dvorak
- Pediatric Allergy, Immunology and Blood and Marrow Transplant Division, UCSF, Benioff Children's Hospital, San Francisco, California, USA
| | - Stephan Gehring
- Center for Pediatrics and Adolescent Medicine, Mainz, Germany
| | - Andrew Gennery
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Kimberly C Gilmour
- Camelia Botnar Laboratories, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Luis I Gonzalez-Granado
- Immunodeficiencies Unit, Hematology & Oncology Unit, Pediatrics, Hospital 12 Octubre, Madrid, Spain
| | - Ute Groß-Wieltsch
- Pediatric Hematology, Oncology and Immunology, Olga Hospital, Stuttgart, Germany
| | - Marianne Ifversen
- Department of Pediatrics, Copenhagen University Hospital, Rigshospitalet, Denmark
| | | | | | - Rolf Mesters
- Department of Medicine/Hematology and Oncology, University Hospital Muenster, Germany
| | - Isabelle Meyts
- Department of Pediatrics, Department of Micriobiology and Immunology, University Hospitals Leuven, Katholieke Universiteit Leuven, Belgium
| | - Joris M van Montfrans
- Department of Pediatric Immunology, Wilhelmina Children's, Hospital/University Medical Centre Utrecht, The Netherlands
| | - Jana Pachlopnik Schmid
- Jeffrey Modell Diagnostic Center for Primary Immunodeficiencies, University Children's Hospital Zurich, Switzerland
| | - Sung-Yun Pai
- Division of Hematology-Oncology, Boston Children's Hospital and Department of Pediatric Oncology, Dana-Farber Children's Hospital, Boston, Massachusetts, USA
| | - Pere Soler-Palacin
- Pediatric Infectious Diseases and Immunodeficiencies Unit. Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Spain
| | - Uta Schuermann
- Children's Hospital of Datteln, University of Witten-Herdecke, Datteln, Germany
| | - Volker Schuster
- Hospital for Children and Adolescents, University of Leipzig, Germany
| | - Markus G Seidel
- Pediatric Hematology-Oncology, Medical University of Graz, Austria
| | - Carsten Speckmann
- Center of Chronic Immunodeficiency, University Medical Center Freiburg, Germany Center for Pediatrics and Adolescent Medicine, University Medical Center Freiburg, Germany
| | - Polina Stepensky
- Pediatric Hematology-Oncology and Bone Marrow Transplantation, Hadassah Hebrew University Hospital, Jerusalem, Israel
| | | | - Bianca Tesi
- Childhood Cancer Research Unit, Department of Women's and Children's Health, Karolinska Institutet, Karolinska University Hospital Solna, Stockholm, Sweden
| | - Thomas Vraetz
- Center for Pediatrics and Adolescent Medicine, University Medical Center Freiburg, Germany
| | | | - Yenan T Bryceson
- Center for Infectious Medicine, Department of Medicine, Karolinska Institutet, University Hospital Huddinge, Stockholm, Sweden
| | - Despina Moshous
- Unit for Pediatric Immunology, Hematology and Rheumatology (UIHR), Hôpital Necker-Enfants Malades, Paris, France
| | - Kai Lehmberg
- Department of Hematology and Oncology, Children's Hospital, University of Hamburg, Germany
| | - Michael B Jordan
- Division of Bone Marrow Transplantation and Immunodeficiency, Cincinnati Children's Hospital Medical Center, University of Cincinnati Medical School, Ohio, USA
| | - Stephan Ehl
- Center of Chronic Immunodeficiency, University Medical Center Freiburg, Germany Center for Pediatrics and Adolescent Medicine, University Medical Center Freiburg, Germany
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Álvarez-Cardona A, Rodríguez-Lozano AL, Blancas-Galicia L, Rivas-Larrauri FE, Yamazaki-Nakashimada MA. Intravenous immunoglobulin treatment for macrophage activation syndrome complicating chronic granulomatous disease. J Clin Immunol 2011; 32:207-11. [PMID: 22119934 DOI: 10.1007/s10875-011-9616-5] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2011] [Accepted: 11/08/2011] [Indexed: 02/06/2023]
Abstract
OBJECTIVES Chronic granulomatous disease is a rare phagocyte disorder characterized by an increased susceptibility to infections and inflammatory complications. We describe two patients with chronic granulomatous disease (CGD) complicated by macrophage activation syndrome (MAS) (secondary hemophagocytic lymphohistiocytosis) treated with intravenous immunoglobulin (IVIG). METHODS A report of two cases of CGD complicated by MAS who were successfully treated with IVIG was made, and a comparison was made with ten other cases reported in the literature. RESULTS MAS is a severe potentially fatal complication of CGD. Most cases are associated with Burkholderia cepacia and leishmaniasis infection. The treatment of these patients varies between centers, and one example is the use of the HLH-2004 protocol. IVIG could be an effective first line option for this complication in CGD patients. CONCLUSIONS The exaggerated inflammatory response characteristic of CGD patients could play a role in the development of this complication. IVIG appears to be a safe and effective first line treatment in these patients.
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Affiliation(s)
- Aristóteles Álvarez-Cardona
- Clinical Immunology Department, Instituto Nacional de Pediatría, Insurgentes sur 3700-C, Insurgentes Cuicuilco Coyoacan CP, Mexico City, Mexico
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